Therapy for adolescents in detention for violent crime

by Arnaldo Novelletto e Gianluigi Monniello

The psychotherapeutic treatment of adolescents being detained for violent crimes may be based on psychoanalytical theory and technique, but it obviously cannot be called psychoanalytical treatment proper. For one thing, it is carried out in a highly peculiar setting, namely a juvenile prison. Our experiences can be related to those of Balier (1988) at the Varces prison in France and of Williams (1983) at Wormwood Scrubs in the United Kingdom.
This article springs from clinical consulting by both authors, at different times, for the Rome Children's Court and from exchanges of views that ensued. The thesis that led us to offer this contribution is that there are substantial links between certain crimes of violence committed by adolescents who cannot be considered as clinically psychotic and a mode of psychic functioning that directly evokes the concept of breakdown.
Frequently, we find, this psychic functioning is decisive in the genesis of the crime but is not such as to preclude or seriously impair the subject's possession of his mental faculties, which under Italian law is the requirement for a penal indictment of adults (aged 18 and over).
However, this paper does not seek to address legal psychiatric problems as such. Rather, we are interested in finding the best way to provide psychological assistance to adolescents charged with or guilty of serious violent crime (murder, attempted murder, infanticide, assault for purposes of robbery or rape, etc.) both before the trial and after sentencing. Actually, we find that the judicial process in which the adolescent is caught up may offer opportunities for change and growth. If appropriately seized on by a good adolescent therapist, these occasions can be helpful to the subject's future psychic maturation, quite independently of developments on the penal and juridical front.
Here, we describe the cases of two boys. In the first, therapy was conducted for about six months during the period of pre-trial detention. In the second, it lasted for about a eighteen months.


From what he told the judge, it seems that one day Mario (17-' years old) went to see a football game. At the entrance to the stadium, together with some other boys, he started asking passers-by for money for the ticket (a common practice in Italy). One of the others was Antonio, a former schoolmate. The two received a bill from a passer-by and should have shared it, but Mario refused and, after getting his share of the rest, told Antonio to go away. A fight began, but the other boys broke it up. When they separated, Mario warned Antonio that he would "fix him later".
Mario attended the game, and nothing else happened. The next day he stayed home with his mother. "I joked around with her, like I hadn't done for a long time". Then in the afternoon, without telling anybody, he took his father's hunting knife, went to Antonio's house, and asked him to come down and have a talk. Antonio came with his younger brother, and Mario had a friend of his own along. The two started to talk but soon started fighting. Mario took a hard punch on the ear and got so angry "I no longer knew what I was doing". He got out the knife and stabbed Antonio several times; luckily the wounds were not too serious.
When he realized he had blood on his hands he broke off fighting and ran away, waving the knife in the air. Witnesses say he was screaming "I'll kill you all! I swear on my mother's dead body that I'll kill you all!" In a few minutes he calmed down and when the police came to take him away he went peaceably.
Additional information was obtained by the prison social worker. His family is composed of father (a mason, aged 47), mother (housewife, aged 41), and a younger brother (aged 14). Only the father works. Their apartment is very small; no one has a room of his own.
Mario's mother comes from a large family (5 brothers and sisters) and had a twin sister who died at six months. She left school after 5th grade; before marriage she worked at a factory job, but her husband did not want her to continue. She is often depressed, and a year earlier she was hospitalized for a time for that reason.
Mario's father attended school only up to 3rd grade. His mother died when he was five, and he was brought up by his older sisters and brothers. He feels he is a hard worker and prides himself on his ability to raise a family on just his own labour.
For Mario, pregnancy and birth were regular. His mother was very proud and called the unborn boy "my great man". Breast feeding was extremely difficult; it turned out that her milk ducts were atrophied. Mario's sleep-waking rhythm was irregular. He was an extremely active boy and often had accidents, twice fairly serious ones.
He suffered recurrent otitis, diagnosed at age 8. Apparently at that time the doctor reproached Mario's mother for not having noticed it earlier, and she became very anxious over Mario's health.
His parents describe him as a very lively boy until puberty, when he grew more reserved and distant. He was also sensitive to the family's problems and tried to do something to help. At first he was extremely jealous of his brother, but now they seem to team up.
He dropped out of school, even though he had done quite well, because he had problems with a teacher. He was ashamed of his father's occupation and tried, unsuccessfully, to find some other kind of work. He spent a lot of time at home reading, mainly encyclopedias.
The therapeutic experience with Mario took place in a juvenile detention center. Therapeutic intervention was requested within three weeks of incarceration because of Mario's isolation, refusal of food, suicide threats, sudden aggressive acts, inability to fall asleep and early waking, and physical disturbances such as itching and eczema. The boy always asked for drugs.


At the first meeting Mario walks in slowly, crouching slightly. He is a sturdy young man with a suspicious gaze. His words are precise and appropriate.
He says he's feeling down because of what he has done, as he has given his parents another, and ultimate, disappointment. "They will never forgive me."
