Brief, Time-Limited Psychoanalytic Psychotherapy

Research findings relating to young offenders reveal a history of maltreatment and loss in up to 90% of those interviewed (Boswell, 1996; Fonagy, Target, Steele et al., 1997). Such experiences are linked to security of attachment. In this context, a meta-analysis of over 10,000 Adult Attachment Interviews (AAI) found that individuals likely to engage in criminal behaviour overwhelmingly have insecure states of mind on the AAI (Bakermans-Kranenberg & van IJzendoorn, 2009). Moreover, a meta-analysis of 62 surveys of the prison population found that the prevalence of psychosis, major depression, personality disorder, and post-traumatic stress disorder was considerably higher amongst prisoners than in the general population (Fazel & Baillargeon, 2010). These findings accorded with my clinical experience when I worked as a probation officer with adult offenders in the community. In common with Cordess (1997), I found that those who had committed violent offences had themselves been victims of childhood abuse and/or suffered emotional neglect or loss experienced as traumatic and disorganising. Indeed, the violent enactment of unresolved childhood trauma was a consistent feature in the behaviour of those with whom I worked and was frequently associated with the misuse of alcohol and illicit drugs.

The case study that follows illustrates the clinical application of an integrated therapeutic model in a probation setting. It is presented as an example of the work that I undertook with violent people and to draw links between childhood trauma and subsequent violent offending. The case elucidates the way in which attachment theory may be used to explicate offending behaviour and assess risk in a forensic setting. In line with Boswell’s (1998) advocacy of research-minded practice, the study seeks to demonstrate the importance of asking offenders about their traumatic backgrounds at the point of assessment (Bowlby, 1944). The therapeutic model illustrates a brief, time-limited approach (Balint, 1972; Mander 2000), and how the clinical application of a therapeutic model, with attachment theory and infant research at its core, may enhance the offender’s capacity for affect regulation, mentalisation and narrative intelligibility. The improvement in these capacities reflects the integration of dissociated trauma, the development of second-order representational models, and a concomitant decrease in the risk of violent behaviour (Bowlby, 1988; Fonagy 1999b).

An Attachment Theory Paradigm

With regard to traumatic childhood experiences involving separation and loss, Bowlby (1969) found that when a young child is unwillingly separated from the attachment figure, he or she expresses emotional distress. In the event of the separation being prolonged, necessitating the child being placed in unfamiliar surroundings, such distress is likely to become intense. Typically, the child’s distress follows a sequence of protest, despair and emotional detachment. Bowlby (1969) suggests that these phases may be linked to three types of responses, viz., separation anxiety, grief and mourning, and defence. Further, he argues that these responses are phases of a single process - that of mourning separation and loss. The traumatic quality of the child’s grief reaction is encapsulated in Bowlby’s poignant observation that: “Loss of a loved person is one of the most intensely painful experiences any human being can suffer” (Bowlby, 1980, p. 7).

Bowlby (1979, 1980) emphasises that the crucial process of mourning generally takes place in the context of the family’s characteristic attachment behaviour towards the child. He contends that the family may either facilitate the expression of grief by responding sympathetically to the child’s distress or adopt an inhibiting attitude that causes the child to suppress or avoid typical feelings of fear of abandonment, yearning and anger. Bowlby (1979, 1980) found that a supportive and sympathetic attitude within the family may lead to a process of healthy mourning even in children as young as two years. The process consists of normative behavioural responses of anxiety and protest, despair, disorganisation and detachment, and reorganisation. By means of this process, the loss is gradually accepted by the child whose capacity to form new attachment bonds is restored following a period of disorganisation.

By contrast, in pathological mourning the child’s unexpressed ambivalent feelings of yearning for, and anger with, the attachment figure are split off into segregated or dissociated systems of the personality, and the loss may be disavowed. As a consequence, and in the absence of a trusted substitute attachment figure, the child has little alternative but to move precipitately to a defensive condition of emotional detachment, thereby internalising a representational model of attachment that is avoidant, ambivalent, or disorganised in respect of separation and loss. In such instances, the child’s attachment behavioural system may either remain deactivated or hyper-activated. Although expressed in different ways, the factor that these two main strategies have in common is that attachment-related information is being defensively and selectively excluded from consciousness (Bowlby, 1980, 1988).

In describing childhood pathological mourning, Bowlby (1979) makes the important point that his hypothesis is not confined to the actual death of, or separation from, the attachment figure. Indeed, he stresses that the child may experience separation and loss in numerous, less overt ways. For example, in the form of threats of abandonment, parental rejection, depression, neglect and/or abuse, as well as loss of love (Bowlby, 1979, 1988). Such a child’s family situation may be said to consist of both dramatic trauma and cumulative developmental trauma. Bowlby (1979) emphasises that the common factor in these various situations is loss by the child of a parent figure to love and to attach to. He contends that representational models shaped by childhood experiences of pathological mourning may be activated under conditions of separation and loss in adulthood, together with the expression of dysfunctional anger, shame, hatred and violence (Bowlby, 1969, 1979, 1984, 1988). This assumption accords with my clinical experience and has been confirmed by adult attachment research (Mikulincer, Gillath & Shaver, 2002; Simpson, Rholes & Nelligan, 1992; Simpson, Rholes & Phillips, 1996).

Main, Kaplan and Cassidy (1985) utilised the Adult Attachment Interview (George, Kaplan and Main, 1985) in order to classify parental states of mind with respect to attachment and trauma. Using this research tool, and Ainsworth et al.’s (1978) Strange Situation procedure, which observes and classifies the attachment status of children, Main (1991) found that the child’s discrete pattern of attachment organisation has, as its precursor, a characteristic pattern of caregiver-infant interaction and its own behavioural sequelae. Thus, as predicted five years previously, there was a significant match between the mother’s and her child’s attachment classifications. In the main, secure/autonomous mothers had infants who were securely attached; those with a dismissing state of mind had avoidant infants, while preoccupied mothers had ambivalent-resistant infants. There was a strong correlation between mothers whose discourse transcript in the AAI was classified as unresolved in respect of trauma and abuse and disorganised/disoriented infants. The unresolved classification is made solely on the discussion of trauma, abuse and loss experiences and is superimposed on one or other of the three main attachment classifications – secure/autonomous, dismissing, and preoccupied.

These findings, then, indicate that secure, fearful and traumatic states of mind are transmitted across generations via processes of interactive regulation, cross-modal attunement and reflective functioning or mentalisation (Renn, 2008a). However, recent research with fathers reveals that attachment is ‘relationship-specific’, with the child’s representational models of mother and father developing separately (Main & Goldwyn, 1995; Steele & Steele, 2008). Thus, a child may be securely attached, or indeed, disorganised, with one parent but not with the other. Nevertheless, there is broad agreement that malignant childhood events relevant to attachment, such as separation, loss, neglect and abuse, may cause difficulty in integrating and organising information, and that such difficulty may play a crucial role in the creation of security in adulthood.

Peterfreund (1983) suggests that different representational models are in operation during different activities and in different situations, making predictive calculation and adaptive behaviour possible. In advocating a ‘heuristic’, as opposed to a ‘stereotypical’, approach to the process of psychoanalytic psychotherapy, he stresses the significance of information processing and error-correcting feedback in this process, arguing that these are the means by which perceptually distorted representational models are modified, updated and fine-tuned. Peterfreund’s (1983) synthesising approach reflects Bowlby’s emphasis both on empirical observation of human relationships and the fact that many of the concepts underpinning attachment theory are derived from cognitive psychology and developmental psychology. Given this, attachment theory may be seen as acting as a bridge between cognitive science and psychoanalysis (Holmes, 1993; Renn, 2010).

In line with this thinking, my work with violent people in the criminal justice system was informed by findings from infant research, adult attachment research, traumatology, object relations theory, relational psychoanalysis, intersubjectivity, and neuroscience, particularly in respect of findings relating to affect regulation and the functioning of the implicit/procedural memory system. These perspectives provided me with a particular way of listening to the offender’s narrative and discrete discourse style, and of understanding the clinical process (Slade, 1999). In accordance with this view, Stern (1998) argues that “search strategies” which explore the patient’s past are an integral aspect of the therapeutic process, contending that: “In good part, the treatment is the search” (p. 203). Similarly, Fosshage (2011) suggests that: “The exploratory process itself contributes to new relational experience” (p. 68). In line with attachment theory, Stern (1985, 1998) views psychopathology as deriving from an accumulation of maladaptive interactive patterns in childhood that result in character and personality types and disorders in adulthood.

