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We try to understand the mind of David Berkowitz in particular, and serial killing and psychopathy in general. The question is whether our self psychological analysis of Berkowitz can be valuable in also understanding other serial killers.

2.7.1. Methodological issues with a case study

Using “Confessions of Son of Sam” in the interpretation

Confessions of Son of SamIt is of significance to note that Abrahamsen based his interpretations upon first hand information from D.B. Some of the interviews were with face to face contact with him, and this could be a source of information that one might miss when one is analyzing out of a book, like for example revealing expressions in D.B.’s face or other bodily movements. Additionally, the psychoanalytic angle that Abrahamsen is using might have (un)consciously influenced D.B,, which potentially can have affected him in his understanding of himself, and this way also of the answers and statements that he gave. This way, the use of “Confessions of Son of Sam”, might not be a totally neutral source of interpretation, which can have affected the validity of the study in this work.

Using a serial killer to understand a serial killer

What is also important in a valid qualitative study is that the subject that is being tested has a moral integrity (Kvale, 2002, pp. 236-237). Based on the assumption that D.B. has a psychopathic personality (Abrahamsen, 1985, p. 136), one might be critical to whether he is telling the truth. According to Abrahamsen, D.B. was the one who suggested that he could be the subject of a book. In relation to this one might wonder why D.B. wanted the whole world to get to read about his “unpopular” killings. One reason could be that he was interested in being forgiven and potentially get his sentence decreased. But as he was sentenced to 547 years in jail, it does seem unlikely that he was hoping for reduced time in jail. At the same time, his reveals does not either seem to be aimed at getting forgiveness. This is as he in the book tells unconcealed about the murderers. Examples are telling how he was singing and being satisfied after the murders and how he wanted to destroy the girls (Abrahamsen, 1985, pp. 161, 178). A hypothesis could be that the book- idea was an effort to give nurture to the grandiose self.


An important question in relation to the study in this thesis is whether the understanding can be valuable in also understanding other serial killers. In research methodological terms, one asks if the findings are to be generalized. The view of what is objectivity and generalizable, is related to what perspective one have on how to understand the world (ontology and epistemology). Some will claim that the world is a fundamental mathematical universe, where everything exists within a quantifiable order. Consequently, what is viewed as objectivity is when one has quantitative data about the studied objects. This ontological way to consider relations has this way other demands to what is to be considered objective, than if one sees the valuable information as lying in the linguistic, interpersonal constructed social world and thereby use qualitative research methods. The understanding of what is objectivity is also attached to the epistemological demands one have. Natural scientific proponents demand that research data needs to be quantitative to be comparable across theories. This view will also have other demands to objectivity, than if one is using a hermeneutic method (Kvale, 2002, pp. 75, 276). This way, if one is seeing quantification as the criteria for science and legitimation, qualitative methods, like the case study in this work, might appear subjective and non- scientific. But, if one is having the view that information is to be found in the humanistic domain, where the individuals is appearing as a construction of its culture, quantitative research will not be of particular interest or value. In relation to this, the philosopher and sociologist, Jurgen Habermas has argued, that one can seek out norms in the communications (Habermas, 1974; Christensen, 2003, p. 130), meaning that qualitative research can be seen to give normative indications that can also be used in other situations.

Also Hugh Coolican (1999), who has written a book about research methods, states, that is not always seen as a purpose with research to generalize the findings directly to specific populations, groups or contexts. This way, it is not always interesting to find out what is typical, (like with mean and standard deviation) but it can be of substantial value to if, for example, thought processes are similar to the thoughts of other people in similar circumstances (Coolican, 1999, p. 470). This means that, even though case study can be criticized for lack of objectivity and generalizability from a natural scientific point of view, a more humanistic scientific entrance angles sees the natural scientific view on objectivity as irrelevant. This way, it is likely, that the case study is generalizable and valuable, in the sense that it is probable that the findings of the thoroughly and closely analyzed study in this thesis has similarities and shared qualities with other cases. It is therefore to be underlined that the understanding of D.B. can be transferred to other cases.

However, Coolican also indicates that it would be profiting if one can show that the research outcome is related to similar previous research and/or also if one can demonstrate that some of the findings can be transferred in other situations (p. 470). So, even though the case study per se can be seen as having generalizing attributes, it would improve the validity of the study, if further serial killers could be analyzed within the self psychological perspective, to potentially demonstrate that the findings can be transferred to other cases. This has, however, not been the scope of this thesis, but it is a dimension to considerate in a potential later extension of this study.

2.7.2. Critical aspects with the self psychological approach

Kohut’s self psychological theory has been exposed to considerable criticism. His disagreements and break-up with the traditional psychoanalytic drive theory, has been said to have characterized as a “paradigm-replacement within the world of psychoanalysis” (Gorday, 2000, p. 446). This way, it is not unexpected that he received criticism from spokesmen within the perspective that he had earlier been a marked representative for. The most significant differences between these two theories have been discussed in the above interpretation of D.B. Some of the criticism from psychoanalytics is the self psychologies ignorance of inner conflicts and impulses (Karterud, 2000, p. 43). Perhaps, more relevant than the rather natural dissatisfaction among earlier colleagues, is the criticism that has been directed against Kohut’s theory from other fronts.

Kohut’s way to conceptualize the self is one aspect that has been a controversial issue within his theory. Rom Harr& who is a well known theoretic within the understanding of self, has written books about the self within a psychological and philosophical frame. He criticizes Kohut’s concept of the self, because he states that his definition and understanding of the structure of self, does not contain its dynamic and transient characters (Harr& 1998, p. 74). However, what might be of biggest interest in the views of Kohut, and his theory, is the criticism that has been directed from other psychological psychotherapeutic perspectives. Some ooppositional perspectives to self psychology, criticises, among other things, the focus on empathy in the theory in which they claim is an unfortunate attempt to “cure by love” (Karterud, 2000, p. 13). Criticized is also the lack of empirical research of the self psychological method to collect information, in which introspection is used (Messer & Warren, 1990, p. 388). Kohut has also been referred to as making both “confusions” and “contraindications” in his theory (Strozier, 2001, p. x) and for only paying attention to dyadic relations and not considering the importance of a third party in the development of the self (Gammelgaard, 2003).

A substantial degree of criticism has come from psychologists and psychiatrists that see the value of some of the main concepts in Kohut’s theory, but that are not satisfied with all aspects in it. This has resulted in the development of new self psychological approaches. It has been suggested that one can talk about two main self psychological approaches, in addition to the traditional one (Karterud, 2000, p. 64).

What has been characterized as the most critical approach is the intersubjective self psychology of Robert D. Stolerow, Bernard Brandschaft and George E. Atwood. They are putting considerable importance in searching for an understanding of a personality in the context in which the person is interacting and how the interaction is taking form with the mutual influence an individual and its environment has on one another (Black & Mitchell, 1995, p.167; Messer & Warren, 1990; Stolorow, 1994). Kohut has in some occasions talked about the self as a multiple structure. However, Kohut usually seems to talk about the self as one dimension (Tonnesvang, 2002, p. 21). This can be seen in the way he referrer to the terms; the coherence of the self and the nuclear self. However, Kohut also talks about the self as having two (bipolar) or three (tripolar) dimensions. Stolerow has criticized Kohut for his conceptualizing of the self into the bipolar and tripolar structures, where he sees this as an unnecessary demarcation of the self which causes a mechanistic way of thinking and a view of the self that is restricted to the bi- or tripolar self. Stolorow, however, sees Kohut as viewing the self as being constructed by “multiple dimensions” (Karterud, 2000, p. 61). This emphasis can be seen related to the social constructionistic approach with its focus on relations between individuals and the interactions that finds place. Kenneth Gergen, a representative for this approach, sees, in relation to this, the self as being constituted in the interaction with other individuals, and hence it contains of as many selves as there are social situations. The term “multiple self’ stems from this assumption that the self changes from situation to situation (Christensen, 2003, pp. 71-72).

Joseph D. Lichtenberg and Michael F. Basch were also in disagreement with some of the self psychological aspects, and they developed another self psychology approach with emphasis on developmental psychology and infant research. They based their new perspective empirical and neurological research. This was in opposition to Kohut, who was critical to also consider other theoretical aspects than his already developed theory (Karterud, 2000, p. 64).

It is indeed important to consider, and be aware of critical aspects with a theory. In the highlight of thegiewer and revised self psychological perspective, one might wonder if the traditional self *pychology is an outdated theory. It is however, to be mentioned that Kohut died when he was 68 years, when he had barely worked 10 years with self psychology and simultaneously had been suffering from a severe chronic disease these last 10 years of his life. Due to a limited time to develop the theory it might be a reason for its claimed incompleteness and “confusing” and “contraindicating” character, both in the theoretical and therapeutic manner (pp. 26, 49). This way, it is to be stated that there can be find aspects that are not completed and that can be criticized in the Kohutian theory. How can one then defend using this perspective in analyzing patients (and in this case a serial killer)?

Even though the traditional Kohutian self psychology are seen to have critique leveled at it, the newer self psychologists still tend to emphasis empathy and selfobjects, which is often regarded as the “most central and creative features” of Kohut’s theory (Mitchell & Black, 1995, p. 167). This way, even though one possible can improve theories by including other aspects, the basic elements with Kohut’s self psychology are still remaining in the new theories as well, so whether one is using the traditional theory or the newer theories, one is still concerned with these aspects.

However, one will not come aside from the fact that there are aspects with a traditional self psychological analysis that is not perfect. According to Ornstein (1997), who is one of the prominent “traditional” self psychologists, also Kohut knew that his theory “…were not final’ words, and he trusted that those who adopted his ideas would put them under the high-powered investigative lens of their own clinical work”. (p. 3). In relation to this, Ornstein argues that Kohut gave as good expression of his theory, as he was able to at that time. Ornstein points to the fact that the significant thing is to be able to see the “greatness” in the theory and not be troubled with exact definitions, as they are in fact only guidelines (p. 3). Ornstein and also other traditional self psychologists have the opinion that one does not have to change or revise Kohut’s theory, but instead to further elaborate on, and broaden his theories (Karterud, 2000, p. 202; Ornstein, 1998). This way, there are arguments for both making improvements and changes with the theory on one side, and withholding it on the other. The contribution in this work, have been based on a withholding of the traditional theory, but it is still of importance to be aware of the criticism there exist. By using Kohut’s theory, it is not necessarily claimed that it is better than the newer self psychological theories, but most of all it is used as there are aspects with this theory that seems to be a valuable tool for understanding the case in this work, D.B. For that reason, it was found to be of the greatest value to use the original theory of Kohut as this is where the concepts were originated and not to use “secondary” understandings of his theory. There will be some more critical reflections of the self psychological theory in relation to the therapeutic implications in part 3.3.3.