He has always hated blood. He dislikes prison above all for the lack of privacy. He says he is ashamed when he washes or goes to the bathroom. "I am very fastidious. I have refused some job offers because I don't like to get dirty. I always have to feel clean." He does not complain about his confinement because he thinks it is just.
He seems relieved when we agree on meeting once a week. From the start he makes me feel very important for him. "I'm in your hands. Everything depends on you." He asks about my work, saying he knows something about psychology from the encyclopedia. He is proud of his cultural interests and learning and says, grandiosely, "I could make a lot of money if I went on a quiz show."
His criminal act is invariably described as the inevitable outcome of Antonio's behavior: "I couldn't be a coward, I had to discharge a weight. And, then, he hit me on the ear, and I've always had trouble with my ears."
Gradually, however, the focus of the therapy shifts to his psychic pathology. In the boy's telling of it, the crime becomes enormously grave. He asks about Paula Cooper and the death sentence on her. He is tormented by the idea that if he lived in the U.S. he might risk the death sentence. He says, "I feel I am in a dark tunnel. I think it is death row." He complains of being unable to sleep and lying awake at night. His feelings of sadness and depression are mainly related to what his parents think of him rather than to the crime itself.
He says he fears retaliation by Antonio (he is afraid of leaving prison too soon), adding "When I am in my room, in the dark, I am afraid someone is there. I keep checking every corner. And my mother says I have no sense of danger!"
The fears he experiences in fantasy are a way of evoking his inner objects, alive and present, which he gradually brings to the therapeutic situation. He says "Lately I was often at home. My mother nagged me because I didn't have a job and didn't go to school. I felt terribly ashamed. My parents have always been proud that I did well in school; my problems began when I dropped out."
"My mother was a beautiful woman. Now she is skinny, almost flat-chested. It all started with my breast feeding. I cried and Mamma felt bad. She couldn't feed me because the milk didn't come out of her nipple. My Grandma had the same difficulty, so that my aunt, my mother's twin sister, died when she was six months old from drinking infected milk. When I was a baby I was terrible. I would eat only certain types of food, I didn't sleep at night. My brother is a quiet type, although he was bottle fed too.
"PapÖ is always at work; he comes home dirty and dead tired. When I see him in that state I get really angry, and sometimes I tell him so. But PapÖ is proud and doesn't want anyone's help. When he gets home he just goes to bed and sleeps. By temperament he's too easy-going. He told me that when he was in the army his mates wet his bed, but he didn't do anything about it, even though when he was young he was good with his fists. Often, when he was asleep, I would take his car keys and go out driving around. Then I'd put them back in their place and he never noticed; but once I had an accident. He did not get very angry, but he didn't speak to me for nearly a month."

Once I am unable to go to the detention center for our session, and Mario isn't told until the last minute. The next time we meet, the contents of his account are quite different. He says he doesn't want his relatives to attend the trial.
"If Antonio comes, he will have to be careful what he says. My uncle knows karate and has been in jail. He's not afraid of anything or anybody."
I relate his tension to the fact that the date for the trial has been set, but also to my absence at a moment when he probably felt the need to tell me about the trial. He responds that in his last talk with his parents, once the trial date was set, they talked mainly about the difficulties of an uncle of his who is a drug addict.
I tell him it must have been hard for him to feel that he represented such a problem for his parents as to force them to talk about that instead of about himself and his worries. "I often went to Mamma and wanted to talk about myself. But I just ended up asking her for a little money. At night PapÖ was always too tired."
When he is denied parole, he says "Well, now my room is really clean. But I can't stand my roommate Bruno. He always wants to watch porno films on TV so he can masturbate. He is not ashamed. I turn away, but one of these days I'll give him a good thrashing. I loathe him. Masturbation is good until you're 16. I haven't masturbated for a long time. At home I used to do it in the bathroom, so no one could see me. Well, I'm really telling you everything, aren't I!"
As the trial draws near, he tells me his first dream. "This dream woke me up. I was riding a motorcycle with Bruno and maybe Sergio [two fellow inmates]. One of them was surely Bruno. We wore helmets. We went into a supermarket with guns. I was a robbery. Policemen came and started shooting. One policeman died, then the three of us died one after another. I was the second to die, Bruno was the last, I am sure. We have become friends in jail. Everybody here seems to think Bruno is stupid, and so did I at the beginning. But now I protect him. Last night I talked a lot with him. I don't know if I am an introvert or an extrovert. I don't quite get the meaning of these words. I even looked them up in the dictionary. What do you think I am? In a way I am like my father. My problem is that I don't think before acting. I realize it only after I have done somnething. But when you have done something, it is not like writing with a pencil. You can't erase it."
Six months after the beginning of treatment, at the last session before the trial, Mario comes in a bit late and apologizes, saying he needed time to get ready. His voice is calm and relaxed. "I washed and shaved. Tomorrow is an important day: I decided how to dress."
I think that his making me wait is an attempt to control actions, and I tell him that although he is very scared of the outcome of the trial, he has managed to find relief by getting ready and imagining what will happen.