The Offender - John: Personal History

John, the subject of this case study, has given his permission for this paper to be published. Names have been changed, however, and personal circumstances disguised in order to protect identities. John was 48 years old at the time we met. He grew up in a large family, being one of eight children. He is the youngest of four brothers, one of whom was killed in a road traffic accident several years previously, and he has two older and two younger sisters. He spoke of his father as being “distant and always at work”, and his mother as “anxious and over-protective”. He recalled that she had played out an elaborate pretence in respect of his father’s occupation by telling neighbours that he worked in a bank, whereas, in fact, he was a barman. John completed his secondary education at the age of 15, leaving school with no academic qualifications. By this time, he was misusing drugs and alcohol. He went on to develop a dependency on the latter. As a consequence of this problem, John’s employment record is inconsistent and, in the main, comprised of manual and semi-skilled work.

John has had a series of unstable relationships with women characterised by violent, controlling behaviour, possessiveness and sexual jealousy on his part. Because of his problematic attitude to women, John consulted his GP when aged 18. He was referred for psychiatric assessment but not offered ongoing treatment. John married when aged 28, but insisted “there never was a true love”, adding, “I haven’t wanted to commit myself”. He avoided doing so in part by “always having relationships with two women at the same time”. This situation obtained during the course of his 13-year-long marriage, which John described as an “on-off affair”. He related how he would often pick fights with his wife so as to give himself an excuse to leave home and go on a drinking binge. The marriage was childless, but John has three children from a subsequent relationship, which, typically, was brief, intermittent and volatile. He has had no contact with his children for several years and was unaware of their current whereabouts. At the time we met, John was largely estranged from his own family and not in an intimate relationship.

Forensic History

John has been involved in the criminal justice system for over 30 years, appearing before the courts for the first time as a juvenile. Though he has convictions for motoring offences and, when younger, burglary, the most prominent and consistent feature of his offending behaviour is drink-related intimate violence. The latter commenced in adolescence and, as mentioned above, was the reason why John was eventually referred for psychiatric assessment. He has convictions for grievous bodily harm, assault with intent, assaulting the police, possession of a firearm, and criminal damage. On one occasion he went to his ex-partner’s home armed with an axe which he used to break in to remonstrate with her for leaving him. John has been subject to a range of sentences including discharges, fines, probation, community service, and imprisonment. He has had numerous sojourns in rehabilitation units for his alcohol problem, but always returned to misusing drink. One of his brothers also has an alcohol problem but John is the only member of the family to become embroiled with the law.

The Index Offence

The index offence consisted of a serious assault on John’s then-partner, Sylvia. The couple had been in a relationship for two years but lived separately. John came to suspect Sylvia of being sexually involved with someone else. He went to her home in a drunken state one evening and accused her of having sex with another man, calling her a “slag and a whore”. When Sylvia denied John’s accusation he attacked her with his fists and feet in an uncontrollable rage, causing serious injury to her head and body. He only desisted when finally she told him “what I wanted to hear”. At court, the photographic evidence of Sylvia’s injuries was said to be “horrific”. John denied the offence when arrested, maintaining that Sylvia’s injuries were self-inflicted. He was convicted following a jury trial and sentenced to 2½ years’ imprisonment.

First Contact

John’s case was allocated to me when I transferred to the probation office in his home area. His reputation at the office was that of a perpetual client with whom everything had been tried. I wrote to John in prison to introduce myself as his new through-care officer. In his reply he alluded to the attack on Sylvia, saying: “It wasn’t anger, it was alcohol talking, I’m not angry by nature”. Though clearly John was distancing himself from his anger and violence in this statement, there was at least an implicit admission of his assault on Sylvia.

The Initial Assessment

I met John for the first time during his temporary release from prison on home leave. He had managed to retain his local authority tenancy by sub-letting to a male alcoholic friend, but previously had lived alone. John was due to be released on parole a month later and his period on licence would run for just eight months. At this first meeting, I assessed John’s attachment history, which included asking him about childhood experiences in respect of separation, loss and abuse. He was clearly surprised and puzzled by the tenor of my questions as he had not been asked about such issues before. After some initial hesitation, John spoke of having had frequent separations from his family from about the age of five. These were the result of a series of operations for ENT problems necessitating his hospitalisation. He recalled struggling with the nursing staff on one occasion as he fought to retain consciousness whilst being held down and given “gas”. However, he did not believe that these experiences had had any adverse effect on him.

John’s discourse style when discussing these experiences was brief and dismissive, indicating a deactivating attachment strategy with respect to these memories. The dismissive quality of his narrative, together with his history of unstable intimate relationships and propensity for violence, suggested the development of an avoidant/disorganised pattern of childhood attachment (Main, 1991; Main, Kaplan & Cassidy, 1985; Main and Weston, 1982). Given these clinical features, I held in mind the possibility that John may have responded to the enforced, multiple separations from his family by precipitately entering a state of emotional detachment (Bowlby, 1973, 1979). In reviewing studies linking insecurely attached children and subsequent criminal behaviour, Fonagy et al. (1997) suggest that insecure attachment constitutes a distinct risk factor. Further, the authors argue that patterns of attachment operate as mechanisms of defence to help the child cope with idiosyncrasies of parental caregiving, and that criminality involves disturbance of attachment processes. These findings accord with De Zulueta’s (1993) proposal, based on Bowlby’s (1984, 1988) thinking, that “violence is attachment gone wrong” (p. 3).

It soon became clear that John’s ideal view of himself was that of a passive, non-violent man who, in his own words, “wouldn’t hurt a fly”. My tentative hypothesis at this point, in the context of his extensive history of violence towards women, was that John was carrying powerful unprocessed emotional pain; that he was disowning feelings of anger, shame and hatred and that, lacking the capacity to contain, regulate and process such emotions, these built up in response to stressor events, generating intense internal conflict which eventually became overwhelming, compromising his tenuous capacity for mentalisation (Fonagy, 1999c; Fonagy et al., 2004). At such times, John resorted to binge drinking. Under the disinhibiting effect of alcohol, it would seem that his dissociated emotional turmoil was unleashed and enacted in the form of violent rage. This clinical picture indicated that John might be prone to experiencing a traumatic stress reaction and the re-emergence of implicitly encoded childhood trauma when embroiled in an intense, emotionally-charged situation characterised by actual or expected separation and loss (de Zulueta, 1993; Herman, 1992; Lyons-Ruth & Jacobvitz, 1999; Meloy, 1992; Renn, 2006, 2007, 2008; Schacter, 1999; Schore, 1994; van der Kolk, 1989; West & George, 1999). From this perspective, traumatic affect is seen as having a disorganising effect on mental functioning and to be a significant motivating factor in the manifestation of psychopathology (Tyson & Tyson, 1990).

I harboured reservations about John’s ability to engage in a therapeutic process. These misgivings centred on the fact that he was denying the violent assault on Sylvia, and that his record of attending appointments when on licence in the past had been far from exemplary. Further, as noted above, John was resistant to the idea that past experience may have a maladaptive effect on behaviour in the present, specifically in relation to his alcohol misuse, as he had been told at a rehabilitation centre that “alcoholism is a disease”. He, therefore, expressed a good deal of scepticism about the prospect of change, having passively accepted this fatalistic diagnosis. Nevertheless, I explained what our work together would involve, should he decide on this option, emphasising the collaborative nature of the process. John responded by saying that he would “give it a go” as nothing else he had tried had been successful. Despite John’s seemingly dismissing attachment state of mind, I felt that we had established a rapport and that the all-important “match” or “fit” prerequisite for therapeutic work to commence had emerged at this first meeting (Kantrowitz, 1995). John signed a standard medical consent form giving me permission to contact his GP in order to discuss any relevant issues.

