IAFP, Oxford, 26 March 2010Anne van den Berg, Karel Oei

38 yrs. old Half Dutch (father), half Surinam (mother) Mother in the' 70s and' 80s a known

popsinger Mother’s family large and complex Many offences: from 17th, mostly crimes

against property. Jail in and out. Last one: hold-up with knife (threatening) cashier in supermarket. TBS.

Addiction: softdrugs and cocaine

TBS =placement under a hospital order. Admission date: 2004 - 2010 Individual psychotherapy: 2006 – 2010 WAIS IQ: average with a harmonic profile

Verbal and Performal PCL-R: high (36). Affective and interpersonal

facets. DSM IV: ASPD with narcissistic and borderline

traits Unescorted leave phase with reintegration

( half 2009)

Failed abortion (in a pentecostal church milieu!)

Toddler regularly alone in Spain (4-6) Unreliable parents (6-7) Rejected and maltreated by stepparents (7-

14) Placed by parents in a juvenile center (16-18) Only job: flowershop (18-19) French Foreign Legion (21) In love but betrayed (30)

Existence: I was a mistake Attachment: family, sister, Amsterdam Religious: demons, spirit Mystique: French Foreign Legion (semperfi) Identity: disturbed (2 cultures) Negative feelings: hate, pain, lying, addictive Positive feelings: love, protection, desire Philosophy of life: don’t look back, future Incestuous feelingsSong and images are crumbled. Music and

singing are more harmonious.

Very short and staccato sentences Counter questions Generalizations Blaming Controlled facial expression Somatic suffering Smiling at the start and the end of session Avoiding intimate subjectsFunctioning from his alien self

Very severe personality disorder Not capable of having a long relationship Very dangerous (high risk). Assessment

instruments Instrumental Breaking of the rules in the hospital Keeping the rules and the arrangements Addicted Not reliable

Connecting with the psychological level of him (different modes)

Bridging the antitheses (title of presentation). No as a comment but as a consideration within myself

Making connections between the fragments in his life (autobiographical continuity). May be…

Let him look inside (reflective) Emphasizing the hope

Robber ↔ Floral designerdestructiveness constructivenessegocentric altruisticaggressiveness flower powerbad feelings good feelingsugliness beautyswiftness patiencehate hope

No continuity in his self, borderline, alien parts

Patient: Cognitive behavioral therapy (struggle) Patient with equivalent, pretend and

teleogical modes Avoiding direct contact about his feelings Doesn’t tolerate interference (control) Doesn’t like obligations (control)Milieu: Restrictive Distance: therapist – head of the treatment

unit

Implicit Explicit Nonconscious conscious nonverbal verbal perceived interpreted unreflective reflective mirroring explaining

Implicit techniques Not the usual MBT techniques (stop, rewind) Small reflections of own (good, wrong) thoughts Empathy in terms of feelings like ‘annoying’ Emphasizing voluntariness

Precisely in the appointments with me Let see his face in between for a small talk Some vulnerabilities A little bit confidence in me Life story completed (autobiographical

continuity) The last months more estrangement

January 2010: Unescorted leave → holds up a supermarket with knife

Why? Letter (end of February to me)1. Disappointed in love (reflection in letter)2. Addicted3. Strong undercurrent feeling: ‘I am not allowed

to exist’4. Revenge on the hospital: You will not succeed5. Reaction on placing back into hospital and in

his eyes the maltreatment by us.6. Fear for society

MBT only possible in strong structure MBT only possible in accepting structure MBT in a more implicit than explicit way Narratives show their full advantage in

singing and music than with telling a story There is an urge to tell his story but at the

same time he can’t tell his story very well A very defective fundamental feeling not to

be allowed to exist. Profound destructiveness.