The mediating role of reflective functioning and general psychopathology in the relationship between childhood conduct disorder and adult aggression among offenders.

BACKGROUND: The nature of the pathway from conduct disorder (CD) in adolescence to antisocial behavior in adulthood has been debated and the role of certain mediators remains unclear. One perspective is that CD forms part of a general psychopathology dimension, playing a central role in the developmental trajectory. Impairment in reflective functioning (RF), i.e., the capacity to understand one's own and others' mental states, may relate to CD, psychopathology, and aggression. Here, we characterized the structure of psychopathology in adult male-offenders and its role, along with RF, in mediating the relationship between CD in their adolescence and current aggression. METHODS: A secondary analysis of pre-treatment data from 313 probation-supervised offenders was conducted, and measures of CD symptoms, general and specific psychopathology factors, RF, and aggression were evaluated through clinical interviews and questionnaires. RESULTS: Confirmatory factor analyses indicated that a bifactor model best fitted the sample's psychopathology structure, including a general psychopathology factor (p factor) and five specific factors: internalizing, disinhibition, detachment, antagonism, and psychoticism. The structure of RF was fitted to the data using a one-factor model. According to our mediation model, CD significantly predicted the p factor, which was positively linked to RF impairments, resulting in increased aggression. CONCLUSIONS: These findings highlight the critical role of a transdiagnostic approach provided by RF and general psychopathology in explaining the link between CD and aggression. Furthermore, they underscore the potential utility of treatments focusing on RF, such as mentalization-based treatment, in mitigating aggression in offenders with diverse psychopathologies.

Parity of esteem within the biopsychosocial model: is psychiatry still a psychological profession?

In recent years, the Royal College of Psychiatrists has been engaged in activities to ensure parity of esteem for mental health within the National Health Service, seeking to bring resources and services more in line with those available for physical health conditions. Central to this has been the promotion of psychiatry as a profession that takes a biopsychosocial approach, considering all aspects of the patient's presentation and history in the understanding and treatment of mental disorders. However, there has been a drift away from considering the psychological aspects of the patient's difficulties in recent years. This potentially has profoundly negative consequences for clinical care, training, workforce retention and the perception of our identity as psychiatrists by our colleagues, our patients and the general public. This editorial describes this issue, considers its causes and suggests potential remedies. It arises from an overarching strategy originating in the Royal College of Psychiatrists Medical Psychotherapy Faculty to ensure parity of esteem for the psychological within the biopsychosocial model.

Views on psychotherapy research among members of the Medical Psychotherapy Faculty of the Royal College of Psychiatrists.

AIMS AND METHOD: Research drives innovation and improved practice in psychotherapy. We describe views of members of the Faculty of Medical Psychotherapy of the Royal College of Psychiatrists (RCPsych) regarding their knowledge, experience and perspectives on psychotherapy research. We sent questionnaires to the Faculty membership emailing list. RESULTS: In total, 172 psychiatrists from all levels of training returned fully complete responses. Respondents considered knowledge of psychotherapy research to be important to clinical work. Many have qualifications and experience in research but lack current opportunities for research involvement and would welcome the Faculty doing more to promote psychotherapy research. Perceived obstacles to research involvement included lack of competence, competing demands and wider organisational factors. CLINICAL IMPLICATIONS: The lack of research opportunities for medical psychotherapists may lead to their underrepresentation in psychotherapy research and a less medically informed research agenda. Providing support at academic, RCPsych and National Health Service organisational levels will allow more clinically relevant research not only in psychotherapy but in other psychiatric disciplines as well.

The search for tailored treatments: Discussion of five interventions for perpetrators of intimate partner violence.

This commentary on five articles comprising this Journal of Clinical Psychology: In Session issue on therapeutic interventions for perpetrators of intimate partner violence (IPV) brings together relevant issues reflected in these papers concerning the need for tailored treatments for a heterogenous population of individuals with differing characteristics, psychopathology, risk factors and needs. Among the key issues addressed in this commentary are typologies of IPV, the influence of personality disorder and attachment in the predisposition to perpetrating IPV and identifying therapeutic factors common to these interventions. The discussion is contextualised within a field beset by controversy and political ideology which limits the impact of empirical research.

Treatment for perpetrators of intimate partner violence: What is the evidence?