Has the psychopath a mental disorder that needs treatment? Can a person with strong antisocial traits be treated at all? If so, we need to know more about current treatment methods. Or is it the case that psychopaths are incurable and should be imprisoned at the first opportunity? In other words: Mad or bad? Treatment or prison?

This part of the work is aimed at discussing the consequences there are for the individual that has committed crimes characterized as serial killings. There are mainly three sub-parts in relation to this. The first discussion is considering the actual legal consequences that there are for serial killing criminals, where there also will be some deeper reflections about their responsibility and freedom to choose in relation to their potential pathology. The next discussion will be concerned with the views there are upon giving psychological treatment to destructive criminal psychopaths.  As it is not usual to work therapeutic with serial killers, it is not a simple case to refer to experiences from, or research of therapy with serial killers. Literature is though occupied with “criminal psychopath”, and therefore this term will be frequently used when looking at the implications for therapy, as this term can be seen to include a serial killer.

The last discussion will be aimed at giving a suggestion to how psychological treatment of serial killers could be conducted, within a self psychological perspective.

If a person with schizophrenia breaks societies' rules by killing, he is typically deemed; "not responsible by reason of insanity" and probably gets convicted to treatment. When a person diagnosed as a psychopath breaks the same rules and kills, he is judged sane and usually sent to prison. Is it right?

3.1.1. What are the legal consequences for serial killing?

Court systems around the world have varying points of view in relation to intentionality and responsibility for serial killers (Ferreira, 2000, p. 5). In Denmark, “straffelov” § 16, considers responsibility and punishment in relation to criminality the following way: “Persons, who at the time of the crime were insane (“utilregnelige”) because of mental illness (“sindsygdom”) or conditions that must be equated with this, are not punished” (Adserballe, 2000, p. 598. My translation). What is at present included within the term “utilregnelig”, are conditions such as severe organic mental disorders, like dementia and also psychosis that are caused by drugs, schizophrenia, paranoia or affective sufferings (Poulsen, 2004, p. 310). Similarly § 44, first part, is a law in Norway that states that: “Persons, who at the time of the crime was psychotic or unconscious, are not punished” (Rosenquist & Rasmussen, 2001, p. 51. My translation). This way, both in Denmark and Norway, are individuals with personality disorders seldom considered exempted for punishment, if no other condition is also present. But, additionally, there is also a law (§56) in Norway that states that a person can be given milder punishment; “when the criminal at the time of the crime had a severe mental illness with a substantial weakened ability to realistic evaluation of its relationship to the outside world, but were not psychotic”. (p. 62. My translation). Even though there in the legal systems are not any totally clear definitions of whom are to be included in the insanity plea, or the sanction that can give milder punishment, personality disorders are not explicitly considered in these extenuating circumstances.

As for how the consequences for criminals are in the U.S., it has been stated that it is not only the presence of a mental illness or defect that is determining the legal responsibility, but also the criminal’s “intentionality” and “awareness” (Palermo & Knudten, 1994, p. 4). This way, antisocial PD or psychopathy is not accepted in the legal defense of insanity. This is because the

conditions do not qualify under the “McNaghtan rules” which have existed, though in different forms, since 1843. These rules are considered both in Great Brittan and in the US. The essence in these rules, is that punishment is not given or considered if; “the defendant did not know the nature of and quality of his actions, or if he did, that he did not know that what he was doing was wrong” (McCallum, 2001, p. 3).

This way, personality disorders like psychopathy and consequently, most serial homicide criminals, are not included in the insanity plea and are therefore considered legally responsible, both in Denmark, Norway and in the U.S. This is because serial killers are often considered not to be “mentally ill or out of touch with reality” and because they can be understood as rational and aware of what they are doing (Ferreira, 20001 p. 6). This can be seen in D.B.’s statement: “I knew what I was doing. I knew right from wrong, and I knew that my gun could snuff someone’s life.” (Abrahamsen, 1985, p. 100). However, the issue of mental illness in relation to personality disorders and serial killings will be further discussed in part 3.1.3.

The relevant question, then, is what happens with serial killers. In the U.S., serial killers are often getting death penalty, like Gary Ridgway (killed at least 49 women), Aileen Wuornos (a women who killed at least seven men) and Ted Bundy (killed at least 28 women) or life time sentences like D.B. and Jeffrey Dahmar (Dahmar killed at least 15 men and was sentenced to 936 years in prison) (Newton, 2000, p. 48). There are 37 states in the US uses death penalty (Internet guide), indicating that death penalty is a highly likely consequence in the US. In Denmark, there does not seem to have been murderers that can characterize as serial killers in modern times, and as there are no specific law that is specifically aimed at serial killers, it is not to be predicted what exactly will happen to them. However, Peter Lundin is a well known killer, who has assassinated his wife and her two sons. As there were no “cooling off’ period between the murders, it does not characterize as serial killing. Instead it characterizes as “mass murder”. To illustrate how the punishment system in Denmark reacts to this kind of violation of law, Lundin got life time in prison for this episode. This is as the hardest sentence (life time) can be given in cases of intentional (Danish; forsettelig) murder (§237). However, after 12 years in prison, the inmate can be given release on parole (Justisministeriet, p. 2). This is, however an issue of evaluation. This way, Lundin as an example, can in theory be released after 12 years, or never, depending on the courts decision. This is different from the legal system in Norway, where life time sentence was abolished in 1981 and where the hardest sentence is 21 years in prison (p. 2).

When considering the appropriate consequences for individuals that have committed multiple murders, punishment is not the only aspect involved. It is also of importance to prevent the society against them. This is mainly due to the risk there are for the murders to recur. In relation to this, multiple researchers studying criminal psychopaths in general, have found that they have a frequent recurrence to criminality (Forth et al., 1990; Hemphill et al., 1998).

psychopathy and leagel rightsIn relation to this, there is in Denmark and Norway, also another form for legal consequence for criminal offenders. This is called “forvaring” which is an indefinite sanction, and is given when “the convicted is posing a danger for others life, body, health or freedom” (Det offentlige Danmark. My translation). What is meant by “forvaring” is quite similar in Norway and Denmark. With forvaring, the purpose is to protect the society by not giving a sentence of a fixed duration. With this, the inmate is being evaluated as time goes by, whether or not to be released. This conviction is also finding place in prison, and the kind of section in prison, is adjusted to the specific prisoners. This way, they can in principle also in Norway, be kept in prison for lifetime Even though there are not examples in the modern time of serial killers in Denmark and Norway, it can only be said that it seems highly likely that they would get “forvaring”. Peter Lundin did not, however. But a similar case in Norway, where two children were raped and killed, the leader was deemed to 21 years of “forvaring”. The question however, is whether they are receiving treatment. The aim with “forvaring” as a sanction, is to protect the society, and thus not as aimed at giving treatment, in which “insane” criminals will get (Rosenquist & Rasmussen, p. 69; Kriminalomsorgen). Herstedvester Detention Center however, is a well-known institution in Denmark that treats criminals with mental disorder (Poulsen, 2000, p. 115). This is both criminals that have got “forvaring” and criminals that have got life time sanctions. However, there are no general guidelines for treatment aspects of criminal psychopaths, herein serial killers. § 74 in the Danish laws, state that it is the Minister of Justice in Denmark that is deciding the roles about treatment for the persons that are placed in “forvaring” (Straffeloven).

In relation to the criminal behavior of psychopaths and the claim that they are responsible for it, Hare (1999) has stated: “Their behavior is the result of choice, freely exercised.” (p. 22). But are serial killers really free in their choices? Did D.B. for example have, with the background and personality he had developed, any choice? Did he want to be a feared man?

Finding answers to this is dependent on the view of humanity one have. Therefore, a discussion of whether individuals have a free will or whether they are determined to their behavior is the theme in the following.

3.1.2. Do serial killers have a free will?

The debate concerning whether individuals in general have a free will, can be seen as involving three main positions. These are hard determinism, soft determinism and libertarianism (Sappington, 1990). Determinists state that people are never responsible for their behavior, because their behavior is always determined by prior factors (mental, physiologic or sociologic) and one does not have an ability to choose ones behavior, and therefore not responsibility for ones actions (Ltibcke, 1996, p. 187). This position can be attributed to the behavioristic perspective, with the front persons John B. Watson and Burrhus F. Skinner and also to Sigmund Freud. The radical behavioristic psychology that Watson and Skinner represent, stresses that human behavior is controlled by genetic and environmental factors and this way, they regard human behavior to be determined. This position can be seen to exclude the existence of free will and freedom to make ones choices (Schultz & Schultz, 2000, p. 302). Also Freud is often termed as a determinist, in that he sees drives and traumas in the childhood as being determinants for the behavior of the individual and it is the unconscious factors that are seen as controlling the behavior. This way, he is of some seen as having the view that everything is predetermined and that nothing happens as a result of a free will or an opportunity to choose (Christensen, 2002, p. 134; Sappington, 1990; Schultz & Schultz, 2000, p. 413). As hard determinists probably would consider free will and moral responsibility as meaningless (Sappington, 1990), a hard-deterministic view on a serial killer, might entail in the assumption that, because of the killer’s life conditions, this was the one and only alternative. Thus, taking a hard deterministic stand would carry the assumption that nobody, including serial killers, is responsible for their behavior.

Contrary to the deterministic point of view are the libertarianists in which someone name indeterminists. They are proponents to the assumption that ones choices are not determined by uncontrolled factors and consequently, that, individuals are free to make their own choices (Sappington, 1990). Sartre, Heidegger, Kirkegaard and Kant are high-profiled philosophers with this point of view. This way, individuals are always being responsible for their behavior (at least all their intentional actions) (Ltibcke, 1996, p. 188). As a consequence to the assumption of the possession of a free will, the philosopher Kant has, according to Abrahamsen (1945) stated: “Before the earth perishes the last thief should be hanged in the guts of the last murderer.” (p. 4). This way, based on individual’s free will, he showed no mercy for the criminal and at least not for the murderer.

