ABSTRACT
Rob Hale is a psychiatrist and psychoanalyst who works at the Portman Clinic. He has many years’ experience of consulting to medium-and high-secure units. He was the medical member of the Buchanan Homicide Enquiry. This chapter, which emerged from clinical discussions with Raj Dhar, is based on these experiences.
Hale’s chapter focuses on a type of patient who is typically given a triple diagnosis—schizophrenia, drug and/or alcohol addiction, and personality disorder. Hale suggests that it is more useful to consider these categories as a single entity. The underlying cause is a breakdown of the mother–infant relationship, followed by disruptions of care and often abuse. This leads to an underlying psychotic state from which there is no real progression and to which the person will always be vulnerable. In the people on whom Hale focuses here, the defences employed against this are psychopathy and drug and alcohol addiction.
Hale suggests that people like this turn early to drugs and alcohol as self-medication. He suggests that cannabis is the most dangerous. With continuous use and progression to a stronger form of the drug, 110 the ego boundaries dissolve, the psychopathic defences break down, and an active paranoid state emerges. It is in this state of mind that violence potentially occurs.
This model has implications for the type of services that are best placed to meet these patients’ needs and also identifies the window of opportunity in which therapy can take place. For treatment to be effective, it may be necessary to remove the patient from the corrupt psychopathic or drug culture that sometimes prevails on secure wards. These can be compared to the pathological organizations described by Marion Bower in chapter three.
Hale’s chapter has implications for the way in which diagnosis is approached in forensic services, but the significance of his ideas goes beyond diagnosis: in considering the interrelatedness of these apparently different types of pathology, substance misuse, personality disorder, and psychosis, Hale brings a psychoanalytic perspective to this issue, inviting us to think about the whole person with his or her developmental history and defensive structures.
