This book is a collection of clinical papers on the treatment of patients who have acted violently against others or, in attempting to end their own lives, have acted violently against themselves. This is one of the comparatively few books that contribute to the psychoanalytic literature on the treatment of violence. Repeatedly, it is made clear that this is about ACTUAL physical violence (or its threat) in or out of the clinical situation.
The editor, an analyst of the British Psychoanalytical Society, begins with a comprehensive review on the literature relevant to the subject and this provides an excellent starting point for anyone wishing to look further and in detail into particular aspects of the main theme of the book. Aggression and the controversies that surround the understanding of its nature, origins and manifestations are looked into from different and various perspectives. She also introduces each of the chapters and weaves a unifying threat in such a way that one can get a sense of coherence to the collection despite the different clinical style and thinking of each of its contributors.
Each chapter discusses clinical material in a clear and vivid way and does not for a moment fail to convey what it was like for each of the analysts to be in the room with their patient and the difficulties they encountered. The clinical material discussed illustrates the main three themes that the authors agree on and put forward as features that are present in their work with violent and suicidal patients.
The first is the idea that, in common with most borderline patients, there is a failure to mentalise the self's own or the object's mental states. That is, to internalise a function that will enable the subject to deal with mental states (needs, desires, sensations etc). This function needs to be developed from an early age and in the relationship with the maternal object when the child seeks in his primary object the possibility of getting a representation of his own states of mind. One of the relevant consequences of the failure in the development of this function is that it may leave the child with only the possibility of experiencing his states of mind as body states and processes that need to be evacuated (discharged). This formulation may offer a particular explanation for why the violent response and not another kind may be the recourse of some borderline patients. For instance, in the words of one of Fonagy and Target's patients: "If I kill you, I won't have to think about what you think" (page 55). The violent act thus becomes an attempt "to attack thoughts in oneself or the other" (ibid). All the authors to a large extent seem to coincide in thinking that the violent act, be it against an external or internal object (as in the case of attempted suicide), is a fragile, desperate attempt to maintain a certain degree of [precarious] life in the self and it offers aa delusional sense of safety.
One of the corollaries of the failure to mentalise is that it institutes a particular kind of internal object relationship - more specifically with the maternal object - that is typified, alternatively, by a fear of engulfment or abandonment. Most of the authors use Glasser's 'core complex' to describe the nature of these ties. If the patient is understood, he may feel engulfed and if not understood, he may feel abandoned, rejected or criticised, mirroring in that way the characteristics of their earlier experience of their ties to the maternal object. A sado-masochistic object relationship (usually between ego and superego) gets established to 'modulate' between these two extreme sets of experience.
All the authors coincide in saying that the problems that arise from the core complex (and this would be the second main unifying theme of the book) call for the presence of the paternal figure as one that will either serve as an alternative or draw the child away froma traumatising situation. The role of the father (the 'third') in the case of these patients becomes crucial. The authors coincide in illustrating how there have been serious problems with the father's 'presence'. In the treatment situation, this presents particular problems. The possibility of finding a third position from where to be able to reflect on what is going on with the patient becomes very difficult as the patient will tend to draw the analyst into a 'safe' sado-masochistic exchange that masks the patient's predicament.
The third main idea, described by Perelberg herself as central to patients prone to acts of violence, is the existence of a core phantasy that conceives the primal scene as one where there is no father but mother and patient engaged in a violent intercourse.
In having done the injustice of schematising the three main ideas of this book encountered by this reader, I hope I have conveyed that this book constitutes an important contribution to the understanding of those patients that engage in violent acts. I felt the need for further elucidation on the difference between an actual suicidal act and a violent attack against another. The book offers a contribution for all those that are engaged in clinical work with violent and suicidal patients. As a bonus, most of the patients described in this book are young adults and in the clincal descriptions one can perceive those specific developmental aspects of the transition from adolescence to adulthood that bear an influence on this kind of psychopatholgy. However, the ideas presented can be of great value to anyone working with these often worrying, if not frightening, individuals.