Intimate partner violence (IPV) is recognized as a worldwide health issue that calls for urgent interventions to prevent the significant physical and mental harm it poses to the individuals involved and to reduce its wider deleterious impacts on society. Despite 40 years of research in the field, incidence rates of IPV have not significantly declined and treatment services for perpetrators of IPV are scarce. Empirical research has been hindered by ideological disputes, and the most commonly used treatment approaches-the feminist-oriented Duluth approach and cognitive-behavioral treatments-lack evidence for their efficacy. This introduction to this issue of In Session reviews these ideological controversies and the current state of empirical evidence for the treatment of perpetrators of IPV; and summarizes the five papers, commissioned from different countries in Europe, North America, and Africa, comprising this issue, each of which presents a novel therapeutic intervention for this heterogeneous population.

Mentalization for Offending Adult Males (MOAM): study protocol for a randomized controlled trial to evaluate mentalization-based treatment for antisocial personality disorder in male offenders on community probation.

BACKGROUND: Antisocial personality disorder (ASPD), although associated with very significant health and social burden, is an under-researched mental disorder for which clinically effective and cost-effective treatment methods are urgently needed. No intervention has been established for prevention or as the treatment of choice for this disorder. Mentalization-based treatment (MBT) is a psychotherapeutic treatment that has shown some promising preliminary results for reducing personality disorder symptomatology by specifically targeting the ability to recognize and understand the mental states of oneself and others, an ability that is compromised in people with ASPD. This paper describes the protocol of a multi-site RCT designed to test the effectiveness and cost-effectiveness of MBT for reducing aggression and alleviating the wider symptoms of ASPD in male offenders subject to probation supervision who fulfil diagnostic criteria for ASPD. METHODS: Three hundred and two participants recruited from a pool of offenders subject to statutory supervision by the National Probation Service at 13 sites across the UK will be randomized on a 1:1 basis to 12 months of probation plus MBT or standard probation as usual, with follow-up to 24 months post-randomization. The primary outcome is frequency of aggressive antisocial behaviour as assessed by the Overt Aggression Scale - Modified. Secondary outcomes include violence, offending rates, alcohol use, drug use, mental health status, quality of life, and total service use costs. Data will be gathered from police and criminal justice databases, NHS record linkage, and interviews and self-report measures administered to participants. Primary analysis will be on an intent-to-treat basis; per-protocol analysis will be undertaken as secondary analysis. The primary outcome will be analysed using hierarchical mixed-effects linear regression. Secondary outcomes will be analysed using mixed-effects linear regression, mixed-effects logistic regression, and mixed-effects Poisson models for secondary outcomes depending on whether the outcome is continuous, binary, or count data. A cost-effectiveness and cost-utility analysis will be undertaken. DISCUSSION: This definitive, national, multi-site trial is of sufficient size to evaluate MBT to inform policymakers, service commissioners, clinicians, and service users about its potential to treat offenders with ASPD and the likely impact on the population at risk. TRIAL REGISTRATION: ISRCTN 32309003 . Registered on 8 April 2016.

Shame, culture and mental health.

BACKGROUND: Shame is a powerful negative emotion, associated with many mental disorders, both as an aetiological factor and as a consequence affecting symptoms, psychological defences and therapeutic outcomes. AIM: To summarise some of the findings to date regarding cultural influences on the role of shame within mental disorders. METHODS: This lecture explores the concept of shame and its impact on mental disorders from a transcultural perspective. RESULTS: Although there has been growing interest in recent years in the role of shame in mental disorders, there has been little research examining the links between shame, mental health and culture. Guilt and shame are often used interchangeably, but there are differences in their respective meanings in different cultures. CONCLUSIONS: Addressing patients' experiences of shame is an important part of the culturally competent treatment of mental disorders.

Psychoanalysis in modern mental health practice.

Like any discipline, psychoanalysis has evolved considerably since its inception by Freud over a century ago, and a multitude of different psychoanalytic traditions and schools of theory and practice now exist. However, some of Freud's original ideas, such as the dynamic unconscious, a developmental approach, defence mechanisms, and transference and countertransference remain essential tenets of psychoanalytic thinking to this day. This Review outlines several areas within modern mental health practice in which contemporary adaptations and applications of these psychoanalytic concepts might offer helpful insights and improvements in patient care and management, and concludes with an overview of evidence-based psychoanalytically informed treatments and the links between psychoanalysis, attachment research, and neuroscience.