Time Framework

Given the setting within which I then worked my intervention with John would be brief and time-limited. Hence speed in assessing the clinical issues was a major consideration. In fact, I had a total of 13 sessions with John, each session lasting a full hour. A follow-up meeting was held six months after his period on licence had ended. I incorporated such meetings into my practice, as I saw these as serving a dual purpose: of evaluating the effectiveness of my work and providing the client with a sense of continuity and connection to a ‘secure base’ (Bowlby, 1988), or at least to one experienced as secure-enough. In my experience, the availability of an ongoing link at this critical time helped to preclude the often noted, though anecdotal, phenomenon whereby the client re-offends towards the end of the supervisory period, seemingly in reaction to the impending loss of a relationship with an attachment figure that had become significant.

Therapeutic Intervention

The first meeting following John’s release from prison came to focus on helping him recognise and own disturbing thoughts and feelings. An example of this difficulty emerged when John spoke in mild terms about the friend whom he had allowed to stay at his home whilst he was in prison. John returned to find the place a complete tip and rent arrears of over £1000 owing to the housing department. At first, John spoke of feeling “a bit let down” and, later, when I questioned his passive response, of being “fucking angry”, vacillating between these two attitudes. It seemed to me that John was quite confused and ambivalent as to how he actually felt about his friend. He seemed to be in two minds about how to respond, speaking in the same breath of going to reason with this person and of beating the hell out of him!

This narrative appeared to provide a glimpse of the conflict and disorganisation characterising John’s representational world of object relations or confused, unstable internal working models of attachment. On the one hand, he seemed to be identifying with the hurt, angry, disappointed child who had been let down and whose trust had been betrayed; on the other hand, to be identifying with a dismissing parent who deflected and perhaps even forbade the expression of difficult thoughts and painful feelings. This situation seemed to be re-created in the session, in that John anxiously deflected any attempt on my part to connect with him on an emotional level. Indeed, I felt under immense pressure not to talk about meaningful issues and events, and I experienced a countertransferential sense of futility and despair.

It would have been all-too-easy to have succumbed to the sense of hopelessness that I was experiencing and thus given up the attempt to engage John. Instead, I sought to understand his emotional state and subjective experience. In ways not too dissimilar to the stress-inducing aspect of the Strange Situation procedure (Ainsworth et al., 1978) and the Adult Attachment Interview (George, Kaplan and Main, 1985), I viewed the emotionally heightened exchange with John as having activated an archaic representational model, together with a habitual, procedural way of experiencing himself in relation to other people (Bowlby, 1969; Mikulincer, Gillath & Shaver, 2002; Simpson, Rholes & Nelligan, 1992; Simpson, Rholes & Phillips, 1996). Such mental models take the form of non-verbal, nonconscious implicit/procedural memories (Schacter, 1987, 1996). These emotional procedures were expressed in John’s subtle behavioural performance, the observation of which provided a micro-behavioural basis for me to experience, share and cross-modally match his affective state (Beebe, Jaffe & Lachmann, 1992; Beebe & Lachmann, 1992, 2002; Stern, 1985, 1998). In the light of recent neuroscience and developmental research, my emotional and psychophysical response to John may be conceptualised as the activation of the mirror neuron system at the level of implicit relational knowing (Bruschweiler-Stern et al. 2002; Gallese, 2009; Lyons-Ruth et al. 1998).

Despite the intensity of the interaction, my reading of John’s overt behaviour influenced me to stay in the affective moment, which I viewed as an unconscious communication of unmanageable feelings. I decided to share aspects of my countertransferential experience of being with him in these moments, wondering whether the powerful thoughts and feelings stimulated in me mirrored something of his own experience (Casement, 1990; Maroda, 1991). John confirmed that he had felt a mounting sense of anxiety, verging on panic, adding that he usually avoids talking about his feelings. Avoidance of this sort, particularly in men, may reflect the way in which gender, culture and inner prohibition coalesce, resulting in a defensive splitting of thought from feeling – an enacted manifestation of the ‘unthought known’ or of ‘unformulated experience’ (Bollas, 1987; D. B. Stern, 1997). From a developmental/neurobiological perspective, such behaviour may indicate a failure of parent-child interactive affect regulation and a concomitant incapacity to self-regulate emotional states when under stress (Beebe & Lachmann, 1992, 2002; Lyons-Ruth & Block, 1996; Schore, 1994). Research suggests that in such instances, the lack of a contingent parental response to the child’s attachment needs may, if characteristic of the relationship, come to be associated with negative affect and escalating arousal, leading to prolonged and severe states of withdrawal and the defensive exclusion of attachment cues. The internalisation of such sub-optimal interactive patterns may interfere with the person’s ability to regulate arousal. This, in turn, compromises the capacity to mentalise one’s own and the other’s emotional and intentional states of mind, and the ability to stay attentive in order to process information in situations involving interpersonal stress (Beebe, Jaffe & Lachmann, 1992; Fonagy & Target, 1996; Fonagy, 1999c; Fonagy et al., 2004; Main et al. 1985). My capacity to mentalise John’s states of mind, and willingness to share my own thought and feelings, appeared to enhance his mentalising capacity in this particular therapeutic encounter (Diamond & Kernberg, 2008).

Disclosure of Childhood Trauma

Somewhat paradoxically, John appeared relieved by the dawning realisation that inner emotions may be recognised, shared and understood (Benjamin, 1995). Seemingly in consequence of this intersubjective experience of interactive regulation, a more reflective mood and positive affective state prevailed. This exchange, in turn, appeared to evoke in John memories of a traumatic event that had taken place when he was eight years old. Tentatively, John related how he and his then best friend, Ricky, had been playing near a fast-flowing river. John’s memories of the event were somewhat vague and hazy, but he recalled that Ricky had slipped on the moss-covered embankment into the river and drowned. John came to believe that people suspected him of having pushed his friend into the river. Indeed, I found myself silently questioning whether John might have had a hand in Ricky’s death. Again, I observed the nuances of his facial expressions, direction of gaze, vocal inflections, bodily orientation, and gesture when relating this traumatic event, as well as monitoring my own affective and bodily responses. I detected nothing in John’s overt behaviour at that time, or subsequently, to indicate that his narrative was anything other than authentic in regard to this matter. I, therefore, concluded that Ricky’s death had, indeed, been a tragic accident.

In addition to feeling blamed and accused, John came to view himself as a “bad” person because his attempts to save Ricky had failed. John went on to speak of having confused and intangible memories of being in court in the aftermath of Ricky’s death and of growing up feeling burdened by “guilt”. The court in John’s memory was probably that of the coroner who carried out the inquest into the circumstances of Ricky’s death. It seemed likely that, in a similar way to those who live through a major disaster, John experienced a deep sense of guilt at having survived when Ricky had died (de Zulueta, 1993; Herman, 1992), and that this whole situation had been exacerbated by his having to appear at the coroner’s court.

I wondered whether the trauma of Ricky’s drowning had activated John’s earlier trauma: that of being separated from his family and held down and “gassed” in hospital - drowning in gas, as it were. This observation seemed to resonate with John’s subjective experience. He became deeply thoughtful and reflective, sitting in silence for a considerable time. He looked sad and forlorn and his eyes brimmed with tears. When he surfaced from this pensive mood he appeared to recognise aspects of himself as if for the first time. He spoke about persistent feelings of sadness, anxiety and watchfulness, and questioned whether these could be linked to his disturbing childhood experiences. It seemed that the recollection of these state-dependent memories had started the process of unlocking the affective components of John’s unresolved trauma (Stern, 1985). Despite the similarity in our ages, my primary countertransference at this point was that of a benign, concerned parent seeking to understand and ameliorate a child’s confused state and emotional distress.

Although the session had been challenging and intense, John seemed buoyed up and expressed the hope that ghosts could finally be laid to rest. His positive affective response and disclosure of unresolved childhood trauma suggested that a secure-enough therapeutic alliance had been speedily established. To my mind, my challenging yet contingent interaction with John managed to be neither avoidant nor enmeshed but mid-range, and thus engendered a sufficient sense of felt security for him to risk a somewhat new way of experiencing himself in interaction with me (Beebe, et al., 2000). This, in turn, appeared to facilitate the process of exploring dissociated thoughts and feelings associated with his unresolved trauma. I would argue that the gradual modification of sub-optimal representational models initially hinges on such micro-processes of interactive regulation in the nonverbal, implicit/enactive domain, but that such interactions need then to be explored and elaborated over time in the verbal, explicit domain.

