Abstract
Two psychoanalytic treatments are described for patients suffering from severe personality disorders who have killed. These treatments have been conducted in a high security hospital and are part of the overall treatment plan for any patient. Structural changes can emerge in the course of long-term continuous treatment which is conducted within the framework of a multidisciplinary team under conditions of physical security. These changes are described and clinically illustrated using the model of mental structure of the Operationalized Psychodynamic Diagnostics (OPD) system. The traumatic effect of “improvement” is emphasized as well as the risk of further enactment of lower severity. The latter might however trigger considerable anxiety in those who are contributing to the care of these patients. This is of importance for the gradual steps of integrating the patient back into the community. The psychoanalytic contributions are considered as necessary immunization against the contagiousness of these disturbances in these settings and also can help clinical teams to have more realistic prognostic expectations.
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