Psychiatrist, Irvin D. Yalom, with his existential position, states that a deterministic point of view is a serious problem. He claims that humans abilities to come with resolutions and to choose what aspects of themselves they want to present, is a proof of the free will. He also states that even though Freud’s model is considered deterministic, Freud too, agreed at some level with the indeterminism. This is, as Yalom sees a determinism perspective as a rejection of psychotherapeutic relevance, as he sees responsibility as an obvious prerequisite for the possibility to change (Yalom, 2003, pp. 303-305). Schulz and Schulz (2000, p. 302) states that if the assumption of determinism is right, then there would be no point in making any efforts, either for one self or for any one else in this world. This way it can be seen within a psychological frame, a problem to take a hard deterministic position to understand humans. But it also seems problematic to assume that external factors will never influence ones ability to freely make ones choices. Most reasonable seems to be a soft deterministic stand, in which seems to be the most widespread view within philosophy (Greenspan, 2003), psychology (Hare, 1999) and legal justice (Poulsen et al., 2000). Within this perspective, one will probably see people as normally having the ability to make their own choices and that they are therefore normally responsible for their behavior. This might be the explanation for how it is usually decided that psychopathic individuals are not only considered legally but also as psychologically responsible for their behavior as they are seen to have the ability to freely exercise their action and that they therefore can make a choice to kill, for example, and additionally be responsible for their actions whereas they get punished to jail. Psychotics, on the other hand, are not seen as possessing that skill, and are therefore usually perceived as non-responsible. But, however, even though a soft deterministic stand is taken, this does not necessarily mean that there is consensus in the opinion about the presence of freedom in individuals. In relation to this, one might wonder if an individual with a psychosis and an individual that is a psychopath, can be as sharply divided as that (treatment versus punishment). Does D.B. really have a free will and did he freely choose to kill? In relation to this, Adrian Raine, who has written a book about the pathology of crime in 1993, has a statement that seems to adequately denote how free will is manifested in D.B.’s behavior:

“It seems much more likely that free will lies on a continuum and that there are differing degrees to which each of us as individuals have a free choice in most of our daily actions as well as those most extreme acts such as killing another individual. While it is true that in most cases a criminal has a choice regarding whether or not to commit a criminal act, the decision is likely to be heavily weighted by a large number of preceding events, including the individual’s social history and the presence/absence of both social and biological predispositional influences.” (Raine, 1993, p. 310).

This way, Raine does not see free will as something one either have or do not have, but instead as something one might have more or less of, depending on previous events in life. Based on an agreement with this point of view, it seems like D.B.’s ability to make choices have been substantial influenced by his “preceding events” and that this also has affected his acts of destruction. This is, as has been meticulously illuminated in the self psychological analysis of him, because the killings seem, quite clear, to be closely linked to his earlier experiences of having been rejected and neglected and an accompanying deep wish of being recognized in the terms of giving nurture to the grandiose pole of his self. This way, it seems like it should be singled out, that his choice was “heavily weighed” by his experiences in his childhood and upbringing, where this also should have some influence upon the degree in which he should be termed as responsible for the murders.

Responsibility, free will and choice are often discussed in relation to evil and illness. This is, as one might argue, that evil is a matter of choice, and thereby something people are responsible for, whereas sickness is an absence of choice and thus indicating non- responsibility (Vachss, 2002). Because of this widespread hypothesis, the next will discuss more closely the responsibility of a criminal, with a focus on the debate about whether serial killers should be characterized as evil or ill.

3.1.3. Are serial killers evil or/and ill?

The debate about madness and badness can be related to philosophic positions regarding whether individuals are seen as inherently good (Rousseau) or born with the potential to do bad things (Hobbes). If one takes the perspective of Hobbes, then it is up to the rest of the society to prevent the evil potentials of individuals (Ltibcke, 1996, pp. 243-245, 482). Many theoretics are critical to the tendency to excuse destructive actions with pathological explanations. Riidiger Safranski is a German philosopher who posits a version of this view (Andkjxr Olsen & Karpatschof, 2003, p. 12). Also Douglas and Olshaker (1998) state, based on their FBI work with criminals that: “We have to stop excusing the inexcusable and insist that people be held accountable for their actions”. (p. 348). Hare (1999) also states that psychopaths behaviour “result not from a deranged mind but from a cold, calculating rationality combined with a chilling inability to treat others as thinking, feeling human beings”. (p. 5). For this reason they are usually referred to as “bad” instead of “mad” and the law has not developed special considerations for “bad” criminals (Ogloff & Lyon, 1998, p. 403). Cleckley (1978) has stated that even though it is popular to call murderers sick, he himself refers to them as “vicious”. (p. x). He is critical to the idea of relating this to psychiatry. He states: “1 have not encountered vehemently expressed opinions that Hitler, however many features of psychiatric illness he may have shown, should be exonerated of blame and responsibility for the tragic disaster he brought upon the world.” (p. x). Another psychiatrist, Thomas Szasz (1987), is also critical to “excusing” criminality. He is doing this based on his rather radical view of claiming that mental illness does in fact not exist and that it is based on mistakes: “Clearly, if mental illness did not exist, it would be necessary to invent it” (p. 359).

Due to the disagreements that exist concerning the nature and meaning of evil, a clear definition of it is not an easy task. However, in the introduction part, evil was limited and defined, based on Kuschel and Zand’s (2004) understanding of it. They see evil as involving an individual’s aim to reduce others’ quality of life and characterized by the individual’s lack of empathy for the person that are affected by the “extreme” act (p. 17). If this definition is what one considers as a correct understanding of what evil is, it can seem like psychopaths, with their characteristic lack of empathy, are synonymous to evil, and that also serial killers are necessarily incorporated in the understanding of what evil is. The definition reminds significantly of the nature of a serial killer, with its “extreme” and “cross-frontier” character and that they indeed can be said to “reduce others’ quality of life” (p. 17). Psychotic killers will, on the other hand not be defined as evil as their purpose is not understood as being aimed at reducing others life, but that it is often more a matter of defending oneself.

An acceptance of Kuschel and Zand’s definition seems to indicate that serial killers and thus D.B. are evil. Is this an adequate conclusion of D.B. and his behavior? Should it not be considered that pathology is something that potentially can influence the momentum of what one call evil? It does from literature seem like evil is something that exist when pathology/illness is not present and thus that evil is a contra-indication of illness. This can be seen in the frequently used problem formulations: Bad or mad? (Krober & Lau, 2000), crime or sickness? (Szasz, 2002), monsters or victims? (Online crime library). The most frequent conclusion to this problem is that murderers are evil and that consequently, pathology is not considered. They might have a mental disorder, according to DSM-IV, but is can seem like it is not considered “severe” enough that it is of relevance to consider their pathology when judging their actions. This is seen both in court and in the additional population. Among others, Hare (1999, p. 22) states, that psychopathy is not to be understood as a mental illness, as the psychopaths are calculated and not mad and insane and that they don’t have a distorted experience of reality, like that of the psychotic individuals, in which Hare claims to be the mentally ill. Also professor in psychiatry, Michael Stone and his co-workers, who have studied 500 cases with violent criminals, claim that serial killers are evil. They reject any psychiatric explanation for it. Stone has made a 22-level hierarchy of evil behaviour, in which several “calculated” serial killers are at the highest level. He is now working on a book, where he suggests that evil should not be considered within psychiatric diagnoses (Carey, 2005) In relation to this, one might wonder how, based on the Raine and Reisby’s definitions (introduced in the introduction), one can relate serial killers to mental disorder.

As for the eight different definitions that Raine (1993) is considering, it can seem like a serial killer can be seen to fall into most of them. First, it can be discussed whether a serial killer is experiencing distress himself, but “distress/suffering to self or others” is indeed an adequate description (p. 8). Second, serial killing can seem to be defined as a “deviation from ideal mental health”. This is as mental health can be defined, like it has of WHO; “a state of complete physical, mental and social well-being…” (p. 7). Even though, an issue of controversy, it can be argued that an individual a psychopath is characterized with an inside pain and sadness (Reid, 1978), thus indicating that they might not often feel “complete well-being”. Third and forth, are the definitions of a mental disorder as a “deviation from the social norm” (Raine, 1993, p. 7) and as “impairment in functioning/efficiency” (p. 11). These also seem to suit a description of a serial killer. The fifth definition is that it is listed in DSM (p. 13). As antisocial PD is listed in DSM, it is likely that a serial killer will also fall into this definition. Sixth is the definition of mental disorder as a “biological dysfunction” (p. 17). Related to this is the argument that psychopathy can be characterized as involving some biological factors. (This will be discussed in part 3.3.3.).

As for the definition of Reisby (2000), he sees mental disorders as lying on a continuum, where the most severe disorder has less ability to participate in the “normal societies activities” (p. 31. My translation). It can be argued that a serial killer does in fact have this possibility, as he often is going on the loose a great amount of time, until he (potentially) is found. This can indicate that he is actually very good at making activities, as he is not suspected or imprisoned. As an example D.B. worked at a post office the last five months before he was arrested, meaning that he also worked there when several of the murders found place, without being suspected (Abrahamsen, 1985, p. 118). But, still, how far from a normal activity is the activity of a serial killer? Regarding this question, serial killers seem to adequately be characterized as having a mental disorder that is in fact quit severe, and that it is deviating in a large extent from what is normality.

This way, it is in this understood that when one is, in accordance to Kuchel and Zand’s definition, naming serial killers as evil, this evil can be seen as a result of some kind of pathology. This is as; “those of us who function “normally” could not possible have the propensity to commit these acts (serial killing. My remark). They are deviant and engaged in only those with noticeable signs of psychopathology.” (Ferreira, 2000, p. 15). The way I see it, it is not of relevance to put the term evil aside when describing the actions of a serial killer. The definition of Kuchel and Zand does indeed seem to fit their behavior. What is nevertheless important is that the aspect of evil in a serial killer is probably not an isolated condition. The existence of evil/”badness” does this way seem to be closely correlated with illness/”madness”. This way, it is hypothesized that what is usually termed as evil, is existing as a consequence of pathology.

3.1.4. Concluding remark

If a person with schizophrenia breaks societies’ rules by killing, he is typically deemed; “not responsible by reason of insanity” (Hare, 1999, p. 22) and probably gets convicted to treatment. When a person diagnosed as a psychopath breaks the same rules and kills, he is judged sane and usually sent to prison (p. 22). The differences in consequences for the two different cases, seems to be based on; 1) The presence of a mental illness in the schizophrenic person and the absence of one, and consequently the assumption of evil intend for the psychopath and; 2) The assumption of an absence of a free will in the schizophrenic person and the presence and the acting on it, in the psychopath. In relation to this, James P. Ogloff & David R. Lyon (1998, p. 404) who work with psychology and law, have made an illustration of the relationship between the Law, mental illness and determinism. Additionally, I have added how evil and illness seems to traditionally be related to the rest of the terms.

Psychopaths and free will

The remaining question is, in relation to the illustration, where serial killers are to be inserted. As for today, they seem to be put in the criminal responsible (evil) circle, with a high degree of free will and a small, if any, degree of mental disorder. This is especially for the procedure in the U.S., where death penalty is often given. In this context, a statements of Raine (1993) will be given to illustrate how it seems relevant to consider serial killers’ will; “…predispositions clearly place constraints on the individual’s free will, though not in the dramatic way as some severe mental disorders such as schizophrenia may place constraints on free will.” “…acknowledge that there are clear predispositions that form the basis for recidivistic crime, and acknowledge that in most cases these predispositions are beyond the individual’s control”. (p. 312). Also to use a statement of Raine to illustrate the accompanying implication this have for the punishment aspect; “…then the implication is that criminal offenders should not be punished as severely as they are currently for their actions” (p. 312).