Repetition of The Trauma

During subsequent sessions, John and I tried to give meaning to what, in symbolic terms, he might be enacting unconsciously via his offending behaviour. It seemed to me, at least in part, that he was re-enacting a destructive and self-destructive pattern of behaviour in identification with the “bad”, traumatised eight-year-old child who had been unable to mourn Ricky’s death, and who was left carrying a tremendous burden of shame and guilt. My tentative hypothesis was that an aspect of this re-enactment involved John being drawn compulsively and repetitively to stand accused in the dock of a court, thereby reliving the trauma and, at the same time, confirming his negative core belief or implicitly encoded fantasy of himself as a bad, guilty person (van der Kolk, 1989). Moreover, I wondered whether the repetitive experience of being adjudged guilty and sentenced to a period of incarceration had the temporary effect of assuaging John’s deep and pervasive sense of guilt and shame. This hypothesis rang true for John and became a ‘key therapeutic metaphor’ in our work together (Stern, 1985). Further, the co-construction of significant events in John’s childhood seemed to go some way towards filling gaps in his personal history by beginning to provide his fragmented experience with coherent narrative meaning (Holmes, 1996; Main, 1991; Main, Kaplan & Cassidy, 1985; Roberts, 1999). John elaborated on these thoughts, saying that he feels safe and secure in prison, whereas on the outside he is continually assailed by feelings of panic, anxiety and an impending sense of danger, as if something dreadful were about to happen. In phenomenological terms, it would seem that John’s sense of ‘nameless dread’ and ‘primitive agonies’, linked to his unresolved trauma, were experienced as “a fear of a breakdown that has already happened” but which has not been “experienced”, and thus as prone to being repeated at an unconscious level of mental functioning (Bion, 1984; van der Kolk, 1989; Winnicott, 1974, p. 104).

Continuous Assessment and Ongoing Intervention

At this point in my work with John my assessment had crystallised. Keeping relevant research findings in mind, I based my assessment of John’s psychopathological behaviour on the theoretical premise that cognitive-affective states associated with his traumatic experiences had been subject to perceptual distortion, defensive exclusion and selective inattention, becoming encapsulated in a segregated or dissociated disorganised and multiple representational model (Bowlby, 1980; Liotti, 1992, 1999; Main, Kaplan and Cassidy, 1985). In line with Herman (1992), I surmised that the lack of an appropriate response to John’s trauma had left him with a pervasive sense of alienation and disconnection in his relationships. I concluded, therefore, that the main therapeutic tasks were to facilitate a process of mourning by assisting him to make connections between dissociated thoughts and feelings associated with the traumatic events he had described (Bowlby, 1973, 1979, 1988; Spezzano, 1993), and to modify sub-optimal, implicit/procedural representational models (Bowlby, 1988; Fonagy, 1999b). This work had, of course, already commenced to some extent during the assessment process, reflecting Stern’s (1998) contention, alluded to above, that the search process is, in itself, therapeutic.

By this stage, John seemed committed to working on these unresolved issues and he stuck doggedly to the task, appearing to have an active need to tell his story and create a coherent narrative. He admitted to being desperate for a drink after the previous session, but instead had made a conscious effort to think about what we had discussed. In line with Main’s (1991) research into metacognitive monitoring, I had enjoined John in quite a directive way to bring focal attention to bear on what he was experiencing in any given moment and to develop a dialogue with himself. This involved the employment of the consciousness system - using thought and his mind in a new and novel way so as to contain, explore and assimilate raw psychic pain, and of stepping outside of himself in order to closely observe and monitor his thoughts, feelings and behaviour. Following Fonagy et al.’s (1997) development of Main’s (1991) research on metacognitive monitoring, these therapeutic strategies were designed to enhance John’s reflective functioning, thereby increasing his capacity to contemplate and understand (mentalise) both his own and others’ emotional and intentional states of mind in a coherent way. The overarching therapeutic goal was to assist John better to regulate his emotional anguish and visceral-somatic bodily states without becoming overwhelmed to the extent that he misused alcohol as a maladaptive form of self-regulation, with the attendant risk of his violently enacting his unresolved trauma in his intimate relationships. As we have seen, an important aspect of the therapeutic process involved the evocation of key traumatic experiences encoded and stored in the systems of implicit/procedural memory, as conceptualised as self-other representational models, and of making these models consciously available for dyadic regulation and ideational elaboration (Bowlby, 1988; Fonagy, 1999b; Fonagy & Target, 1998; Renn, 2012; Schore, 1994; Spezzano, 1993; Stern, 1985).

As the weeks went by, John reported that he was keeping his drinking within sensible limits and had tidied up and decorated his flat. He looked healthier with clear eyes and a better colour to his complexion, and he seemed more at ease with himself. The impression of John being less anxious and conflicted was quite pronounced and he related how, prior to this improvement, the mere act of leaving home to catch a bus to the town centre would engender anxiety, panic and a sense of danger which he would quell with drink. John also noted changes in the way he was responding to others, and they to him, acknowledging that in the past he would often deal with his aggressive impulses by provoking aggression in others, thereby giving himself a ready excuse to be violent and resort to alcohol misuse. He went on to recall feeling acutely persecuted and paranoid as a child following Ricky’s death, saying that he lived in a state of fear and anxiety about the prospect of being attacked by Ricky’s family because “they thought I’d killed Ricky”.

Such fears may well have been realistic but, in my opinion, were also likely to have been fuelled by fantasies of retaliation which flourished in the absence of an affectively attuned, containing parental response in a family system that was cumulatively traumatising. It seemed to me that John’s later violent behaviour reflected respective research by Greenberg et al. (1993) and Solomon et al. (1995) which reveal that disorganised children develop representational models characterised by chaos, fear, helplessness, and hostility. Having no coherent strategy to deal with experiences of separation and loss, the child relates to others in a coercive and controlling way. As noted above, Main, Kaplan and Cassidy’s (1985) longitudinal research supports the proposition that representational models developed in childhood tend to persist over time. Moreover, neuroscience research indicates that such implicitly encoded models may be activated in situations that reprise the original trauma, leading to the re-emergence of childhood trauma and an unregulated release of negative neurochemicals. These nefarious processes increase the risk of the traumatic experience being violently enacted in the person’s current intimate relationship (Perry et al. 1995; Renn, 2008b, 2012; Schacter, 1999; Siegal et al. 1999; van der Kolk, 1989, 1994).

Certainly, lack of trust and controlling behaviour became major issues for John as he developed into adolescence and adulthood, together with clinical issues of affect regulation, mentalisation, autonomy, dependence, intimacy, attachment, separation, and loss. He spoke of his surprise at being able to talk to me about personal and painful matters, and he went on to risk rejection by asking if he could contact me after his parole licence had ended, should a crisis arise. I agreed to this request, viewing it in terms of an adult relational need rather than the gratification of an infantile desire (Mitchell, 1993). Also, as previously mentioned, I told John that I would like to have a follow-up meeting with him in any event. This exchange seemed to indicate that he was internalising his relationship with me in the form of a secure enough base from which to explore and elaborate his traumatic experiences, but that he still needed to feel there would be the opportunity for direct proximity-seeking should something untoward occur (Bowlby, 1980, 1988). I was encouraged by the fact that John was beginning to make links between his traumatic childhood experiences and the anxiety, panic and aggression manifested in later years. He seemed increasingly able to appraise the significance and meaning of these distressing affects (Schore, 1994), and to use the working alliance or developing attachment relationship, to negotiate and reorganise unresolved clinical issues (Stern, 1985).

Childhood Amnesia/Dissociation

Some confirmation of this progress emerged towards the end of the session. John related that when aged 28 and on the point of marrying, “my mother told me I’d changed when I was eight”. Apparently, she had offered no explanation as to why this should have happened. Significantly, John went on to say that to this day no one in his family has ever alluded to Ricky’s death, adding that he had suffered “amnesia” between the ages of eight and 11. It seemed likely that, lacking the emotional and cognitive capacities to assimilate the traumatic event unaided, John’s only option was to resort to a form of dissociation, that is, an altered, detached state of consciousness (de Zulueta, 1993; Herman, 1992). For whatever reason, it would appear that John’s parents were insensitive to his needs and unable to help him deal with the aftermath of the tragedy, perhaps misguidedly believing that ignoring the event was for the best. Indeed, there was nothing to suggest they were intentionally cruel or malign, but that for reasons stemming from their own attachment histories, they were defensively excluding from consciousness John’s attachment needs as a means of avoiding vicarious distress (Lyons-Ruth & Block, 1996; Main, Kaplan & Cassidy, 1985).

