David Mittleman presents an interesting dilemma regarding the possibilities
of treating a 17 year old man who is incarcerated for his participation in a
violent crime. Dr. Mittleman emphasizes the complexities of frame
(coordination with RTC, confidentiality, trust, control versus treatment,
etc.) but I am equally struck by the complexities inherent in psychoanalytic
treatment of patients with significant sociopathy. Of course these issues
overlap.

I would want to carefully evaluate this young man with respect to his
capacity for forming a relationship that is not exploitative, deceitful or
manipulative. I would be concerned about his own motivations for treatment
(apart from compliant one). Although the questions of frame might be
significant ones, I would rather use them to establish clearly that a
therapeutic exploration of anger does not include any vindication of violent
behavior. I am reminded especially of Winicott's brief paper on the
Antisocial Personality where he emphasized that when there is hope of
rescuing such young persons from a life of crime it consists of equal parts
compassion and containment. So I wonder not only how to provide compassion
while this young man is still contained but how to provide containment once
he is released.

Dr. Mittleman's thought that perhaps an evaluation now followed by treatment
when this young man is released (should the evaluation suggest that
psychoanalytic treament is appropriate) makes sense to me. Perhaps in the
interim they could meet a few times to help establish an alliance for future
work.

An interesting problem.....


Paul Hamburg M.D.
Harvard Medical School

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