"I used not to think about it, but now I use external signs to get clues on how the trial will go. In my room I have a puppet: it's an acrobat turning around on a string. I often ask it how things will go by giving it a turn. If it stops showing me its back, my day will be bad; otherwise, I feel relieved. I have always been superstitious. Mamma has a book where you can find the explanation of dreams, what lottery numbers they correspond to."
I think Mario's attention to the external environment and to my reactions in the transference situation is the expression of his effort to test the existence and strength of coherent cores of the self and their relationship with self-objects. I tell him that now he has found some ways to calm down, that now he can face uncertain and difficult moments. Then I ask him how he feels with me today.
"This morning I woke up earlier than usual. I thought about everything. I think I am clever in some things, but sometimes I simply don't think. And then it's as if I were stupid. Before acting, I should think, but I can't because I'm nervous, like everybody else at home. I didn't like Antonio, he was part of it, but I should have stopped. There were no serious motives.
"This morning I awoke suddenly. I was dreaming I was in a room with the judge, we were sitting facing each other. He was neatly dressed, but I don't recall his face. He leafed through a large book slowly and carefully. Then he said my name and sentenced me to three years in jail. That wouldn't be so wrong. Bruno killed someone and got six years. The book was very similar to my mother's book."
With reference to the dream, I tell Mario that he has been able to wait for the trial, that he is preparing himself in fantasy, so that he will be able to accept punishment, at least partially. I also talk about his ability to face adults and to judge himself.
This dream is an important moment in the therapy, as thanks to the therapeutic relationship to a self-object Mario moves to a less persecutory position.


Reconstructing the story of Mario from the start, we can see that the mother-child relationship began abnormally owing to the coexistence of two conflicting conditions. On the one hand there was a narcissistic overinvestment in the child ("my great man") and on the other a malformation of the mammary ducts, accompanied by doubly negative phantasms: the hereditary defect and the death it may bring (the mother's twin sister).
Thus death made its entry, at the fantasy level, in the mother-son relationship. It would mark Mario's psychic development profoundly, and the boy would find it possible to distinguish between constructive aggressiveness and destructive violence. He was always trying to cope with a destructiveness That lacked all possibilty of modulation, leading from rage to death as the almost automatic consequence. The archaic nature of this aggressiveness is clearly evident in Mario's fury immediately after the attack when he swears on his mother's "dead body" to "kill them all". And it returns later as well, as the sense of guilt that haunts him when he thinks he is "on death row". This expression inevitably calls to mind an embrace, a mortal holding fueled by a circular, symbiotic relationship. And in recounting his breast feeding, Mario says "I cried and Mamma felt bad."
The mother's failure, years later, to notice her son's otitis shows that the narcissistic circuit was still preventing her from recognizing him as an object detached from herself. This is the mother-son relationship typical of the borderline case, as in the adolescents described by Masterson (Masterson, 1971; Masterson and Rinsley, 1975) and applied to juvenile delinquents by Marohn et al. (1980).
The oedipal conflict, both when it first arises and upon its post-puberal reenactment, is the acid test that can throw the narcissistic structure of the self into crisis. Crisis may be manifested in the most variegated ways and behaviors; what they have in common, at the profound level, is fragmentation of the self (and, hence, of objects), regression, scission of parts of the self and of the ego, with an obvious maladjustment to external reality.
In the case of Mario, such a collapse of self during the early childhood oedipal phase can only be presumed indirectly, insofar as the brief term of therapy and the subject's limited capacity for introspection made more thorough exploration of that crucial period impossible. The strongest evidence is his early nervousness, his poorly idealized "dirty and dead tired" father figure, and his accident proneness, presumably the product of self-agressiveness resulting from a sense of guilt.
The adolescent revival of the oedipal conflict generated unmistakable signs of a disorganization of the self: dropping out of school, maladjustment vis-Ö-vis work, isolation and introversion, attacks against his father (secret joy-riding), megalomaniacal traits, the emotional reactions following his criminal act and his extremely primitive, almost delirious sense of guilt.
Even the determinants of the assault would appear to be deeply imbued with oedipal-linked feelings. We refer in particular to the incident outside the stadium, i.e. the sharing of an object (the banknote) that both Mario and Antonio wanted.
Antonio had stayed in school and succeeded in getting things Mario had not (friends, a motorbike, girls, and so on). In a word, he was a good, well-behaved teenager, and socially integrated; an aggressive clash with him might well signify competing, going up against a solid, self-assured person unconsciously representing an oedipal object, a substitute for the father.
Equally oedipal is Mario's account of the time spent with his mother before the assault, although here we also see the whole passive side of the conflict, what Laufer calls the "surrender of the sexual body to the mother".
Fragility of the self and the merging with the mother typical of the narcissistic personality structure predispose the subject to an inevitably passive, losing solution to the oedipal conflict. Mario's passive, fragile side emerges in the detail of the punch on the ear. True, through his history of otitis Mario is still objectively branded by his relation of merging with his mother. But it is also true that from time immemorial the word "orecchione" [mumps, big ear] and the gesture of touching someone's ear have carried a homosexual allusion. The subject's mother identification inevitably falls on the narcissistic wound of the perceived blockage of instinctual development, immediately prompting the fantasy of proving himself a man, i.e slayer of the father.