The information provided by John, when listened to with relevant research findings in mind, led me to tentatively surmise that his parents had been unable to respond to his distress because of the fear this evoked in themselves (Lyons-Ruth and Jacobovitz, 1999, 2008; Lyons-Ruth et al., 2005; Schore, 1994). In this event, it seemed likely that John came to perceive his parents’ dismissing, non-reflective response to his fear as both frightening and frightened, and thus to experience his own state of arousal as a danger signal for abandonment (Main & Hesse, 1990). In consequence of the family’s disorganised caregiving-attachment system, and the fear and insecurity to which this relational matrix gave rise, it would appear that John’s attentional strategies were compromised and that he developed an exquisite vulnerability to trauma and dissociation (Liotti, 1992, 1999; Lyons-Ruth & Jacobovitz, 1999). His subsequent behaviour suggests that he adapted to this unhappy situation by inhibiting his mentalising capacity, becoming increasingly emotionally detached from his parents, as well as from aspects of his own subjective experience, particularly affective states of anxiety, fear, shame and rage (Fonagy, 1999c; Fonagy et al., 2004). Thus, although John’s mother was physically present, she appears to have been inaccessible psychologically and emotionally and, therefore, unavailable to help John develop the capacities to regulate, reflect upon and process negative affect and traumatic experience. His subsequent misuse of addictive substances may be seen as having its aetiology in these very incapacities, with first drugs and then alcohol being used to suppress dreaded psychobiological states and hence restore a semblance of affect regulation (Schore, 1994). In this context, it would seem reasonable to hypothesise that John’s childhood attachment to his parents was characterised by what Settlage et al. (1990) and Schore (1994) term ‘proximal separations’.

Discussion

John’s clinical material brought to mind research that addresses the aetiology of cognitive-affective disturbance in children. For example, Solomon et al. (1995) have shown how the disorganised child resorts to controlling, aggressive behaviour in the absence of a coherent strategy to cope with the trauma of separation and loss. Liotti (1992), following Main (1991), posits a connection between disorganised/disoriented attachment and dissociative disorders. According to Liotti’s hypothesis, the child’s disorganised/disoriented attachment behaviour corresponds to the construction of an internal working model of self and attachment figure that is multiple and incoherent, as opposed to singular and coherent. Liotti (1992) suggests that a multiple internal working model of this kind may predispose the child to enter a state of dissociation in the face of further traumatic experiences. Similarly, Davies and Frawley (1994), in their work with adult survivors of childhood sexual abuse, view dissociation as existing on a continuum, with multiple personality disorder or dissociative identity disorder (MPD/DID) representing the most extreme form of mental defence against severe, protracted trauma. This opinion is shared by Mollon (1996) who questions whether MPD/DID should be conceptualised as part of a broad grouping of trauma-based psychiatric disorders or as a unique form of personality organisation deriving from dissociative and post-traumatic factors.

From a social constructionist perspective, D. B. Stern (1997) views cognition as an amalgam of thought and feeling and an integral aspect of a continuous phenomenological process operating within the interpersonal field. Under optimal conditions, this process functions to organise, structure and unify subjective experience, thereby providing the individual with a sense of coherence and meaning. However, Stern (1997) argues that experience may be split for defensive reasons in reaction to trauma and result in the isolation of emotion from mentation. Van der Kolk & Fisler (1995) found that, in effect, the traumatised subject is left in a state of ‘speechless terror’. Lacking the words to describe the traumatic event and construct a coherent personal narrative, the individual experiences great difficulty in regulating internal states. Moreover, the authors’ findings show that subjects traumatised in childhood experience more pervasive biological dysregulation than those first traumatised in adulthood. In both instances, however, the traumatic incident is initially “remembered” in the form of fragmented somatosensory experiences (van der Kolk, 1994). Similarly, McDougall (1985, 1989) argues that cumulative trauma consequent on a mother’s insensitive way of handling and interacting with her infant may, during the course of development, lead to a split between word-presentations and affect-laden experiences. McDougall (1985, 1989) adopts Nemiah’s (1978) and Sifneos’ (1973) concept of alexithymia, that is the inability to recognise, describe and express discrete emotional states. She postulates that affective reactions associated with the traumatising caregiving process are either avoided or rapidly ejected from consciousness. As a result of this developmental failure, the individual may be susceptible to psychosomatic symptoms in later life, a view also espoused and eloquently articulated by Krystal (1988).

Fonagy et al. (1997, 2004), posit that the child’s capacity to explore the mind of the other and develop as a thinking and feeling being arises within the matrix of a secure attachment relationship. Insecurity of attachment, on the other hand, undermines the child’s capacity to reflect on and integrate mental experience. The authors argue that such individuals lack insight into the representational basis of human interaction and intentionality. This being so, they resort to concrete solutions to intrapsychic and interpersonal problems, attempting to control their subjective states and self-cohesion through physical experiences such as substance misuse, physical violence, and crime.

Van der Kolk (1989), in reviewing studies pointing to the underlying physiology of attachment, posits that endorphin releasers are laid down in the early months of life within the context of attachment to caregivers with different styles of care-giving. He concludes that affectively intense experiences are accompanied by the release of these neurochemicals, and that this psychobiological process comes to be associated both to states of security and trauma. With these findings in mind, Mitchell (2000) comments on the seemingly addictive propensity repeatedly to forge intimate adult relationships redolent of ties to early objects, even when these are traumatic. He suggests that such behaviour may reflect neurochemical, as well as psychological and emotional derivatives.

Much of the aforementioned theory and research is derived from Bowlby (1988) who presented a paper in 1979 entitled: On knowing what you are not supposed to know, and feeling what you are not supposed to feel. Here, Bowlby cites findings by Cain and Fast (1972) showing how distorted communications between parent and child, which disconfirms the child’s thoughts and feelings of real events, may engender intense guilt. Cognitive dissonance or intrapsychic conflict of this kind may lead the child to develop a chronic distrust of other people and of his or her own senses, together with a tendency to find everything unreal.

The response of John’s parents (though he spoke only of his mother in this context) would seem to suggest that emotional states were characteristically dismissed and deflected. Moreover, as we have learned from John, his mother appears to have entered prolonged periods of denial during his childhood, seemingly prompted by feelings of shame and social embarrassment, as evinced by her refusal to openly acknowledge the reality of her husband’s actual employment status. As noted above, research has demonstrated a significant link between such parental characteristics, in terms of a dismissing discourse style on the one hand and insecure-avoidant attachment behaviour in children on the other (Main, 1991; Main, Kaplan & Cassidy, 1985; Main & Weston, 1982). Further, children with an avoidant pattern of attachment have been found to show a marked lack of empathy towards peers in distress. Indeed, Main and Weston (1982) observed a distinct tendency in such insecurely attached children to behave in an aggressive and hostile way, as did Grossman and Grossman (1991). In John’s case, as with so many men who suffer unresolved childhood trauma, substance misuse and violent behaviour followed. The links between these factors were, again, highly reminiscent of the work on trauma by de Zulueta (1993) and Herman (1992). They also accord with findings cited by West and George (1999). These show that male perpetrators of adult relational violence report a high incidence of childhood histories of severe abuse and trauma (Downey, Khoun & Feldman, 1997; Herman & van der Kolk, 1987; Kalmuss, 1984).