It is right that the pathology of psychopaths is not manifested as delusions, like it can be, for schizophrenics as an example. For an individual with a personality disorder, however, pathology is instead manifested as lasting and deviant patterns of internal experiences and behavior (Karterud, 2001, p. 20). These patterns have probably also affected the ability to behave in accordance to a free will, which thereby should have influence on how to consider their responsibility.

treatment or prison for psychopathsWhen one is considering the responsibility and thereby pros and cons with this aspect, it is worth noticing, that there are in fact two possible, totally different outcomes in such a discussion. Getting prison or getting treatment are two oppositions, as punishment can be seen aimed at “inflict suffering”, whereas treatment can be seen to “ease suffering” (Hansen, 2003, p. 458). Most prisons are not exactly aimed at being a place to harvest positive behavioral or attitudinal change, and they are often found to worsen the prognosis for the inmates. This might indicate that, with its accompanying increased risk for offending after imprisonment, it is not especially constructive for the offender or society (Fishbein, 2000, p. 5). There seem to be disagreements between the two opposites (treatment or punishment). Some times in Denmark criminal psychopaths can get treatment at the institution, Herstedvester but in the U.S., there does not seem to be any alternative sanction for criminal psychopaths that have killed. The question is however, whether serial killers can be treated, in the sense of not longer be a threat to kill. If one is having the opinion that evil actions (like that of serial killers) are something that one can not administer, manage or change, this might lead to a view of treatment as meaningless. However, this work has gone in the direction of an understanding of serial killers as psychopathological, and that evil is a definition one might use to describe the actions, but that it is to be understood as a consequence of psychopathology. Consequently, the following will be aimed at looking at treatment aspects for serial killers.

Lying, manipulation, lack of conscience and seductive tendencies are characteristics of the psychopath's personality that makes treatment difficult. In addition, the therapist will often struggle with empathic involvement in the antisocial patient, and that makes psychotherapeutic treatment inadequate. Fact is that psychopaths respond poorly to medication and psychotherapy. When treatment does not succeed, may be prevention is our best choice?

3.2.1. Deep pessimism or light pessimism

There is widespread pessimism concerning rehabilitation of criminal psychopaths. Treatment of psychopaths and criminals seems to be described with more pessimistic prognosis than any other deviant condition in literature. Hare (1999), who has been very much occupied with psychopaths, has stated: “If you are dealing with a true psychopath, it is important to recognize that the current prognosis for significant improvement in his or her attitudes and behavior is poor” (p. 205). Reid and Gacano (2000) are also negative in that they claim, based on research, that neither psychological therapy nor medical treatment has positive effect on antisocial behavior. These viewpoints can also be seen within the writings of Cleckley (1976, pp. 438-443). Ogloff et al. (1990) have in a study found that criminal psychopaths are more likely to become drop-outs in therapy and that they show less motivation and generally less improvements than other patients.

psychotherapy treatment will not workHare (1999, p. 199) refers to a study of Rice et al. from 1992, where psychological treatment was found to actually make psychopaths worse than they were before the treatment. This was measured by how, after the release, psychopaths, that did not receive treatment were less violent than the psychopaths that had received treatment. Hare (1999, p. 97) and Reid and Gacano (2000), remark one aspect that give rise to optimism of a disappearance of psychopathic traits. This optimism is though, anchored in the evidence there seem to be of a natural “burn-out” of the antisocial symptoms when they reach the age of 40. Hare relates this, among other factors, to the fact that the psychopath gets tired of being in conflicts. However, he does also emphasize that this does not necessarily mean that there has been fundamental changes in the personality of the person.

The presented empirical and clinical based conclusion can be interpreted as an argument that there is no other justifiable way to handle serial killers, than putting them in jail for life and that there is no point in trying to treat them. This is as the negative prognosis might give the impression that serial murderers must be kept in jail as they are not able to change. But is this a proper inferential?

Despite the general pessimistic opinions of treatments of criminal psychopaths, more positive views also exist. As have been mentioned, Herstedvester in Denmark is a place for treating criminal psychopaths, or “the untreatable”, like George K. Stirrup, names them (1968). Stirrup was the header of the institution for over 40 years. He does not think that criminal psychopaths can be cured, but instead that their symptoms can be eased: “I never say that I cure psychopaths; I do claim, however, that during their stay in Herstedvester they have been helped to become nicer psychopaths.” (p. 2). The psychological treatment here is a psychodynamic form for therapy and also an environmental form for therapy, where the staff is meant to influence the patients’ everyday routines (Hansen, 2003, p. 459). Ogloff et al. (1990) have made a research report based on treatment of psychopaths in a therapeutic community program. Out of this, they found psychopaths

to be a complicated clientele to treat but they also states that “it is difficult, if not impossible to prove that psychopaths cannot be treated.” (p. 188). This is due to the fact that the only way to prove that psychopaths can not be treated is by having tried the possible intervention methods. Dennis M. Doren (1987) who has written a book about psychopaths, from a psychological perspective, also claims that therapy with psychopaths is “not hopeless, just difficult”. (p. 244). He states that many psychopaths can indeed be treated. Also John Gunn, a forensic psychiatrist that states that individuals with serious antisocial problems actually do; “respond to a wide variety of treatment strategies” (Gunn, 2003, p. 38). To take a look into what is of some seen as a meaningless endeavor, though of others as a possibility, the following will be an extension to this.

3.2.2. The preferred prevention

David T. Lykken (1995, p. 230) states, based on his convince that there are no cure for adult sociopathy, that the only useful option is prevention. He emphasizes this by referring to a child psychiatrist, named Jack Westman that in 1994 estimated the costs of a single sociopath in the U.S. to $3 million over 60 years. This is due to destroyed or stolen property and abuses. However, the personal wounds this might cause are also substantial, as has been indicating with the murderers that D.B. committed.

Even though Kohut emphasizes how individuals are dependent on selfobjects throughout the entire life span, he does also claim, as has earlier been mentioned, that a fragmented self is most likely to develop when failures from selfobjcts occur in childhood (before the age 5). This way, it would in his terms, be of importance to intervene as early as possible in life, so that the self does not develop in a fragmented manner.

Potts et al. (1986), states that experience tells us that the younger patient with more recent symptom onset responds better to treatment than does the hardened, psychopathic, criminal adult. In relation to this, D.B. has given the following statement: “It frightens me to look back and see what I was and what I became. It also angers me, for I ask out loud; Why didn’t someone see all the signs?” (Abrahamsen, 1985, p. 201). If this is based on a truthful reveal, it does seem like a quest for early intervention. Could the six young people have been spared, if D.B. had got help? As a matter of fact, D.B.’s adoptive mother did bring him to a psychologist once a week when he was seven. No more details about this is known, but he stated in relation to this, that he “…resented the psychologist’s snooking in his private thoughts and feelings” (p. 37). This way, even though D.B. states that he did not understand how he could do so many negative things as a child and still go unnoticed, early discoveries are not always infallible (Hare, 1999, p. 200). But Hare also states that this situation might change if one manages to find out more about the roots of psychopathy.

early intervention psychopathyBeing able to get a hold of potential murderers at a young age would obviously be of great value. If intervention starts at an early age, one might be able to modify antisocial behavioral patterns and possibly reduce aggression and impulsivity by teaching the young one other ways to satisfy their needs than by antisocial acts (p. 200). But it is not to be neglected that it can be a difficult job to predict who would become a serial killer and thereby prevent this from happening. This might look more like an issue of Utopia than real life. So the relevant question is probably more concerned with; what if the damages have already been done? In the shadow of the majority of pessimism of criminal psychopaths’ ability to be treated, the following will discuss what it is that seem to be the reason for the poor prognosis.

3.2.3. What makes criminal psychopaths a difficult clientele to treat?

The contextual circumstances

Generally, persons with antisocial PD do not often search for therapy (Karterud et al., 2001, p. 47). Most of the individuals with psychopathy or antisocial PD are this way found in forensic settings (Rosenquist & Rasmussen, 2001, p. 206). Further, it seems obvious that an individual that has killed multiple others is immediately prevented from doing this again and this way, the serial killer is likely to be found in a maximum security prison. So if therapy is given, it will be in the circumstances of a prison environment. Some American psychologists have even claimed that prison psychotherapy has such a problematic nature, that it is “…a waste of time” (Carney, 1978, p. 273). This claim is due to the form and function of a prison society, “…where violence is encouraged and reason reproved” (p. 273). Doren also claims that therapy in prison is very problematic. This can be due to wrong motivations among the patients/inmates, because they see it as an opportunity to be regarded as involved and conscientious inmate and potentially decrease time behind bars. Also boredom can be a motivation for prisoners to attain therapy. These motivational factors might influence the outcome in therapy, and therapy in prison can such be seen as a rather inadequate setting to meet patients in (Doren, 1987, pp. 149-150).

The serial killers personality

angerAs serial killers are often seen to have the traits of a serial killer; poor behavioral control, shallow affect, callousness, lack of empathy, pathologic/chronic lying, manipulations and lack of remorse and guilt (Beasley, 2004), it is quite obvious that these personality traits can have negative consequences for the therapeutic setting. The pathological lying might disrupt the ability for an honest communication with the therapist and the lack of remorse and guilt, will possible make the offender minimally interested or motivated for changes. Hare (1999) claims in relation to this: “Psychopaths don’t feel they have psychological or emotional problems, and they see no reason to change their behavior to conform to societal standards with which they do not agree.” (p. 195). The shallowness, callousness and the lack of empathy might indicate that it is problematic to work with actual emotions in the therapeutic setting (Lose’, 1998). Their deceiving and manipulative character is potentially giving the patient a feeling of success if they have been able to fool the therapist (Gabbard, 2000, p. 510), and it is said that psychopaths often laugh after therapy because of the credulous therapists who are seeing “improvements” (Rosenquist & Rasmussen, 2001, p. 207). As an example, D.B. wrote in a letter to Abrahamsen (1985) the following about one of the therapists who claimed that he had been psychotic:

“I vividly recall the talks I had with Dr. Daniel Schwartz [one of the Court-appointed psychiatrists who had found Berkowitz to be insane] (Abrahamsen’s remark), for they were to me ecstasy. They were the talks that produced the feedback I wanted. What a pleasure it was back then to hear this man exonerate me of all blame for my sic murders. Oh, the pleasure of hearing this man telling his colleagues how sick I was-how ill- how insane. I knew, that all I had to do was slide “Sam Carr” and the demons into the conversation and I’d have him bending over his chair in my direction. Why he’d practically be wiping tears from my eyes and comforting me, saying, in a sense, don’t fret, don’t cry, you’re a sick, sick boy” (pp. 156-157).