In Laufer's view, the blocked development of the adolescent may take essentially two forms: deadlock, a no-exit conflict over the sexual image of the self; or foreclosure, a premature blockage that precludes achievement of the normal steps in development.
Mario's condition certainly more closely resembles deadlock; he sought to force the block by translating his fantasy into a concrete action. Consequently, the criminal episode itself can be held to be the equivalent of a psychotic crisis, demonstrating the presence of "psychotic functioning" as described by Laufer. For when such functioning takes hold, then as in a delirium real objects take on the role of externalized persecutors, against which rage and destructiveness are directed.
Thus the homicidal assault is an attempt -- a desperate one, to be sure -- to safeguard a self in the process of fragmentation, an attempt by the separated self to escape disaster.
Mario's implacable rage at Antonio expresses a primal need for self-assertion, sensed as necessary to growth; not, therefore, a simple reaction to feelings of impotence but the continuing, paradoxical hope for an empathetic response from the internal parental object, at that moment externalized.
The iron law governing the psychic economy of the narcissist, however, immediately inverts the destruction of the object into self-destruction. Whatever the actual, material outcome of the fight, the subject cannot but suffer enormous psychic damage in terms of destruction of his own existence. The inability to modulate destructive aggression precludes its circumscription to castration (of self or the other); instead, castration is confused with extermination.
The guilt and anxiety found in these subjects during pre-trial detention likewise bear the mark of this primitiveness, as is eloquently attested by Mario's robbery dream, in which extermination is the only possible outcome.
Quite a different inner psychic situation is manifest in the later dream of the judge. Here we observe the effects produced by the beneficial containment worked by detention and of an empathetic relationship with an object (the therapist) totally different from those Mario had around him until that moment. The manifest content of the dream turns on the modulation of guilt, but the earlier material supplied by Mario offers a glimpse, at deeper levels, of a latent message concerning the state of the self, the relations between inner needs, the level of thought, and the capacity for symbolization.
As an instrument for establishing correspondence between inner states and their external consequences, the penal code the judge leafs through has a fundamental meaning in relation to the divining methods of Mario's mother. It represents Mario's hopes of finding in the therapist a new sense of his life, a new interpretation of his actions, his feelings, his situation; one different from his mother's book of dreams, with its automatic connection of dreams to numbers or, in other words, its denial of the very possibility of understanding, interpretation, comprehension in favor of magical, automatic, inexplicable answers.
The relation between the judicial system and superstitious beliefs is also clear in Mario's association of his habit of making his little acrobat, with his tumbling, the arbiter of his fate. Now, however, he begins to discriminate, to discern what might really befall him ("They'll give me three years"). What is clear, in short, is his hesitant attempt at separation from an original maternal object that cannot be explored, known, modulated, where there is no possibility of negotiation but only an absolute answer: life or death. The acrobat's answer is that of chance, i.e. that of an omnicomprehensive and omnipotent mother figure.
At least in the unconscious, Mario is beginning to glimpse the possibility of discrimination, of an object relationship that is regulated, governed by rules. Also, we observe the transition to the reality principle by someone coming from the world of fantasy, magic and chance, where anything at all can happen. Life can turn instantly into death, there's nothing strange about that, it is the most natural thing in the world.
Reconstructing this boy's story and psychic structure in these terms, we can see just how close to psychosis it is, and how easily a borderline structure can suddenly erupt in an isolated psychotic act of criminal violence. But we also see that building a relationship, even over such a short period of time, may permit the beginnings of growth.


One winter afternoon Paolo (age 17) was at home in a small mountain village, with his mother, his grandmother and an aunt. The grandmother was sitting by the fireplace. Paolo thought she was leaning too close to the fire, that she might fall and burn herself, so he helped her change position. His aunt scolded him, and he got angry and sent her out of the house. His mother, in turn, reproached him, asking if he was crazy.
A little later, Paolo decided to clean his father's rifle, something he had done many times before but always in his father's presence. He went to the kitchen and picked up the cartridge belt. He loaded the rifle, thinking he had put it on safety. His grandmother told him to point the barrel up, just in case it went off. Paolo then pulled what he thought was the safety catch, but it was the trigger. The shot hit her right in the face.
When he saw her covered with blood, he felt a rage and began firing wildly around, hitting his mother in the shoulder. His vision went black then, and he no longer knew what was happening. He attacked his mother with a hunting knife. He went back to his room, took two more cartridge belts and hung them around his waist. He reloaded the rifle and, with his mother screaming, left the house and shot a passer-by (with no idea why), slightly wounding her. He kept firing into the ground, until two cousins got to him and took the rifle. When he saw his mother bleeding, he asked her who had wounded her. When his mother replied "You have killed me and Grandma", Paolo says, he felt his mind open up again. He came back to his senses and said "What are you telling me, Mamma? Are you crazy?" He went back home and found his grandmother dead. He called her repeatedly, then tried to reattach a flap of skin hanging from a face wound.