Session Eight: Sexuality and Gender Identity

During the eighth meeting with John issues surrounding sexuality and gender identity emerged. Given the avoidant/disorganised attachment behaviour characterising John’s adult intimate relationships, I silently questioned the security of his masculine identity. Despite being a stocky, powerfully built and somewhat gruff and macho man, John was sporting a ponytail hairstyle. Moreover, as already noted, he generally adopted a passive, non-aggressive stance, seemingly disowning authentic thoughts and feelings in a way reminiscent of Winnicott’s (1988) concept of the false self. John’s style of relating at this point elicited feelings within me of inauthenticity and emotional disconnection. Thus prompted, I asked myself whether he might be employing a feminine identification in his interpersonal relationships as a defence against being overwhelmed by anger and rage deriving from archaic ambivalent feelings of separation from and engulfment by the symbiotic mother (Khan, 1979; Mahler et al., 1985; Stoller, 1988; Stubrin, 1994).

On discussing the way in which men and women may incorporate both masculine and feminine attributes, John’s emotional and behavioural responses were initially averse. His reaction put me in mind of the fact that heterosexual men not infrequently form temporary same-sex liaisons when imprisoned for any length of time. On discussing this delicate subject, I keenly observed John’s behaviour for any signs of intrusiveness or persecution as I sought to establish a sense of emotional connection or intersubjective relatedness with him (Stern 1985; 1998). Again, I felt rather parental in the countertransference, as though fulfilling functions that were containing emotionally, as well as informative on a cognitive level. The relational aspect of the therapeutic process, and the salience of interactive regulation, would seem to confirm the importance of utilising a developmental model in clinical work with offenders, given the high incidence of unresolved childhood trauma in the offender population.

Following these exchanges, John was able to elaborate on the experiences he had had whilst in prison. More generally, we explored how heterosexual men with a confused sense of gender identity may manifest homosexual panic and deal with feelings of shame and anger by denying aspects of their sexuality that create anxiety, and instead project these into others by means of projective identification. A dialogue developed exploring the way in which defensive behaviour of this kind, allied to a morbid fear of the other, may act as a touchstone for violence that targets minority groups, for example, ‘gay-bashing’ and racist attacks. Although the latter appeared not to be features of John’s pattern of offending behaviour, this discussion seemed further to enhance his reflective functioning or mentalising capacity. He appeared more able gradually to recognise others as separate from himself and as having distinct feelings, intentions and desires (Fonagy et al., 1997; Fonagy et al., 2004).

Session Nine: Relapse and Transference Issues

Before the ninth session, John attended the funeral of a family friend. During this session, John volunteered the information that he had consumed about six pints of beer at the wake. We discussed this in the context of what the death of his friend had evoked in him. He said that his predominant feelings were anxiety and guilt, linking these feelings directly to a fearful anticipation that I would “misjudge” him for drinking. I wondered whether this dynamic again constituted a transference re-enactment connected with John’s childhood trauma, particularly the unmourned loss of Ricky. At that time, whether in reality or fantasy, John did indeed feel misjudged and blamed for Ricky’s death. Further, as we have seen, it would appear that his parents’ response lacked empathy and was dismissive of his emotional pain and distress. On an unconscious level, therefore, John may well have been expecting a similar response from me, as it would seem that I was being attributed an archaic parental role in the transference (Sandler & Sandler, 1998). His relapse provided the opportunity to explore some of these issues, in that it enabled him to re-experience his traumatic attachment to a dismissing, emotionally unavailable parent in a way that was bearable (Holmes, 1996). My task at such times was to survive John’s omnipotent destructive fantasies without collapsing or retaliating (Winnicott, 1988). This ‘holding’ response appeared to help John recognise my existence as a separate person available to be used and related to intersubjectively (Benjamin, 1995). Moreover, by relating to John in this unfamiliar way, I became a new developmental object, different from the original pathogenic object that he expected to encounter in transferential re-enactments (Fonagy, 1998; Hurry, 1998; Mitchell, 1988; Schore, 1994). It may also be accepted that the therapeutic relationship was providing John with a ‘corrective emotional experience’ (Alexander & French, 1946).

Session Ten: The Aetiology of John's Violent Behaviour

John opened the tenth session by saying he felt on an “even keel”, adding that he was continuing to spend a good deal of time thinking about past experiences, as well as monitoring his thoughts and feelings in the here-and-now, particularly when in an emotionally disturbed mood. At such times, in line with my suggestion, he would try to trace the immediate trigger of the affective distress and then make links between the past and the present. The therapeutic purpose of setting John this ‘homework’ was to encourage him to stay with the dreaded lived experience for long enough to reflect on and attempt to self-regulate primitive, unintegrated affective states, and to recognise when an archaic representational model had been activated, leading him to expect some dreaded outcome. These problematic experiences would then be brought to sessions for collaborative exploration and co-construction of their aetiology and meaning. My expectation was that this therapeutic intervention would gradually assist John to develop the capacity to elaborate and transform disturbing somatic experiences into a coherent narrative (Schore, 1994; Spezzano, 1993; Stern, 1998). With regard to this process, Schore (1994) emphasises that the therapist’s own tolerance of affects will critically determine the range and types of emotion that may be explored or disavowed in the transference-countertransference relationship. It may be accepted that this consideration is of particular relevance in a forensic setting because the practitioner is often starkly confronted with the bleaker aspects of human experience and the darker side of human behaviour. However, I would suggest that this consideration may pertain equally in private practice with non-forensic patients.

The current session focused in a direct way on John’s violence to women. This issue had been a delicate subject up until this point because his violent behaviour, especially in regard to women, jarred with his ideal self, leaving him feeling deeply shamed. At our first meeting, John had displayed a pronounced tendency to minimise his culpability and blame Sylvia. Indeed, we will recall that he had completely denied the offence initially and was convicted following a jury trial. John’s capacity for denial brought to mind his mother who, as we have seen, appeared to have deployed the self-same defence mechanism with equal conviction. In this context, I have learned from hard experience that working precipitately with denial is clinically sterile and counter-productive, generating intense mutual feelings of frustration and rage in the participants as early parent-child roles and patterns of interaction get re-enacted in the transference-countertransference matrix. Fortunately, by this stage in my relationship with John a secure enough working alliance had been forged, and thus the time seemed ripe for us to explore this form of defensive behaviour. As we did so, John’s dissociated affective states of shame and anger became increasingly available for interactive regulation. This process facilitated his gradual acceptance and active responsibility for his violent behaviour, an enhancement in his ability to empathise with Sylvia, and an acknowledgement that her perspective may have differed markedly from his own.

My thinking in respect of John’s violence was that states of anger, hate, rage and shame, as well as pining for the lost object, had been dissociated as a child, primarily in relation to his mother. This adaptive defence was needed because separations from her and the family had been managed insensitively, as had the later trauma in respect of Ricky, reflecting the family’s disorganised caregiving-attachment system (Lyons-Ruth & Block, 1996; Lyons-Ruth & Jacobovitz, 1999, 2008). As noted above, the effects of these events and relational patterns tend to become frozen in time (Herman, 1992), being preserved and represented internally as non-reflective, nonverbal procedural memories in the form of pre-symbolic interaction structures and representational models. It would seem that these unmodified mental models were, in turn, activated and expressed in violent behavioural enactments in John’s relationships, particularly at times of intense interpersonal stress (Beebe, Jaffe and Lachmann, 1992; Bowlby, 1969; Fonagy et al., 1997; Fonagy et al., 2004; Main et al., 1985; Mikulincer, Gillath & Shaver, 2002; Schore, 1994; Simpson, Rholes & Nelligan, 1992; Simpson, Rholes & Philipps, 1996; Stern, 1985, 1998; West & George, 1999). Such repetitive re-enactments of his unresolved trauma were supported by neurochemical as well as psychological derivatives (Mancia, 2006; Mitchell, 2000; Perry et al., 1995; Siegal, 2001; van der Kolk, 1994). This hypothesis received some confirmation when John went on to speak of becoming angry with a man who had recently battered his wife. On discussing the incident, it became clear that much of the anger generated in John was not solely because of the man’s physical abuse of the woman. His feelings were also inflamed because this person had subsequently flatly denied that the assault had taken place, even though all his acquaintances knew full well that it had.