What can here have happened is, what the psychoanalytic, Glen O. Gabbard describes as ordinary behavior of a psychopath; the psychopath simulates tearfulness and remorse, and thereby manipulates the clinician to empathize with them (2003, p. 505).

There is also another important aspect with criminal psychopaths that can have a substantial impact on the therapist and thereby also on the therapeutic process. Jeremy Coid (2003), having written an article about dangerous psychopaths in prison, states that some inmates in prison are psychopaths with such a severe degree of pathology, which, make them dangerous and are hence not safe to have in therapy. This can feel frightening and threatening to the therapist, and thus making him scared of confronting the patient. Safety should always be seen as more important than further analysis (Strasburger, 2001, p. 302; Kernberg, 2003, p. 381).


Adhesive note face offAnother very important aspect that can be seen to influence the effect of therapy with psychopaths is countertransferences. This term refers to the therapist’s feelings and attitudes about the patient (Sandler et al., 1994, p. 100). Because of the personality of a serial killer, and the actions they have made, strong countertransferences are likely to occur in therapy with them. Larry H. Strasburger, with a psychodynamic perspective, has written an article about the therapist’s feelings in relation to treatment of antisocial syndromes, where he writes the following: “The psychopath is the least loved of patients.” (2001, p. 297). The consequence of this, he claims, is that the therapist is doing the exact same thing as the society; “…unconscious rejection of psychopaths.” (p. 298). This rejection might stem from the hatred and aversion that occur in the therapist because of the acts that the patient has done, and the way the patient talks about it (p. 307). An example of what can provoke this aversion in the therapist is statements in therapy like this of the serial killer, Ted Bundy: “What’s one less person on the fact of the earth anyway?” (Online crime library). Further, the psychopaths’ frequent denial of problems and denial of being in need for help might cause the therapist to experience feelings of helplessness, being rejected and also feelings of guilt for not being able to help (Strasburger, 2001, p. 307). Gabbard (2003) claims that the most problematic type of countertransference, that might occur when having antisocial patients in therapy, is “collusion”. This is when one or more of the staff in the institution or prison where the antisocial person potentially stays are corrupted and make illegal or unethical deals with the patient. Gabbard states that this occurs due to a projective identification process, where some of the corrupt aspects of the patient are transformed into the therapist(s) or the staff (p. 505). This can be seen in relation to the fact that it is easy also to be fascinated by a psychopath. This because psychopaths often have a radiance and charisma that sometimes leaves the therapist into feeling seduced by the patient. The manipulative tendency might lead the therapist into viewing the patient as charming and the “daring” behavior of the patient might also cause the therapist to see him as an exciting individual which potentially also can cause unfortunate attraction towards him (Dahl & Dahlsegg, 2000, p. 229). Hare is also marking how there are, in general, especiaty strong attraction towards psychopathic serial killers, in which can be seen in how they receive substantial attention in the terms of groupies, pen pals, supporters and “love-struck fans” (1999, p. 150). There can be seen many reasons for this. As an example Cleckley states that: “Feminine intuition senses that here, concealed beneath an appearance of maturity, is a baby or something very much like a helpless, crying little baby. Her deep instincts to nurse and to protect this winsome little darling are unconsciously called out” (1976, p. 198). If these countertransferences happen in a therapeutic setting, it can potentially cause problematic and unfortunate content in therapy. To avoid this, Dahl and Dahlsegg (2000) suggest that awareness of the countertransferences is essential and that frequent supervision with a qualified professional is of crucial importance (p. 229, 238).

Concluding remark – Treatment of criminal psychopaths

A learning theorist, named Robert Hale, states that serial killers are not deranged but that they rather have behaved in a way that makes sense and is logical for themselves and is derived from “…a perceived wrong” (Hale, 1993, In Ferreira, 2001, p. 15). He also adds that: “You, too, can learn to be a serial killer.” (p. 5). These assumptions seem quit likely and one might, in relation to that wonder if it is not somehow unethical to, like is likely in the US, to punish a serial killer with death penalty. The policy of killing or punish them with up to a lifetime in prison, as a reaction to killing, seems like dismiss of this famous quote from Mohandas (Mahatma) Gandhi: “An eye for eye only ends up making the whole world blind.” (Online quote collection).

Two human head silhouettes with cogs and gearsAdditionally, it does seem likely than an investigation of the potential obstacles in therapy with criminal psychopaths, can improve the possibility to successfully treat these patients. A hypothesis is thus, that the presented potential difficulties in therapy (the patients’ personality and countertransferences) are obstacles that mental health workers have not traditionally been able to overcome, which have influenced the majority of negative views on treatment. This is especially due to how it, because of strong countertransferences, seems difficult to be empathic.

The following statement of D.B. can be seen as a manifestation of the needs there are for improvements in the work with the widespread problematic behavior that he represents:

“Through understanding myself and for learning of my motives for my crimes, which I’ve always consciously known, but which I deliberately suppressed behind a story of demons- rather than openly admitting it-by doing this I hope to be able to better myself to a point in which I don’t need to act out, in reality, my hostilities and frustrations- I won’t have take out my personal revenge on others who have done me no wrong. Hopefully, and with much effort, I will no longer feel the need to act out my childish impulses onto the rest of the human race. Perhaps this all sounds idealistic. It isn’t.”  (Abrahamsen, 1985, p. 223).

If this statement of D.B. is true, it is an indication for a need for good- working therapy and thereby improvements in the prognosis for rehabilitation. Reflections upon what is likely to be effective in therapy with a serial killer will be the focus in the following, on the basis of Kohut and his understanding of pathology.

The prognoses in relation to the rehabilitation and treatment of psychopaths are basically very bad. In this area, there is a fairly widespread pessimistic attitude. Can self psychology, with the emphasis on narcissism and development of empathy, pave the way for better therapeutic strategies? Improving empathy is an important aspect within self psychology, and this dimension is what seems to be absent in a serial killer. Most of the literature in this field will associate the treatment for this group with poorer prognoses than at any other psychiatric condition. Is it hopeless?

From the self psychological analysis of D.B., it seems like the underlying cause for the killings were related to the narcissistic aspects in his personality. Kohut’s theory is aimed at understanding and treating narcissistic disorders, or self-disorders, which they are often referred to (Ornstein, 1997): “Self-psychology is especially important and relevant, when we are investigating psychological states where the experience of a disturbed self accept and/or fragmentations of the self takes up the psychological developmental centre.” (Kohut, 1990, pp. 75-76. My translation). This statement of Kohut is illustrating why this theory seems to suit well to the analysis of D.B.

Kohut was optimistic in relation to treatment of these disorders. This way, the following are considerations and suggestions to a self psychological therapy for serial killers. This suggestion is applicable because of the assumed narcissistic aspects that can be seen attached to the case of D.B. And the aim in this is that the suggested therapeutic strategy will also be applicable for other patients, which have some degree of narcissistic personality. The following will still be based on the understanding of D.B., in which he will frequently be used as an example to illustrate the therapy in concrete terms.

3.3.1. What would be the aims with self psychological therapy with a serial killer

The following will imply three main aims in self psychological therapy with a narcissistic personality.

Understanding of self and the development of a coherent sense of self

Essential for patients in therapy, is to develop and mature the suffering narcissistic content of personality. This can be done by enhancing the understanding of the structure of ones self. If this understanding is emphasized in empathic harmony with the therapist, nurture to the surviving rest of the self will be given. In relation to D.B., this could for example mean to let him understand that his destructive childhood activities (fires and violent behavior), were not evil or disgusting, but that they were made out of a wish to get attention and experience the feeling of being alive (Kohut, 1998, p. 97; Kartrud, 2000, p. 25). The result of this will lead to increased self-acceptance and self-esteem (Kohut, 1990, p. 47). Karterud & Limes (2000) also states, in the spirit of Kohut, that patients who feels understood, will develop a more coherent, vital and authentic self (p. 149). With unconditional empathy, the patient will feel understood and will develop an ability to feel safe and to have trust in the therapist, which will also cause self cohesion to enhance. The changes in the coherent self will first appear in the therapeutic setting, and then the patient will find supportive selfobject milieu in his or her post-analytic life (Ornstein, 1997, p. 4).

Developing empathy and the ability to make confident relations

Improving empathy is an important aspect within self psychology, and this dimension is what seems to be absent in a serial killer. Enhancing empathy in the patient will mean that he will be able to understand more of his own self and other humans and of what is going on in the complex interpersonal relations (Kohut, 2000, p. 25). Developing empathy is important, as it is well-known that; “…empathy is an important motivator of prosocial, or altruistic behavior” (Berk, 2000, p. 411). Prosocial behavior is known as being the opposite of antisocial, in that prosocial actions are beneficial for other persons and not for the acting person (p. 411). This way, if empathy is developed, one can possibly presume that antisociality and acts of killing will disappear, or at least decrease.

Karterud (2000) claims in accordance to Kohut, that a crucial aspect with psychological good health, is the ability to continually be surrounded by close selfobjects, and not drive them away, which is a typical trait with severe personality disorders. Thus, by developing empathy, the patient will again be able to, in a balanced way, both give and take in relations with other people (pp. 25-26).

The uncovering of primary defects

Kohut states that therapy is completed when the primary defect has been uncovered. This is done when the therapy has identified and worked with the defensive structures that are covering the primarily defect. When this is done, the patient can internalize new experiences, and this way make the defect structures in the self function in a healthy manner (Kohut, 1990, pp. 17, 55). In relation to D.B., the primary defects seem to be his feelings of inferiority, neglects, depression and emptiness, in which he tries to defend him self against these feelings with mainly grandiose fantasies and ideas.

3.3.2. How can the aims be reached?

The two stages of self psychological therapy

As illustrated in the diagram that has earlier been presented in this work (part 2.5.3.), Kohut sees the personalities of narcissistic patients as often involving both a horizontal and a vertical split. He also sees these splits, as being the basis for the therapeutic work (illustrated in the figure on next page). The first stage in therapy is related to the line that is indicated with the number 1. Here is the therapeutic aim to remove the vertical barrier, which is maintained with denials. The other stage is related to the line that is indicated with the number 2. Here is the therapeutic goal to remove as much as possible in the horizontal split, which is maintained with suppressions (Kohut, 1998, p. 116; Kohut, 2000, p. 164).