During pre-trial detention, Paolo had moments of all-destructive rage, fits of aggression against himself and his fellow inmates, and refused to take part in any recreational or social activities.

At the beginning of his course of weekly psychotherapy, Paolo appears self-assured. He asks me for an explanation of my professional activities and makes no effort to hide his skepticism about the usefulness of encounters with me. He says "What can you do with words? What have we got to say to one another? How long do we have to keep on meeting?"
He claims that he does not mind detention all that much and says he won the other inmates' respect right away with his fists. His story of himself is dominated by a magical-omnipotent type of thought and the grandiose self. "It all began with convulsive attacks that none of the doctors knew how to cure. In my home village all my friends respect me and I have a girlfriend waiting for me."
The version of the murder that he relates to me is extremely implausible, bordering on mythomania. Paolo stresses his ability to control his impulses. "It was an accident. I'm sure I had the rifle on safety. It fired for no reason, all of a sudden."
Gradually, however, his psychic pathology is taken as the reason for the therapy. Paolo expressly states his need to be contained and reassured in facing a situation that is too big for him. He complains of his difficulty in controlling impulsive reactions to the slightest comment from fellow inmates or staff. I sense that the "provocations" to which Paolo cannot help responding are those that stimulate his internal objects, which are alive and present; he evokes them from the very outset of treatment. He says, "I'll hit someone for the slightest insult mentioning my mother or my dead brother and sister. A terrible rage comes over me. Right away I feel like I'm going to faint, my vision gets cloudy, sometimes I fall to the ground. I mustn't get angry."
Of his father he says, "He never told me that he had once been a professional boxer. He would tell me to hit him in the stomach. I hurt my hands, and my father, hands held above his head, would say 'That's it? That's the best you can do?' I would go ahead, hitting him as hard as I could, but after a while he would shove me aside with a 'Sit down and stay put, or I'll smash you up against the wall.'"
"Now when he comes to see me he spends just about the whole time crying. I try to comfort him, I say I'm behaving myself, but he doesn't believe me. He's so sad. He doesn't go out in the evenings any more, he doesn't go to the bar. ... He used to stay there until late at night. I had to go and call him, plead with him to come back home, dragging him away when he was in a mood to fight with his mates."
"My parents got married when I was six. My father doesn't want my mother to leave the house alone, so he takes care of everything himself: shopping, errands."
Of his mother, Paolo says she "suffers from the same attacks I do. One night I heard a blood-curdling scream. I was terribly afraid. My father came to my room and asked me to help him. My mother was on the floor, immobile."
"My mother is the only person who ever beat me, from time to time. But I was raised by my grandparents, who treated me like a prince."
These first few references to his internal objects show the importance of Paolo's identification with his mother who suffered from epilepsy, like him. He recalls her convulsive fits with terror; they fill him with the deepest anguish.
The oedipal relationship clearly takes a negative form. The rivalry with his father is kept under control by continual declarations of admiration and the wish to be physically strong like him, but merging with the primary object is still the prevailing psychic attitude. We shall come back to this point later.
Paolo's self-image swings back and forth between a state in which he senses the internal presence of dead objects (the stillborn siblings Paolo has introjected) and a state marked by omnipotence and grandioseness, apparently molded by his grandparents' conduct with him.
As our sessions progress, this perception of the parental images is replaced by one that indicates the attainment of a certain emotional distancing, possible thanks to the exclusive relationship with the therapist. Now Paolo says, "My father, if someone suggests that he should do something, does the exact opposite. But if no one tells him anything, he's a good man. The other day I was really sad about Massimo [a fellow inmate] being convicted. My parents came to visit. First thing, my mother told me I shouldn't frequent my uncle, who had no respect for her. My father kept quiet in order not to have the usual fight with Mamma on this. I was paralyzed, but then I told myself 'What have I got to do with this?' I also wanted to tell my parents that there was going to be a party here, but then I thought better of it. I was afraid they wouldn't believe me if I told them I was content here, and anyway the party was only my concern."
The role of his grandmother also begins to come clearer. For Paolo, the image of his grandmother is a protective shield, a source of reassurance vis-Ö-vis his parents and the outside world. Weak, ill and dependent as she is, his grandmother is still an important object of identification. Paolo must have experienced some degree of psychic merging with her, which gave him the feeling of basic resemblance, and this, up to a point, was what sustained Paolo's fragile self. Moreover, this explains Paolo's tendency to identify with "fragile objects" as the only solution possible, so far, to the oedipal conflict.
He says, "Before, the only person I confided in was my grandmother. I spent a lot of time with her, we slept in the same room together, I tucked her in, and during the night I used to get up to get her a glass of water. When I would confide in her, she'd say 'Don't say anything to your father, or he'll get mad.'"
Now, however, Paolo recognizes himself as very lonely, fearful of leaving his home and too shy to approach girls.