This scenario appeared to have powerful associations and resonances with John’s childhood, in that in a similar way everyone had known that Ricky had drowned. As we have seen, despite the reality of this traumatic event, John’s emotional and cognitive experience had been denied or, at best, unacknowledged, with Ricky’s death becoming, in effect, a well-kept ‘family secret’ (Pincus & Dare, 1990). Thus, John’s capacity for metacognitive monitoring or mentalisation was fatally compromised since the information that he was receiving about the traumatic event was contradictory and distorted. This, in turn, seems to have led to the development of a multiple, incoherent representational model in respect of his attachment to his mother, and a concomitant state of disorganisation and dissociation, together with the implicit expectation that his attachment figure would abandon him (Liotti, 1992; Main, 1991).

As Solomon and George (1996) and Solomon et al, (1995) found, disorganised attachment is characterised by controlling behaviour towards the attachment figure in the context of the child feeling frightened, abandoned, helpless and vulnerable. This fraught situation is likely to have been exacerbated in John’s case by the separations he had experienced at a younger age when hospitalised and subjected to surgical intervention. The clinical evidence in the here-and-now attested to these factors having contributed to the development of a predominantly avoidant pattern of attachment organisation which, in line with Fonagy et al. (1997), I viewed as an adaptive defence mustered in the face of unattuned caregiving. Moreover, the overall clinical picture suggested that insecurity stemming from separation anxiety had interfered with John’s capacity to differentiate himself psychologically from his attachment figure and, thereby, attain a state of “mature dependence” (Fairbairn, 1996). In this context, it is of interest to note that West and George (1999) suggest that psychological merging may explain the conflict between engulfment and abandonment that appears to be so characteristic of the physically abusive male. The volatile shifts between such states of mind would again suggest the development of disorganised/disoriented attachment in a context of unresolved trauma (Liotti, 1992; Main & Hesse, 1990).

As we have seen, Bowlby (1973) emphasises that anger at an attachment figure who fails to provide the expected comfort at times of stress is a normal and integral aspect of the attachment system. It would appear that this safety valve was not available to John, as he lacked both external and internal permission to experience disturbing negative affect (Spezzano, 1993). He had little option, therefore, but to develop a defensive organisation against anger and rage, in part, identifying with the dismissing, non-reflective qualities and characteristics of his relationship with his mother as a way of defending against feelings of guilt and anxiety (Ferenczi, 1933; Fonagy et al., 1997; A. Freud, 1968). When these mental defences were overwhelmed in his adult relationships because of actual or predicted abandonment, a disorganised, multiple representational model was activated, together with the re-emergence of his childhood trauma, which was enacted with the violent, destructive force of an adult (Bowlby, 1969; Mikulincer, Gillath & Shaver, 2002; Simpson, Rholes & Nelligan, 1992; Simpson, Rholes & Phillips, 1996). From the perspective of Liotti’s (1999) motivational conceptual framework, John habitually ‘chose’ to inhibit the attachment motivational system and, instead, to activate the “agonistic” motivational system, characterised by aggression and rage, in order to avoid experiencing dissociation and unresolved attachment trauma.

In the latest incident of this repetitive pattern, this internal dynamic was externalised, being displaced or redirected from John’s original primary attachment figure (his mother) and projected into Sylvia who, at the point of the break-up of their relationship, he perceived as untrustworthy, rejecting and abandoning. Indeed, John’s “theory of mind” appears to have led him to expect betrayal and shame at the hands of Sylvia (Fonagy et al., 1997; Schore, 1994; West & George, 1999). Thus, she became a vehicle for his intolerable and persecutory self-states, that is, for the internalised aspects of his relationship with his mother that he experienced as alien, frightening and unmanageable (Fonagy, 1999c; Fonagy et al., 2004). Further, aggression, rather than love, seems to have become an emotionally ‘rewarding’ way for John to express his ambivalent world of object relations (Dicks, 1993).

Fear of abandonment, then, seems to have been the primary affect that led to the sudden activation of John’s attachment system and maladaptive representational model of the relationship with his mother. As already noted, a salient feature of this mental model was John’s expectation that his primary attachment figure would not be available or accessible at times of affective stress to provide comfort and protection (Bowlby, 1969; Schore, 1994; West & George, 1999). The clinical evidence, combined with John’s forensic history, indicated that his mentalising capacity was prone to becoming compromised and disorganised by intense separation anxiety and dysregulated fear, shame, hatred and rage when he felt threatened by the loss of a female partner with whom he had formed an intimate attachment.

The theoretical model of male violence proposed here converges with that delineated by West and George (1999). These authors contend that intimate adult relational violence is rooted in attachment disorganisation, viewing this pattern as inextricably linked to unresolved trauma and to a segregated representational system characterised by dysregulated affect and pathological mourning. West and George (1999) suggest that the perpetrator’s defensive and tightly controlled regulation of his attachment system breaks down at the moment of the assault as a consequence of his becoming flooded with negative affect and distorted perceptions deriving from his personal trauma.

With regard to the index offence, the significance for John of Sylvia’s perceived sexual infidelity lay, in part, in the fact that it represented her independence of mind and psychological separateness. In my opinion, any move by her towards a separate, independent existence would have conflicted with the explicit and implicit role expectations that John had brought to the relationship, being construed as a threat to his sense of security (Dicks, 1993). Thus, John’s violence was, in part, a frantic attempt to control Sylvia so as to ensure her continued availability, both to protect him against infantile loneliness and immature dependence (Dicks, 1993; Fairbairn, 1996), and to carry the alien, persecutory parts of himself (Fonagy, 1999c; Fonagy et al., 2004). The thought of being abandonment by Sylvia instilled terror in John because loss was experienced as a re-traumatisation and, therefore, as a threat to the coherence and stability of his very sense of self (de Zulueta, 1993; Fonagy, 1999c; Herman, 1992).

I was struck, moreover, by the fact that John’s vicious assault on Sylvia had been triggered at the very point that she denied having sexually betrayed him, and that John continued to beat her mercilessly until she told him the ‘truth’. Again, I silently wondered to what extent this ghastly episode was a re-creation in the present of unresolved aspects of John’s childhood relationship with his mother who, throughout his life, adamantly denied and invalidated the reality of his traumatic experience (van der Kolk, 1989, 1994). Thus, it would appear that John’s violence not only had the effect of making him feel coherent and real, but also of eliciting the response from Sylvia he so desperately needed to hear - a voice that validated the ‘truth’ of his subjective experience (Fonagy, 1999c). Clearly, John’s violent behaviour could easily have escalated out of control and led to a charge of murder or manslaughter, as in the case of so many insecurely attached men who respond with extreme violence when their female partners end the relationship. Sharing these thoughts with John seemed to have a sobering effect on him and again engendered a state of deep, prolonged and silent reflection.

Session Twelve: Indications of Changes

At the twelfth session, John announced with great confidence that he no longer thought of himself as an alcoholic. I was surprised to see that he had had his hair cut short. I silently wondered whether this dramatic change in his personal appearance was emblematic of a firmer sense of masculine identity, together with a concomitant lessening of his need to defend against feelings of anger and aggression. In terms of Mahler et al.’s (1985) process of separation-individuation, I asked myself whether John’s apparent sense of a more secure male identity indicated the achievement of a higher level of psychological differentiation from the internalised symbiotic mother.

Be this as it may, John again spoke of feeling more at peace with himself, seeing this as manifested in his ability to entertain more positive thoughts and feelings about himself and others, and by the fact that he had effected a reconciliation of sorts with his family and had got himself a job. He then drew a creative analogy with a childhood situation, telling me that he had under-achieved educationally because he had gone deaf in one ear as a result of his ENT problems. Having been seated at the rear of the classroom, John had been unable to hear with clarity what the teacher was saying and his schoolwork suffered accordingly. Once this problem had been identified, John was brought forward to a front-row desk and subsequently came top of the class. With a twinkle in his eye, John said that now the problem of his unresolved trauma had been recognised he could move to the top of the class in terms of his emotional and psychological development.

Though clearly there were elements of affectionate teasing and idealisation in this comment, it seemed to me that his narrative competence had markedly improved, in that he now appeared able to speak in a coherent, concise and plausible way about painful childhood events. This new found autobiographical capacity seemed to indicate that John had begun to mourn and, thereby, integrate previously unassimilated traumatic experiences (Holmes, 1996), and thus was developing a sense of ‘earned security’ (Hesse, 1999). Thus, from an attachment theory perspective, the positive therapeutic change reported by John and observed by me indicated that maladaptive representational models of himself in relation to others, as well as to the traumatic event of Ricky’s death, had begun to be modified and updated. In addition to the improvement in John’s narrative intelligibility and discourse style, change was manifested in his enhanced sense of felt security and reflective capacity.