Mind the baby: The role of the nanny in infant observation.

The influence of nannies and other significant caregivers on a child's psychological and emotional development may be profound and if unrecognized may contribute to psychopathology in adulthood. However, the significance of the nanny has been relatively neglected within the psychoanalytic literature. In this paper I will discuss the impact of early caregivers other than the biological mother on the psychic development of the child, and the role of the nanny within the family dynamics as a figure attracting powerful unconscious phantasies and unwanted projections. These ideas will be illustrated by a detailed account of a year-long observation of an infant who had a succession of several different nannies in her first three months before her parents employed a more permanent nanny. It is proposed that the baby's emerging attachments to her two primary caregivers, mother and nanny, developed in parallel and influenced each other, with observable impact on her behaviour and developing personality. The paper concludes with a review of the place of infant observation within psychoanalytic training and how the experience of witnessing the earliest infant-caregiver relationships in an extra-analytic setting both refines understanding of developmental theory and builds a foundation for psychoanalytic practice.

Psychiatry, subjectivity and emotion - deepening the medical model.

Morale among psychiatrists continues to be seriously challenged in the face of recruitment difficulties, unfilled posts, diagnostic controversies, service reconfigurations and public criticism of psychiatric care, in addition to other difficulties. In this article, we argue that the positivist paradigm that continues to dominate British psychiatry has led to an undervaluing of subjectivity and of the role of emotions within psychiatric training and practice. Reintegrating the subjective perspective and promoting emotional awareness and reflection may go some way towards restoring faith in the psychiatric specialty.

The violent true believer as a "lone wolf" - psychoanalytic perspectives on terrorism.

The existing research on lone wolf terrorists and case experience are reviewed and interpreted through the lens of psychoanalytic theory. A number of characteristics of the lone wolf are enumerated: a personal grievance and moral outrage; the framing of an ideology; failure to affiliate with an extremist group; dependence on a virtual community found on the Internet; the thwarting of occupational goals; radicalization fueled by changes in thinking and emotion - including cognitive rigidity, clandestine excitement, contempt, and disgust - regardless of the particular ideology; the failure of sexual pair bonding and the sexualization of violence; the nexus of psychopathology and ideology; greater creativity and innovation than terrorist groups; and predatory violence sanctioned by moral (superego) authority. A concluding psychoanalytic formulation is offered.

Seeing, mirroring, desiring: the impact of the analyst's pregnant body on the patient's body image.

The paper explores the impact of the analyst's pregnant body on the course of two analyses, a young man, and a young woman, specifically focusing on how each patient's visual perception and affective experience of being with the analyst's pregnant body affected their own body image and subjective experience of their body. The pre-verbal or 'subsymbolic' material evoked in the analyses contributed to a greater understanding of the patients' developmental experiences in infancy and adolescence, which had resulted in both carrying a profoundly distorted body image into adulthood. The analyst's pregnancy offered a therapeutic window in which a shift in the patient's body image could be initiated. Clinical material is presented in detail with reference to the psychoanalytic literature on the pregnant analyst, and that of the development of the body image, particularly focusing on the role of visual communication and the face. The author proposes a theory of psychic change, drawing on Bucci's multiple code theory, in which the patients' unconscious or 'subsymbolic' awareness of her pregnancy, which were manifest in their bodily responses, feeling states and dreams, as well as in the analyst s countertransference, could gradually be verbalized and understood within the transference. Thus visual perception, or 'external seeing', could gradually become 'internal seeing', or insight into unconscious phantasies, leading to a shift in the patients internal object world towards a less persecutory state and more realistic appraisal of their body image.

Locks, keys, and security of mind: psychodynamic approaches to forensic psychiatry.

In this article, we discuss psychological approaches to the understanding of acts of violence and, specifically, psychodynamic approaches to both formulation and treatment. We suggest that the key theoretical paradigm of a psychodynamic approach involves the exploration and elaboration of the meaning of a violent act for the offender and describe the relevance of this approach for both legal assessments and clinical services in secure residential care. We argue that a psychodynamic approach can improve the quality of assessments of both psychopathology and risk and inform effective therapeutic interventions in hard-to-treat patients.