The imaginary figures of his stillborn sister and brother (they died when Paolo was three and four years old) have a particular significance. "I've often thought that I could easily be with them. ... Before, if someone mentioned them, I'd get so angry I couldn't see. ... Sure, but how could the others know?" He has always forcefully defended small children, and even now, when he successfully takes their side, he says he has "found the light again".
Paolo displays a powerful tendency to act, to go into action when feelings of tension or anguish emerge. Yet his capacity to recognize his guilt, to sustain and develop a relationship hinging on feelings of sadness and desire for "redemption" suggest that therapy is possible.

After six months of treatment the risk of psychotic development, which had been a real threat at first, appeared to have been averted. The possibility of depression that had been observed testified to the presence of sufficiently cohesive nuclei of the self. Paolo's self-mutilating behavior during the initial period of detention, consisting mainly in wounds to his hands, indicated on the one hand the prevalence of a poor self-image and weak present object investment. On the other, however, it may also have represented an attempt to limit anguish and guilt to parts of the bodily self, and thus to prevent them from overflowing in suicidal directions or massive psychosomatic discharges like his initial convulsive attacks. In any event, this behavior indicated the great need, at that time, for positive contributions from outside, of good self and object images.
During this period Paolo related the following dream.
"I had another dream of the accident. This time I was just very angry. Aside from my aunt, Mamma and Grandma, an uncle of mine was also there. They all agreed to leave. My uncle didn't get angry; instead he said he understood my state of mind. 'Don't get mad, we're going,' he said. I was happy."
This dream indicates a first movement away from the merging in which Paolo was caught up, which had become persecutory, as during the murder itself, when all these female figures seemed to have coalesced against him. It was this state of persecution that Paolo was trying to escape, at the moment of breakdown, through his murderous acting out. Escape had now become possible thanks to the therapeutic relationship. I limited my interpretation to the emergence of a less primitive male identification and the simultaneous rise of hopes of restoring his confidence in the outside environment.

After twelve months of treatment Paolo's attitudes and his life in the detention center had changed greatly. He was working regularly at the crafts workshop, cultivating a small vegetable garden with pleasure and taking part in social life. He enjoyed a certain reputation, was considered an old-timer at the jail, or what army slang would call a "grandfather" with respect to new draftees. This revaluation of the "grandfather" figure, which in a sense Paolo could now impersonate in real life, seemed important. Now he could transform the weak, dependent part of the self that had developed through his identification with his grandparents into something powerful and authoritative. These internal objects thus acquired a new, positive meaning, reducing Paolo's narcissistic vulnerability and reinforcing his self-image.
Now his changes in mood were less sudden, less frequent. Fights and moments of rage were isolated episodes, and less intense. Paolo was taking good care of his room, which signified a greater investment in self. He was neat, clean, tidily dressed, and he was taking classes towards his junior high school diploma.
Thanks to the increased self-esteem that came from feeling appreciated and listened to, and the availability of the therapist as object of idealization and identification, the therapeutic relationship had permitted a reduction of his aggressive drives.
Paolo had also begun to bring the gravity of the events into the framework of his own responsibility. While right from the start he had said he was sorry, sad about the "accident", the quality of his sadness and a capacity to cope with depression with less massive use of archaic defense mechanisms (scission, idealization, omnipotence, denial) now indicated that a mourning process had certainly been initiated.
As for job plans, after a phase marked by mainly imitative identification with me and other prison personnel in which he said he would like to be an activity group leader or a guard, Paolo went back to his original desire to be an auto mechanic. The significance of this in terms of "reparation" is evident, but this choice also indicated that through therapy a healthy need for authentic self-assertion had re-emerged.
Towards the end, he would often remain silent during our sessions, saying he had no desire to say anything. "I was often alone before, too. Secretly I used to go up a hill near our village. Here, now, I openly say that I want to be alone. I no longer want to tell everybody, superficially, what happened to me. I feel that I can stay still and silent."
As his trial drew near, Paolo displayed a new need to "know" how things had really gone, demonstrating his continuing need to try himself, in fantasy, but at the same time to check his progress and be able to feel ready to face not only the judicial process but also his own inner process of growth.
He had an extremely significant dream. "I was together with a lot of my family, up before the judge. He read out a guilty verdict. Strangely, I didn't feel discouraged or agraid. Calmly I told the judge that he hadn't understood my feelings, what I really felt. I was taken to a room filled with light, but there weren't any bars on the windows or iron doors. In the room there was a women and two children. I felt a sense of satisfaction, and even though I knew of the sentence, I didn't feel convicted."
Obviously, such successful expression of one's own point of view embodies the hope not just of being understood but of being able to make oneself understood, , and thus demonstrates a more advanced object relationship.

After fifteen months of therapy, the trial is held. Paolo is convicted and sentenced to six-and-a-half years. He takes the sentence with composure, and later says "Everyone told me I behaved like a man."