The Final Session

At the final meeting, John reiterated his belief that a “weight” had been lifted from him. Specifically, he spoke of no longer feeling persistently anxious, paranoid and persecuted, or of experiencing a deep and pervasive sense of dread, sadness and depression. The abatement of these symptoms indicated that an enhancement had occurred in his capacity to use thought and language to transform dysregulated somatic experiences into subjective states of consciousness that could be thought about and reflected upon (Schore, 1994). John was still in employment and managing his drinking. I confirmed that I would contact him in six months’ time and that he could telephone me in between times should the need arise. He expressed a sense of loss and frustration at not having had this kind of help years ago. He also questioned why, in over 30 years of being involved in the criminal justice system, no one had thought to talk with him about his early traumatic experiences, saying he felt that much of his life had been “wasted” as a result. This situation emphasises again the importance of obtaining relevant information about the client’s formative experiences and developmental history as part of a process of effective assessment, particularly in brief, time-limited work. I thought that John’s feelings of loss were being conflated with sadness at the ending of our relationship. I acknowledged the paradox he seemed to be highlighting: that even positive change involves loss of one form or another. On a positive note, I concluded that John’s newfound ability to express attachment-related affective experiences was, in itself, evidence of the progress he had accomplished during the past eight months.

The Therapeutic Process

The progress made by John was dependent on his ability gradually to organise and integrate error-correcting information received as an ongoing aspect of the therapeutic process (Bowlby, 1980, 1988; Main, Kaplan & Cassidy, 1985; Peterfreund, 1983). A significant aspect of the process of change was John’s enhanced capacity to mentalise his own and others' psychological states (Bateman & Fonagy, 2004; Diamond & Kernberg, 2008). Following Tronick et al. (1978), I viewed this process as consisting, in significant degree, of the moment-to-moment micro-repair of attunement or misaligned interaction - an intersubjective process operating at the level of implicit relational knowing (Bruschweiler-Stern et al., 2002; Lyons-Ruth et al., 1998; Stern et al., 1998a, 1998b).

This process was informed by the tracking and matching of subtle and dramatic shifts in John’s mood-state as he narrated his story (Schore, 1994). This interactive process led, in turn, to the recognition of a shared subjective reality (Fonagy, 1998). By these means, my facilitating behaviours combined with John’s capacity for attachment. Though operating largely out of conscious awareness, this mutual, reciprocal relational process permitted the development of a working alliance or attachment relationship (Schore, 1994) that was secure enough to facilitate a collaborative exploration of painful, unresolved clinical issues linked to his misuse of alcohol and violent offending behaviour. As we have seen, key aspects of this intersubjective and reparative process were the interactive regulation of dreaded states charged with intense negative affect (Schore, 1994), and the co-construction of a coherent narrative (Holmes, 1996). Thus, I became a new developmental object, the relationship with whom provided a corrective emotional experience by disconfirming John’s pathogenic transference expectations, as encoded in implicit/procedural representational models. This overall process also enhanced John’s mentalising capacity (Alexander & French, 1946; Fonagy, 1998; Fonagy, 1999b; Hurry, 1998; Schore, 1994). Moreover, following Schore (1994), I assumed that the interactive process involved in regulating John’s emotional states had facilitated a connection between his nonverbal and verbal representational domains, resulting in the transfer of implicit information in the right brain to declarative systems in the left hemisphere (Schore, 1994).

Follow-Up Contact

As agreed, I contacted John for a follow-up discussion six months later. His progress had been sustained, in that he was still in work, keeping his consumption of alcohol within sensible limits, and had not re-offended. Prior to the ending of John’s period on licence, I had liaised with his GP who, in consultation with John, agreed to refer him to the local mental health resource centre. John attended an assessment session there with a clinical psychologist. It was mutually agreed that no further work was needed at that stage.

Conclusion

Given the wide incidence of intimate violence in Western society, understanding the clinical issues underlying such behaviour and developing an effective therapeutic model to address the problem is a pressing social concern. An important consideration in this context is the traumatic effect on children who repeatedly witness scenes of abusive male violence in the home (Cawson, Watton, Brooker and Kelly, 2000; Lyons-Ruth & Jacobvitz, 2008; Werkerle & Wolfe, 1999). I would argue that an integrated relational model, centred on attachment theory and research, as outlined in this paper, has a significant contribution to make in this area of work.

With regard to my brief intervention with John, it remains to be seen whether this proves to be effective in the long term. I was keenly aware that far more could have been achieved therapeutically, not least in consolidating the progress he had made in regulating his somatic and affective states without resorting to alcohol misuse. This, however, was not a viable option, given the constraints of time and resources obtaining within the probation service, and the limited period of his parole licence. Nevertheless, I consider that the brief, time-limited work undertaken with John helped to modify his sub-optimal representational models and to resolve, in some degree, the childhood trauma underlying his adult violent offending behaviour. This, in turn, enhanced his sense of security and capacity for narrative competence and mentalisation, thereby strengthening his ability to activate second-order representational models and consider other peoples’ perspectives (Fonagy, 1999b). These interlinking positive therapeutic changes should fuel the potential for further personal growth and so provide John with a greater ability to empathise with others and make more reasoned choices in the future (Fonagy & Target, 1998; Holmes, 1996). That said, John had not developed an intimate relationship during the period that we were working together. Any progress he had made would, in my opinion, be sorely tested in such a relationship. Despite his evident progress, I would harbour grave concerns for the safety of any future female partner, particularly in a context of separation and loss.

More generally, I consider that this case study illustrates that it is not the traumatic childhood event in and of itself that is salient in personality development and adult psychopathology, but rather the characteristic caregiving-attachment system within which the child experiences the trauma. As previously described, research has demonstrated that the securely attached child develops the capacity to stay attentive and responsive to the environment, using error-correcting information to construct a coherent narrative when presented with scenarios involving separation and loss (Main, 1991; Main & Hesse, 1990; Main, Kaplan, & Cassidy, 1985; Solomon et al. 1995). As already noted, it would seem reasonable to hypothesise that the secure/autonomous adult has developed the mental capacity to process information more readily in the aftermath of a traumatic event than the insecure, disorganised subject whose ability to regulate states of arousal at moments of stress was compromised during early development. As Bowlby (1973, 1979) observed, the quality of the emotional bond between the child and caregiver will vitally influence whether mourning proceeds along a healthy path or takes a pathological course. He also emphasised the therapeutic benefit of modifying the patient’s internal working models (Bowlby, 1988). From an attachment theory perspective, therefore, the overarching therapeutic task in my work with John was to help him to express and mentalise dissociated thoughts and feelings linked to the trauma of unmourned childhood loss, and modify maladaptive representational models. This facilitated his capacity to experience himself in relation to others in new and more enriching ways (Bowlby, 1979, 1988; Fonagy, 1999b; Fonagy & Target, 1997, 1998; Fonagy et al., 2004).

Outcome Studies

In a meta-analysis of outcome studies, Roth & Fonagy (1996) found that the extent to which ruptures to the working alliance were adequately addressed during the course of the therapy was predictive of the efficacy of the intervention. The authors conclude that the relationship component is the common effective ingredient in positive outcomes. Their findings accorded with my clinical experience in applying attachment theory in my work with violent people, and would seem to confirm the respective findings of Shedler (2010), Schore (1994) and Stern et al. (1998) viz., that the interactive emotion-transacting aspect of the therapeutic encounter is the main mechanism of intrapsychic change.

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Paul is a qualified Psychoanalytic Psychotherapist, based in Twickenham, United Kingdom.

With a commitment to mental health, Mr Renn provides services in English, including Psychoanalysis.

Mr Renn has expertise in Abuse (Emotional / Physical), Anger Management Issues, Anxiety Disorderss (Panic), Anxiety Disorders (Phobias), Attachment Issues, Behavioural and Emotional Problems, Bereavement and Loss, Depression, Dissociative Difficulty and Divorce and/or Separation.

Click here to schedule a session with Mr Renn.

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