Self psychological model 3.3.2

This working model is different from the psychoanalytic position of Freud. Freud would claim that one has arrived at the deepest level, when one has reached the patient’s experience of his impulses, wishes and drives. This means that a Freudian psychoanalysis would be regarded as successful when the patient has become aware of his unconscious processes (Freud, 1999, p. 228). Freud will this way, only work with the barrier for suppression (horizontal split). But self psychology does not believe that the curative process is ultimate when the unconscious has become conscious (Kohut, 1984, p. 64). How the work in the therapeutic self psychological lessons will be, either one is at the first or second stage in the work, will be described in the following.

Selfobject transferences in therapy

As has earlier been outlined, Kohut suggests that an individual that have been exposed to enduring lack of empathic selfobject in childhood, has not developed a healthy and consolidated self. As a result of this, Kohut claims that all existing defects in the self become spontaneously mobilized as “selfobject (narcissistic) transferences”. Further, Kohut states, that it happens in everyday settings, and also in a therapeutic situation, that the narcissistic patient has a self that is likely to be in search for appropriately responsive selfobjects (Kohut, 1984, pp. 4, 70-71). These transferences, Kohut claims, are unique for narcissistic disorders, and differ from transferences that other patients develop. The narcissistic transferences develops in connection to the three different parts of the self; the pole of ambitions, the pole of ideals and the pole of talents and skills which is manifested in the twinship-seeking pole. This way, Kohut identified the possible transferences (selfobjectobject transferences) as; 1) the transferences that are based on the damaged pole of ambitions and grandiosity, which is attempting to elicit the confirming-approving responses of the selfobject (mirror transference); 2) The transference based on the damaged pole of ideals, that searches for a selfobject that will accept its idealization (idealizing transference); 3) The last possible transference is based on the damaged intermediate area of talents and skills, that seeks a selfobject that will make itself available for the reassuring experience of essential alikeness. This is called the twinship- or alter ego transference (pp. 192-193). Whether it is a mirroring, idealizing or twinship transference that develops, it is the task of the therapist to use the particular transference, and understand the vital selfobject function the patient has (unconsciously) given the therapist. This is because this transference is equal to the function that was not provided by the original selfobjects (Consolini, 1999, p. 74). In relation to serial killers, it seems likely that it is a mirroring selfobject transference that will develop. This assumption is based on the fact that the killing actions are possibly aimed at getting attention or approve (even though they are negatively laden). This interpretation seems especially to concern D.B., as has earlier been illuminated.

Kohut sees defects in the self as causing maintenance of a patient’s selfobject (narcissistic) transference. Because of this, hi sees the working through of this transference as significant when attempting to fill the defects in the self (Kohut, 1984, p. 4). This way, he states that in order to be capable to treat a patient, the patient must be able to let the therapist function as a selfobject. This is done, when the patient is using his inner experiences and reactivates, re-experience and work through the depressions and rages of early life in the transference with the therapist (p. 5). If the selfobject transference is well established and the patient does not experience disappointments in relation to the expected selfobject function of the therapist, he will gradually

internalize (“internalized transformation”) the new experiences and make them his own. This is named “optimal frustration” (Karterud, 2000, p. 19; Kohut, 2000, p. 51). In relation to D.B., and the assumed lack of mirroring selfobjects throughout his life, it is likely that if the therapist will be able to represent D.B.’s archaic mirroring selfobjects and give him the attention he needs, the fragments in the self will develop into a more coherent structure. It is however important to do this in a balanced way, as overindulgence and extraordinary attention might give nurture to the grandiose fantasies that already exists. If however, healthy attention and gratifications are given to the patient, it is likely that he will internalize this experience and therefore make the grandiose self satisfied, this time in a healthy manner and not due to “macabre” actions like killing.

The vital empathy

Empathy has earlier been described as the essential quality that individuals’ selfobjects ideally should have, for the individuals’ ability to develop a healthy self. As an extension of this, it is also essential that the therapist is experienced as empathic, since he optimally, will get the role as a selfobject for the patient.

EmpathyTo understand and treat a patient with a disorder of the self, the most important aspect, is the therapist’s ability to put oneself into the patient’s situation and show genuine empathy. Empathy is seen as the entry point, firstly to understand the patient’s subjective experiences, and also to be able to treat. This way, empathy is both “…a methodological principal and the therapeutic position” (Karterud & Urnes, 2001, p. 146. My translation). Being able to be unconditional empathic will gain insight to the strengths and vulnerabilities of the patient and this way understand the patient. But empathy is also important, because, with the therapist’s experience of the inner world of the patient, he is able to predict and avoid vulnerable interpretations and thereby avoid “resistance” in the patient that might be elicited by a fear of retraumatization (Ornstein, 1997, p. 3). Kohut (1990) states that it is necessary to support the crumbled self by explaining what it is that makes the self feel threatened by disintegration, and not to come with rationalizations, like for example with confrontations (p. 85).

If then, the therapist is able to give a consistent and sustained empathic submersion in the patient’s inner life, it is what can create a constructive atmosphere for the necessary tool; selfobject transference. Ornstein claims that the empathic observational position, a non judgmental, a non- confrontational and a truly accepting attitude towards the patient and his problems, will contribute to the vital development of trust and safety. Trust and safety are provisions for the emergences of selfobject transference, where earlier unanswered archaic wishes and needs can be manifested and worked with (Ornstein, 1997, p. 3).

Countertransference as a challenge to empathy in the therapist

Two of the elementary aspects in self psychological therapy (selfobject transferences and empathy) have been described. One might wonder, if it is possible for a therapist to be unconditional empathic towards a multiple, well planned murderer, and whether a therapist can allow himself to take the role of an archaic genuine mirroring selfobject in the transference. These two affairs seem to be very challenging aspects in therapy with criminal psychopaths, and I believe that these, at least, the tendency to lack empathy as a therapist, is the core explanation to why psychopathic criminals, in general are found to have such pessimistic prognosis for treatment.

Freud introduced the term “countertransference” in 1910, and he was arguing that this was something that the therapist had to overcome (Sandler et al., 1994, p. 101). More recent views, sees countertransferences differently. These newer and more positive attitudes look at countertransferences as something that should be recognized and used as a source of information. An argument for this is that the other part that is involved with the patient is often experiencing the affect that the patient is avoiding (Strasburger, 2001, pp. 301-302). But there are indeed potential problems with countertransferences. This can be due to repressions of them, or at the opposite, from becoming overwhelmed by them (p. 302). This last consequence is what seems to be relevant in the treatment of criminal psychopaths and indeed for serial killers. If the therapist’s genuine feeling is disgust, hate or indifference towards these patients, then it does not strike as a surprise that the prognosis are pessimistic.

To overcome the potentially devastating absence of empathy as a potential result of countertransferences, it is a necessity that therapists realize that behind the narcissistic or antisocial facade is the patient’s feelings of inferiority and depression, neglect, worthlessness or rejection and in relation to that, possibly has a hunger for acknowledgement (Kohut, 1990, p. 18). This way, it could in relation to D.B. be essential to focus on the depression he felt after the losses he experienced, and the hopelessness that followed (Abrahamsen, 1985, p. 61; Kohut, 1998, p. 92), and to realize that the manifest actions are defensive structures, that are probably aimed at covering the defects in the grandiose self (Kohut, 1990, p. 45).

If an empathic failure do happen, which inevitable happens from time to time, it is possibly to use this episode to find out about the patient’s vulnerability and in that, what makes the patient experience being injured. The therapist can then use what he learns through further exploration to connect the current experience of narcissistic injury with the original injury inflicted by the selfobjects during childhood (Consolini, 1999, p. 76).

Using countertransferences in a constructive way might not be a simple matter. But it does seem as an essential issue to not be overwhelmed by the countertransferences and thus still be able to take an empathic stand. This is one suit that can be seen of great value with self psychology, and can seem as an aspect that other perspectives fail to pay extra attention to, when conducting and evaluating therapy with criminal psychopaths.

The importance of avoiding confrontations

Anger 2Confrontations in therapy are about interpreting or asking the patient a question that he does not want to accept or identify with (Gabbard, 2000, p. 97). Kohut argues that one must not, like many therapists do, traumatize self disordered patients unnecessarily. Attacks on the narcissism, must be avoided, he claims (Kohut, 1978, p. 639). If the therapist, by any means, confronts the patient in therapy, the patient might react with agitation. This is because traumatic situations from earlier life have been re-experienced in the therapeutic setting. If now the therapist is being confrontational, it is likely that the patient will experience it the same way as when selfobjects were disappointing him earlier in life. The consequences of not giving an empathic response, in the re-traumatized situation, will thus potentially result in the occurrence of narcissistic rage (Kohut, 1990, p. 73). An argument for using empathy and avoid confrontations, is that confrontations and its potential consequence of making the patient feel criticized, will possible make him maintain the already internalized belief that he is rejected and abandoned.

Avoiding confrontation and almost exclusively focus on being empathic, is what Kohut would see as essential in developing a more cohesive self in the patients. According to Kohut, a therapist with a confrontational style, will, in the same way as the original archaic selfobjects, not be able to function as a vital selfobject. Kohut has stated quite clearly that challenging the patient’s grandiosity is not only useless, but that it also is likely to make the patient suppress powerful wishes, and thus make them inaccessible to modification (Consolini, 1999, pp. 77-81).

But what if it appears in a therapeutic setting, that the patient is lying? As lying is a characteristic trait with psychopaths this is a likely scenario in therapy with a serial killer. An example is how, as has been described earlier, D.B. tried to pretend that he was delusional as he claimed that it was demons that had told him to kill (Abrahamsen, 1985, p. 109). This attempt to pretend being psychotic, has also been used of other “sane” serial killers, as an attempt to prevent being judged as responsible (Palermo & Knudten, 1994). Should one not, as a therapist, confront the patient with this, if it happens in the therapeutic setting? Kohut has inferred that for the best outcome in a situation with a patient who is lying, one should use the lye as a source of information to find out about the vulnerable areas of the patient (what is he lying about and why?) and to “accept it with equanimity” (Kohut, 1984, p. 72). Kohut’s attitude concerning this matter seems to differ from the majority of views, where it is emphasized to confront lies and untruthfulness (Gabbard, 2000, p. 511; Kernberg; 2003; Coid, 2003). For Kohut however, it is essential to avoid indignation and rejection, at any price (Kohut, 1984, p. 72).

When the patient is successfully treated

Therapy of a narcissistic personality is seen to have been successful, when the patient’s previous needs for responses from archaic selfobjects are replaced with an experience of having sufficient empathic feedbacks available, and when a sense of genuine security is obtained. In the analytic situation, these reactivated needs are kept alive and exposed, repeatedly and enduring, until the “internalized transformation” occurs, and until the patient has a reliable ability to sustain his self with the aid of the selfobject resources available in his present environment. An increased ability to gain insight, verbalize and have control over impulsiveness may accompany these gains (Kohut, 1984, p. 77).