In therapy, Paolo appears to bring the figure of the therapist and that of the judge together in fantasy, a clear attempt to attenuate the scission between good and bad objects. This enables him to contain his destructive attitudes while also indicating the activation of specific needs for idealization, which his identification with me now allows.
In seeking to reconstruct the story of Paolo, another of his dreams may be a useful starting point. "I was with two friends. We come to an old, tumble-down church. A custodian shows us in. The inside is empty, the church is abandoned. I find a drawer with a pen and a ring in it. I pick up the pen and at that moment everything begins to shake. I leave everything in the drawer. We run away. I find myself at a friend's house. We are met by his parents. They are nice. The offer me a room that I can have all to myself. In it there are two beds. I feel happy."
At the time of his homicidal incident, Paolo had reached a saturation level of anguish, threatening the collapse of his psychic structure. His efforts at emancipation had failed; his parents were dangerous objects, being incapable of bearing and raising children; his castration anxiety took on a tinge of persecution. Paolo, the sole surviving child, was born "very small, very small", he knows he is diseased, he has epileptic attacks. In short, he finds himself in Laufer's "deadlock", in which all possibilities of growth appear to be cut off.
The figure of his grandmother, which until that moment had served as a protective shield against the stimuli deriving from his dangerous parental images, was suddenly undone in that role. Thus the attempt to take up the rifle-pen-penis (that is, to gain an unquestioned masculine identity, integrating his sexual body into his self-image) provokes a breakdown, as the necessity of growth is so urgent that procrastination is no longer possible.
Before his murderous fit, in fact, Paolo's amorous investments were non-existent. "I was obsessed by the idea that I would turn all red and have an attack if I approached a girl." He was also terrified by the reactions that masturbation could produce, associating orgasm with a convulsive attack. These fears are evident in a recurrent dream of Paolo's during the early part of his detention. "A girl wants me to kiss her, she comes near me. Suddenly the earth starts to shake and I wake up in terror." Only towards the end did Paolo talk, with reserve, of his sexual desires and his masturbatory activity.
At the moment of the murder, then, Paolo acted out a fantasy of magical psychic growth in which killing his grandmother meant maniacally freeing himself from his infantile self-image and at the same time attacking the women-mothers who wanted to keep him tied down; this acting-out was modelled on the style of the omnipotent father.
The murder episode, in short, displays a "psychotic functioning". The destructiveness of the homicidal action comes subsequent to the indifferent, objectless discharge of aggression represented by his epileptic fits, which began two years earlier, but it also constitutes the transcendence of such discharge, in that it involves an external object. The homicidal action, in this interpretation, is the abandonment of a situation of what Masud Khan has called epileptic rupture of the self in favor of a desperate attempt to safeguard a self that was undergoing fragmentation.
Over the course of therapy, both Paolo's behavior in the sessions (making me wait for him) and his violent fights with other inmates more and more clearly suggested the possibility of controlling his actions. Moreover, his keen attention to my reactions and those of the external environment to his actions represented an effort to test the existence and the solidity of a separate self that had escaped the catastrophe and of its relationships with self-objects, as defined by Kohut.
The therapeutic relationship enabled Paolo to revisit his impulsive act both as a response to his recognition of his own extreme vulnerability and as a desperate way of seeking to grow and cope with the danger of total annihilation of self.
In these circumstances therapeutic technique relied very little on interpretation (which remained internal to the therapist's own psyche) and was deliberately based on self-object transference to encourage the development of narcissistic charges.
Paolo's personal history does not appear to reveal, in his childhood, affective deprivation severe enough to explain his frequent, intense aggressive reactions or his narcissistic vulnerability. Nevertheless, the murder itself and the other acts of violence can be read in the light of the episode in which Paolo punched his father in the stomach. Far from the acting-out of the oedipal conflict, what that situation expressed was the primal need for self-affirmation, sensed as necessary to growth. That is, the attack on the father in this case was not a reaction to a sense of impotence but continuing hopes in an empathetic response from an object whose function is to safeguard the integrity of the self. From this viewpoint we can more easily explain Paolo's surprise and satisfaction when he discovered that he was understood and accepted by the therapist.


This detailed account of these two cases, in our view, clearly shows that the psychopathology of these patients can be diagnosed as an "antisocial personality disorder". Yet they also display unmistakable traits of narcissistic pathology; these are more obvious in the case of Paolo, whose psychic organization has a number of evident borderline features.
Both patients displayed a clearly passive attitude towards the oedipal conflict being reenacted in the adolescent phase. Structural inconsistency of the self, archaic defense mechanisms and the impossibility of taking advantage of good object relationships induced both boys to seek to resolve unconscious conflicts by action rather than psychic elaboration. In both cases the high degree of narcissistic rage, weak instinctual fusion and the failure of ego integration explain the destructiveness of the aggressive drive. Conditions like these have led theorists of the death instinct to speak of a "death constellation" (Williams, 1983). Also, the unstable balance of object- and narcissistic cathexes accounts for the sudden reversal of aggressive discharge from its object back to the subject (a self-aggressive attitude for Paolo, a suicidal one for Mario).
