When the murderous phantasy is fulfilled: aggression and its place in psychotherapy with patients who committed murder in a psychotic state

Purpose This study aims to address this gap by exploring how patients and therapists in long-term psychodynamic therapy perceive and understand the role of aggression in the therapeutic process. Design/methodology/approach The study was conducted within a qualitative-phenomenological framework, using a purposeful sample of therapist-patient dyads including 17 patients and 14 therapists (total 31 participants). The patients were all men, hospitalized in several psychiatric hospitals after having committed murder while in a psychotic state. Findings The research findings revealed five themes: fear of the patients’ aggression; the danger of inviting aggression; presence of aggression in therapy; “Sobering up”: the process of recognizing and becoming aware of aggression and strategies for dealing with the patient’s aggression. Despite the context of aggression (murder) prior to therapy, it was striking that the subject of aggression remained largely unspoken. Research limitations/implications Findings suggest that the fulfillment of aggressive fantasies in reality can lead to a limiting of the therapeutic space such that discourse on aggression often remains unspoken. Originality/value Many patients who commit murder during psychosis receive psychotherapeutic treatment during hospitalization. However, despite the clinical challenges, this therapeutic work remains under-researched, with no established framework for understanding how aggression emerges and is experienced within the therapeutic relationship.