3.3.3. Implications for using self psychology as an attempt to treat a serial killer

Kohut has named one of his books: “How does analysis cure” (1984). What he means by cure, however, is not necessarily a state with absolute absence of symptoms. He states that cure is about a continuum. When the center of the personality (self) has been reestablished and a productive life is possible, one can talk about having been cured (p. 7). The question is so, whether a serial killer, in self psychological terms can be said to be cured- realistically speaking. The following will take a critical view concerning some of the aspects with treatment of serial killers.

Can a serial killer learn to develop adaptive representations of others and empathy?

Most of the characteristics shown in a psychopath, and a serial killer, seem to be closely linked with a general lack of empathy. This is, to refer to PCL-R, the symptoms; irresponsibility, lack of realistic goals, pathological lying, manipulativeness, lack of remorse or guilt, egocentricity, shallow emotions, deceitfulness, short- term marital relationships, callousness and grandiose self-worth (Hare, 1999, p. 44). This way, improving the ability to be empathic seems to be of great importance when committing treatment with a serial killer, as it might have impact on the traits just mentioned. But is this possible?

There are disagreements among theorists concerning whether personality emerges early and persist due to heredity and early experience, or whether changes are possible and likely to occur, if new experiences support it (Berk, 2000, p. 9). Most developmental theories like, for example, those of Piaget, Kohlberg Freud and Kohut, see empathy and also moral as something that is exclusively or mainly developed in early stages of life. But even though they see moral and empathy as being developed in childhood, they do not reject that they can be changed later in life (Berk, pp. 481-494).

An aspect that can be seen in relation to the potential for changes is the biological perspective and how it is linked to the development of personality. There have been done substantial research concerning the presence of neurobiological factors and changes in psychopaths,

faking empathycriminals and antisocial PD, and there can be seen indications for a link between antisocial behavior and biological conditions. Among numerous theoretics and researchers considering this correlation, Larry J. Siever claims, based on his study of neurobiology in psychopaths, that genetic and/or early environment will potentially cause changes in the neurological development in cortical regions (Siever, 2003, p. 240). Damasio (2001) is also working with the link between biology and psychology and he points, that the development of antisocial behavior can be localized to frontal lobes (pp. 71-80). Another biological aspect is the assumption that the human brain is “plastic”, meaning that it has the ability to develop new structures and compensate for defects or lacks. But most often, this plasticity of the brain is considered to be present the first 6 or 10 years of life. Later, abnormalities in the brain are, according to Berk (2000), more difficult, if not impossible to be recovered from (p. 189). These views might look like contraindications for psychological treatment with individuals who potentially have biological impairments, in that an argument might be that one can not treat biological defects with psychological treatment. But, however, Damasio does see biological and psychological processes as inseparable and he does underline the fact that the brain and bodily reactions develop and change from second to second, because of what is experienced in the world (2001, pp. 236-237). Also Solms and Turnbull (2004) agree with Damasio’s assumption. They claim, just like him, that humans just have one psychic apparatus, meaning that there is no split between the body and the psyche, which means that it is natural that the brain and neurological matters will changes according to mental experiences (p. 293). According to Damasio and Solms and Turnbull, changes and abnormalities will, unavoidable, be manifested in the brain as long as there is mental life. Because of this, there should be no reason why psychological treatment can not promote changes in the brain. If one believes that one can not influence abnormalities in the brain,

one will probably be left with a minimum of patients. Biological defects and psychological treatment do instead seem to be consistent aspects. This way, the biological abnormalities that can be seen in psychopaths does not necessarily indicate that medical treatment is the only alternative or that they are untreatable.

Implications with the unconditional empathy and avoidances of confrontations

Kernberg is in a strong disagreement with the unconditional empathy and lack of confrontations in Kohut’s theory. Kernberg is known for his view that it is necessary to confront narcissistic patients when they are using their defensive maneuvers (Consolini, 1999; Kernberg, 2001, p. 326). Gabbard (2000) also disagrees with the use of continual empathy. He states that when an antisocial patient is revealing his antisocial activities, it is wrong to take the self psychological stand and be unconditional empathic. He states that this would be; “…both misguided and collusive.” (p. 512). Further, Gabbard claims that it is not realistic to think that a therapist can maintain a neutral and empathic stance when listening to, and seeing the patient’s antisocial behavior. This way, the unconditional empathy that Kohut pursues, can be argued to be both over-optimistic and for sending out the wrong signals, when “accepting” the antisocial activities, like for example lying in the therapeutic sessions.

narcissistic personalityOgloff et al. (1990) have some reflections upon confrontations in (group) therapy with psychopaths. In their evaluation of their research with treatment of psychopaths, they have the hypothesis that confrontations in the therapy actually were helpful at some level, as it might have caused the psychopaths to become aware of the impact that their destructive and irresponsible behavior can Ile on their peers and the staff. However, Ogloff et al. also have the hypothesis, that the confrontations are what lead to the substantial drop-out rate of psychopaths, as the insight to their impact on others can cause so uncomfortable feelings that the patient is motivated to quit. If this is a right interpretation, Kohut’s view of the unconditional empathic position of the therapist might be of value to make the patient stay in therapy and thus increasing the chances for successful outcome.

However, one might suspect that unconditional empathy would give D.B., once and again an experience of having manipulated the therapist, just like he did with Dr. Schwartz (see quote in part 3.2.3.). According to Kohut (2000), however, patients with narcissistic problems, have (un)conscious wishes of being in empathic contact with others. Thus, he claims that, no matter what defenses the patient is using, it is a necessity to continuously expose the patient to empathy. This is necessary as it is the only way a narcissistic patient will have the possibility to successfully increase his own ability to be empathic (pp. 267-268). But Kohut also highlight that one should, at the same time as one is empathic and giving the patient attention and not rejection, appear with “equanimity” (Kohut, 1984, p. 72). This means that one must react to behavior or stories that could potentially have caused a re-traumatizing experience, with acceptance and in an unaffected manner, this way appearing in a respective manner.

Is the focus on empathy unique for self psychology?

development of empathyKohut was in fact the aim of substantial criticism when he introduced his prominent focus on empathy (Karterud, 2000, p. 12). But, however, empathy is not only essential within self psychology. The humanistic psychologist, Carl Rogers, is well- known for his focus on empathy (Rogers, 1992) and also Yalom is especially emphasizing the importance of the therapist’s ability to be empathic (2002, p. 17). This can seem like the self psychological theory claims to have a crucial aspect that other theories in fact contain too. It has, however been stated that Kohut’s self psychology “alone views empathy as a means of finding out about the subjective experience of the other” (Messer & Warren, 1990, p. 385) and not only as a therapeutic technique. This statement seems though, not to be totally correct. Rogers defined empathy in 1957, the following way: “To sense the client’s private world as if it were your own.” (1992, p. 829). Also Yalom, though later on, talks of how the relevance of “looking out the patients window” (2002, p. 17). This way, it can look like Kohut, Rogers and Yalom all are seeing empathy as important as both a way to grasp the subjective experience of the patient as both a method to understand and as a method to a treat the patients. Also other therapists like psychoanalysts Bateman and Fonagy (2004), underline that empathy is important in treatment with personality disorders (pp. 167-168). But it does, however, seem like Kohut is more consequent than others. For Kohut, empathy is not something one just needs to do, but it has to be learned, and it will take time, effort and also personal qualifications to be able to really deepen oneself into the subjective experience of the patient, and see the world through the patient’s eyes (Kartrud, 2000, pp. 12-13). Kohut has also thoroughly outlined how empathy is a “vicarious introspection”, which involves a substantial and vital capacity to enter and observe (introspect) the patient’s consciousness with the belonging thoughts, feelings and experiences (Kohut, 2000, p. 261; Thielst, 1998, p. 44). Kohut’s idea does this way seem to be incorporated with more substantial content, than many other theories that emphasizes empathy. As for Rogers and Yalom, it seems like they are also paying considerable attention to this aspect of therapy, and it is likely that they will such be able to contribute in treatment of serial killers.

Nevertheless, the considerable focus on empathy in self psychology, seem to suggest that it is a favorable theoretic stand in therapy with serial killers. This is as it seems likely that it will have fatal consequences if one is not able to fully understand the patient. Without a real understanding, which is likely to be found via empathic introspection, where one is able to realize the serial killer’s vulnerable aspects, one might be trapped in the external symptoms of the serial killer.

Is one theory enough in therapy?

What seems to be the trend in present therapeutic strategies is the “Dodo verdict”; “Everybody has won, and all must have prizes” (Rosenzweig, 1936, p. 412). This revolves the assumption that there are no significant differences in the effect of different psychological approaches (Hougaard, 1993). In relation to this, there has been a widely spread tendency for therapists to take an integrative approach to therapy. The use of pure theories and techniques are hence seen as insufficient to explain and treat psychological problems (Holmes & Bateman, 2002, p. 5). But even though integration is the most popular approach, some fundamental theoretical frame is necessary to avoid that the therapy gets as fragmented, conflicted and changing as the patients’ inner world (Karterud & Wilberg, 2002). When the therapist meets complex problems in therapy, he can be leaded to change strategy of intervention according to the patient’s wishes. This can cause a confusing and minimal organised therapy (Livesley, 2004). The solution to this problem is to have a fundamental theoretical frame that the therapist is completely familiar with, and in addition have some strategies from other theoretical frames, when working with specific problems, like, for example a cognitive strategy when working with a phobia. The integrative trend is such not a contra-indication to the use of a specific theory, like self psychology, in the understanding and treatment of psychological problems. It can instead be seen useful to apply the traditional self psychological theory as a basis, in opposition to start the analysis with the newer, already integrated self psychological theories. This is also as, like has been mentioned earlier (part 2.7.2.), newer self psychological perspectives, tend to regard empathy and selfobject transferences in therapy as the most central and creative features of the traditional self psychology (Mitchell & Black, 1995, p. 167). This way, the newer self psychological perspectives, do not differ in relation to the most essential Kohutian terms.

This way, to evaluate whether self psychology is sufficient in relation to treatment of a serial killer, it can be argued that the a self psychological foundation can be beneficial, as it seems to be consensus in the importance of having one basic theory. So, to add other theories to arrange an integrated treatment method might potentially increase efficacy in treatment. But, as it can be seen of substantial value to have complete insight and overview of one therapeutic theory/strategy (Karterud & Wilberg, 2002), a traditional self psychological based treatment strategy is most likely sufficient in treatment.