Reviewing the psychoanalytic contributions to criminal psychology, beginning with Freud (1916 and 1925), we find that they all focus on the symbolic meaning of the criminal act, at the unconscious conflicts underlying it, and at the significance as acting-out that illegal behavior can assume with respect to a pre-existing relation.
Recent progress in the understanding of narcissistic pathology, however, has resulted in a fundamental shift in emphasis from the psychodynamics of the criminal act to the psycho-economic perspective. This helps us to detect and understand episodes of fragmentation of the self and the defenses the subject deploys to preserve or restore the cohesion and equilibrium of the self.
It is well known that adolescents with primitive narcissistic personality try to reconstitute a crumbling self by actively converting an injury into an assault, utilizing a familiar behavior pattern of destructiveness (Marohn, 1977, 1980). Yet there are cases in which violent destructive behavior is not associated with any well-defined thoughts, wishes, or fantasies. Such episodes appear not to be associated with any content, or psychodynamic meaning. While it may follow an experience that does have psychodynamic significance and ends in fragmentation, the rage-like behavior itself merely represents the disintegrated condition; in some instances it may represent an effort to reorganize the self by restoring its primacy.
This proposition suggested to one of the authors that sometimes, in acts of violent assault, of destructive discharge against his victim, the adolescent enacts a particular unconscious fantasy. These adolescents realize that their psychic growth is stymied and they fantasize overcoming this deadlock at a stroke, leaping the gap that separates them from the prized objective of a more adult status. This objective may be represented, for instance, by a more advanced phase of sexual development, by more direct investment in an extra-family object, or by more mature ego and superego functions. In any event, the magical act of violence is manifested in a way that corresponds to the features of omnipotent thought and the grandiose self. Violent behavior of spectacular self-assertion and a caricatured hypervirility or hyperfemininity often disclose symbolic details that betray the unconscious purpose underlying the act.
Notwithstanding the utter unacceptability of the attempt, it can be argued that in the acts provoked by such fantasies these adolescents reveal at least one legitimate wish: for psychological growth. And this is an element that no one interested in rehabilitating juvenile delinquents can afford to underestimate. This presumed fantasy has accordingly been labelled the "psychic growth fantasy" (Novelletto 1986, 1988).
We believe that when it can be verified in the adolescent criminal's transference on his therapist and received by the latter in his counter-transference, this fantasy can be helpful in establishing an empathetic relationship. Narcissistic rage cannot be treated directly. The therapist must address the empathic rupture that has taken place between the patient and his self-object, causing the destructive discharge. To do so the therapist himself must re-establish the empathetic relation with the adolescent and offer himself as self-object, a substitute for the originals.
In both cases, the period of post-arrest, pre-trial detention was crucial for evaluating the possibility of self-object transference on the therapist. This possibility, which can emerge only from a regular, continuous relation, is crucial both for diagnosis (assessment of self-cohesion, reality testing and preconscious functioning) and prognosis (evaluation of the possible change through the ongoing psychological relation). In both the cases discussed here, moreover, thanks to the cooperation of prison staff and the sound daily organization of the boys' lives, detention allowed the creation of a consistent therapeutic setting whose progressive internalization acted as a shield against external as well as inner stimuli.
From the therapeutic standpoint, we think that fror quite a long period of treatment the therapist absolutely must take account of these patients' demands for attention and recognition as signs of the reenactment of the grandiose self, in Kohut's sense. The principal therapeutic effect deriving from the transferal condition brought about by the enactment of the grandiose self is the possibility for the patient to reenact and maintain a process that can be worked through in which the analyst is used as a therapeutic "buffer". This allows the progressive harnessing of non-egosyntonic fantasies and narcissistic impulses. In other words, the key function of specular translation is to reproduce a condition that actively facilitates the spontaneous development of the patient's narcissistic cathexes towards an objectal type of choice.
A particular feature of our therapeutic approach in these cases was active association, for example between the patients' accounts of their serious antisocial acts and the related fantasy life. Associations were structured according to a set of theoretical assumptions that gradually made it possible to define, discuss and transform into narrative something that otherwise threatened to crystallize within the mind as a mere discharge of acts. This practice performed a function of external symbolization, which substituted for and was conceived as a support to the patients' own processes of symbolization. Both patients responded with an idealizing transference onto the therapist, which we considered as the re-emergence of parental omnipotence, a requisite for the child's feeling of safety in the presence of his parents. One sign of this phase was a series of sessions in which the patients were silent, declaring that they did not want to say anything. These were quiet moments, in which the therapists felt the boys did not want to be pressed. Masud Khan has described a peculiar psychological condition as "lying fallow" like a field to be sown only the next year. This is an intimate, non-conflictual, pesonalized area of self-experience, a healthy ego function that the subject can use. This relates to Winnicott's concept of a child being alone in the presence of his mother, alone with himself in a quiet state of well being. We think that in cases like these, if the treatment goes well, these are moments in which the patients let us know that their childhood did not offer them any such experience.

In Italian, death row is "braccio della morte", literally the "arm of death".