It seems adequate to ask, whether the experienced rejections of mother, father and the rest of the world that was analyzed, really offered D.B. any other alternative than those actions he made. Put in another way, the forensic psychiatrist, Seymour Halleck asks; “If mother, parents, or authority are consistently visualized as all powerful, cruel or arbitrary what behaviors are available to the individual?”  (Halleck, 2001, p. 168). It seems quite likely that an answer to that question, in relation to D.B., should be that his earlier experiences had restricted his alternatives substantially.

However, it can attract criticism, that there are people who have gone through the same as D.B., but who managed not to kill anyone. The concept of resilience can be mentioned in relation to this. Resilience is a quality that seems to be manifested different from individual to individual, and is influencing the degree of how the individual is affected by trauma and other difficulties. A study of Kim-Cohen et al. (2004) indicates that resilience is both a result of genetic and environmental factors. Apparently, resilience is not a quality that D.B. seems to own. This is as it does seem quite clear, that there are factors that have affected him and influenced the personality, and consequently the murdering behavior.

The suggestion in this thesis is that understanding serial killers is essential. If one are not able to understand the behavior, one can not either expect, to do anything about it: “We cannot treat, except empirically, what we do not understand and we cannot prevent, except fortuitously, what we do not comprehend.” (Robert Brittain in Meloy, 2000, p. 19). The following quote made by D.B., does also imply a need for understanding what is really happening in a serial killer: “I believe it is vitally important for workers in the mental field, and the public at large to understand what was on my mind and what really motivated me to commit my crimes. No doubt another ‘Son of Sam’ (multiple murder) will follow in my path.” (Abrahamsen, 1985, p. 224).

Concerning “the myth of untreatability”, Strasburger (2001) has stated that the myth is not only due to the effect of countertransferences, but that it also is a cause to them (Strasburger, 2001, p. 302). This statement it indicating that the widely held pessimism is unfortunate. It is thus to be suspected that the pessimism concerning treatment of psychopaths is based on a contagious epidemic, where the worst threat is that it can become a self fulfilling prophecy.

The intent in this work has included a suggestion to some therapeutic strategies with serial killers that seem likely to be efficient. The suggestion is not necessarily a final solution, but as Kohut has stated in a lecture regarding therapy; “… there is nothing else to do but to work, to improve, to correct. There is no perfection. There is only a striving for perfection.” (1974, p. 4).


Understanding Son of Sam

The questions are straight forward: "Is it possible to understand psychopaths and serial killers?" And: "Can they be treated?" There are a lot of controversies in this field; Are we talking about mental illness or evil? Mental illness should be treated, while evil doings should probably be punished. Imprisonment will surely not rehabilitate a psychopath, quite the contrary, but do they deserve our attention and effort for better treatment strategies?

The intention with this work has been, through illuminating a wide variety of aspects, the problem formulations: “Is it possible to understand serial killers?” And: “Can they be treated?”

4.0.1 Summary – Understanding serial killers

The first part was intended to give an interpretation regarding why serial killing happens. In exploring why it happens, the method that was considered most applicable and valuable in an understanding, was to analyze a serial killer case. Taking Kohut’s self psychological approach, it was understood that the chosen case-person, D.B., had experienced several significant losses and failures from selfobjects. These losses and failure seem to have affected the grandiose pole of D.B.’s self, as it seems to have involved lacks of his needs to gain attention and being mirrored. This lack of mirroring the grandiose self, are likely to have prevented a consolidated core self to develop. What happens in relation to other people, when the self has been fragmented, is that the others are functioning as (archaic) selfobjects. This way, the person with a fragmented self, with injuries in the grandiose self, will continue to search for the missing recognitions that were not achieved in childhood. From what D.B. is explaining, it does not seem like he ever got to experience this. When thus he grew older, there seems to have been a great amount of incidents that had not fulfilled the need that his grandiose self had. Probably, what might have led up to his killings was that he, in many ways approached the unbearable (too many repeated selfobject losses that failed to mirror his greatness and exhibitionistic need). He had earlier used fantasies and also “conduct behavior”, like setting fires, but for his self to keep gathered, these occupations were probably not longer enough for D.B. The killings then, were more intense and extreme, so that they satisfied his grandiose self, in which this was a way for him to prevent his self from going in the direction of being disintegrated. The killings were also probably functioning as a way for D.B. to take revenge against the insults he has experienced towards his self from so many people, in which the women he killed were symbolizing. This is named narcissistic rage and is aimed at repairing the insulted self by getting back on the offender, because the insult is experienced as a threat of a destruction of the core self. Narcissistic rage is characterized by a lack of empathy, which can explain his actions that are of the public often termed “macabre”.

The analysis seem to make sense, and it is found to have been of great value, as With the use of this theory, a suggestion to the riddle of what it is, that can make an individual become a serial killer, have been given. However, to illustrate how self psychology is not the only way to understand a serial killer, a psychological analysis that has previously been made of D.B., was presented. The self psychological and traditional psychoanalytic differ in several aspects. Among other things, the psychoanalytic oriented interpretations of Abrahamsen suggest that the killings are primarily motivated by sexual drives, whereas the self psychological understanding would be more concerned with the interpersonal aspect, in that it was more a matter of recognitions and attention than “sex” in it self. When D.B. is talking about what a relief it was after the killings, Abrahamsen sees it as drives and urges needed to be released, whilst the self psychological interpretation is that it felt like a relief because it was preventing the self from being totally disintegrated. Representatives for each of these theoretical perspectives will necessarily be critical to the other’s point of view. However, in this, the self psychological interpretation was found to incorporate interpersonal dimensions, whereas the psychoanalytic was more focused upon intrapersonal conflicts in the early years of life. This way, because of the many conditions in interpersonal relations as D.B. from childhood to adulthood, the self psychological perspective seemed to be more adequate in the understanding than the traditional psychoanalytic one, and it is therefore also used in the subsequent part. It is to be emphasized that the understanding is not only relevant to be able to solve the mysterious riddle of serial killing in itself, but it is also of crucial importance to have an understanding, so that one is able to know how to handle them and be able to professionally consider the consequences there ought to be for them.

4.0.2 Future directions in an understanding of serial killers

It does seem necessary with more comprehensive studies of serial killers. This is because this area seems to have been neglected, and that studies will enhance the understanding of the nature of the personalities behind serial killings. This is important as there are enormous controversies and ignorance in the view upon these killers, as some claim that they are evil and others, that they are sick. Additional self psychological case studies, might potentially improve the validity of the case study in this book. This is if other studies demonstrate that the findings in this book can be transferred to other cases. However, additional studies conducted differently from this study, within for example a quantitative approach, can illuminate aspects that the nature of this study has not been able to enclose, and thus, they can contribute to further improve understanding of serial killers. This is because understanding is important. No matter whether an enhanced understanding will have consequences for the legal rights and the aspects with treatment, the most important is that professionals who are considering and making these decisions, have a clear construction of what serial killing is really about, and how the potential outlooks for changes are

Only, if this is clear, it can be justified how serial killers are handled in today’s legal and psychological fields. It does seem, in relation to this, a need for a solid bridge between psychology and law, so that there are clear guidelines for who is, and who is not mentally ill, and consequently who ought to get punishment and/or treatment.

Society must protect itself from serial killers and psychopaths, and prison is of course a preferred option. The question is then whether these people shall be punished, and that’s it, or whether to attempt to rehabilitate these people using some form of psychotherapy. In this respect, the problem is that therapy requires a form of empathy from the analyst, and it is not always easy to establish empathy face to face with a cold-blooded killer.

4.1.1 Summary – Treating serial killers

The second part has been aimed at examining the possibilities for successful treatment of serial killers. This part was introduced by the actual legal consequences there are for serial killers, to highlight how serial killers are handled. In Norway and Denmark, “forvaring” can be given, in which the time in prison can last from 12 years to lifetime in Denmark and Norway, and that it seems likely to be lifetime or death penalty in the US. Treatment does not appear to be especially significant in any of these circumstances.

The absence of any considerations of whether serial killers ought to be treated was influencing the following discussions. These were reflections concerning serial killers ability to freely choose their actions and whether they are to be termed evil or ill. These reflections were aimed at illuminate the adequacy of the legal responsibility that serial killers hold. The conclusion of this was, that it seems like serial killers are in a position to appropriately be designated as having a rather severe form for mental disorder, which does suggest that they rather ought to be characterized as “mad” instead of “bad”. This due to the fact that their behavior seem to characterize as a mental disorder (psychopathy or antisocial PD), which also seem to deviate to a large degree, from what is to be considered normality. Due to this, they seem to have some restraints attached to their ability to freely choose their behavior, in that it is anchored in their psychopathologic nature. This does seem to indicate that the legal responsibility of serial killers should be reconsidered and possibly be down-graded.

However, as it can not be denied that serial killers need to be prevented from continue their actions, the alternative to prison was evaluated. By looking at the challenges and potential pitfalls with treatment, the discussion continued in the direction of a suggestion to how treatment, in the terms of self psychology, could take form. Empathy and the use of this in the selfobject transferences in the therapeutic setting, is the key element. This is suggested as an aspect that indicates that self psychology is a favorable theory in treatment of serial killers. This is due to the hypothesis that empathic selfobjects is what has been lacking in the life of individuals with narcissistic injuries, and such that letting this be played out in a therapeutic setting, will strengthen and make fragments in self develop into a more coherent self. Again, to be able to do this, it is crucial that serial killers are truly understood. Elsewhere, relating to them in a constructive way will be threatened. The difficulties with being empathic and other countertransferences are hypothesized as being the main reasons why prognoses for treating criminal psychopaths in general, are rather poor, and it is hypothesized in this, that using empathy, like that of Kohut, both to understand and treat serial killers, is likely to give results in a positive direction.

4.1.2 Future directions in treatment of serial killers

As mental illnesses can be understood as exaggerated forms of phenomenon in the psychic life (Jaspers, 1997, p. 577), it is to be highlighted that the understanding and the suggestion of a treatment aspects is not necessarily restricted to serial killers, but also to other patients that might not have the same degree of “exaggeration” in their psychic life. This way, the therapeutic suggestions might also work very well, with patients with less degree of narcissistic and antisocial conditions.

However, it is to be stated that, as has earlier been mentioned, taking other therapeutic strategies in addition to self psychology, within an integrative strategy, might be valuable. This is, as there might be some incomplete aspects with the traditional self psychological theory, as other theories can fill in. It is possible that the newer self psychological theories that have integrated other perspectives, and are withholding the traditional focus on empathy and selfobject transferences in therapy, will be relevant strategies in therapy. But, it is also a suggestion that other theoretical perspectives might benefit from integrating aspects from self psychology, especially the sustaining of empathy. And such it is suggested that therapists will have the ability to treat serial killers without a pure self psychological entrance angle.

Whether or not therapists in the field of criminal psychopaths, or potentially serial killers, are capable of using the suggested strategies remains to be seen.