Abstract
The difficult patient is here described as the one who does not readily accept the usual definitions of the treatment relationship and who tends to get the therapist to be overly-engaged in the therapeutic process. The therapist must be clear not only about his own characterological issues and counter-transference predispositions, but also about the unique propensity of these patients for the enactment of conflicts. While empathy is the sine qua non of our therapeutic work, the need to set limits and to address hostility should not be underestimated if these patients are to be engaged in any meaningful psychotherapy. To maintain an empathic perspective, the therapist must appreciate the purposefulness of the patient's defensive characterological behavior and that it cannot simply be dismissed as mere pathology. Such a perspective may help the therapist to better respond to the patient's behavior as a communication about his sense of self and his concerns about relatedness. This will facilitate the engagement process.
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References
Adler, G. (1982). Helplessness in the helpers. In P. Giovacchini and L. Boyer (Eds.),Technical factors in the treatment of the severely disturbed patient. New York: Jason Aronson.
Balint, M. (1968).The basic fault. New York: Brunner/Mazel.
Bion, W. R. (1962). Learning from experience. InSeven servants: Four works by Wilfred R. Bion. New York: Jason Aronson, 1977.
Boyer, L. (1983a).The regressed patient. New York: Jason Aronson.
Boyer, L. (1983b). The inevitability of a therapeutic impasse. InThe regressed patient. New York: Jason Aronson.
Boyer, L. (1983c). Analytic experiences in work with regressed patients. InThe regressed patient. New York: Jason Aronson.
Bromberg, P. M. (1982). The supervisory process and parallel process in psychoanalysis.Contemporary Psychoanalysis, 18, 92–111.
Caligor, L. (1981). Parallel and reciprocal processes in psychoanalytic supervision.Contemporary Psychoanalysis, 17, 1–27.
Ekstein, R. & Wallerstein, R. (1958).The teaching and learning of psychotherapy. New York: International Universities Press.
Epstein, L. and Feiner, A. (1979). Countertransference: The therapist's contribution to treatment.Contemporary Psychoanalysis, 15, 489–513.
Fairbairn, W. R. D. (1952).Psychoanalytic studies of the personality. London: Routledge & Kegan Paul.
Frosch, J. (1964). The psychotic character: clinical psychiatric considerations.Psychiatric Quarterly, 38, 81–96.
Frosch, J. (1971). Technique in regard to some specific ego defects in the treatment of borderline patients.Psychoanalytic Quarterly, 45, 216–220.
Gediman, H. K. & Wolkenfeld, F. (1980). The parallelism phenomenon in psychoanalysis and supervision: its reconsideration as a triadic system.Psychoanalytic Quarterly, 49, 234–255.
Giovacchini, P. (1979a).Treatment of primitive mental states. New York: Jason Aronson.
Giovacchini, P. (1979b). The many sides of helplessness: the borderline patient. In J. Le Boit and A. Capponi (Eds.).Advances in psychotherapy of the borderline patient. New York: Jason Aronson.
Greenberg, J. R. and Mitchell, S.A. (1983).Object relations in psychoanalytic theory. Cambridge, Massachusetts: Harvard University Press.
Grotstein, J. (1979). The psychoanalytic concept of the borderline organization. In J. Le Boit and A. Capponi (Eds.).Advances in psychotherapy of the borderline patient. New York: Jason Aronson.
Grotstein, J. (1981).Splitting and projective identification. New York: Jason Aronson.
Guntrip, H. (1969).Schizoid phenomena, object relations and the self. New York: International Universities Press.
Heimann, P. (1950). On Countertransference.International Journal of Psycho-Analysis, 31, 81–84.
Jacobson, E. (1964).The self and the object world. New York: International Universities Press.
Kernberg, O. (1975).Borderline conditions and pathological narcissism. New York: Jason Aronson.
Kernberg, O. (1976a).Object-relations theory and clinical psychoanalysis. New York: Jason Aronson.
Kernberg, O. (1976b). Technical considerations in the treatment of borderline personality organization.Journal of the American Psychoanalytic Association, 24, 795–829.
Kernberg, O. (1980).Internal world and external reality. New York: Jason Aronson.
Kuhn, T. (1962).The structure of scientific revolutions. Chicago: University of Chicago Press.
Langs, R. (1975). Therapeutic misalliances.International Journal of Psychoanalytic Psychotherapy, 4, 77–105.
Levenson, E. (1972).The fallacy of understanding. New York: Basic Books.
Little, M. (1951). Countertransference and the patient's response to it.International Journal of Psychoanalysis, 33, 32–40.
Malin, A. & Grotstein, J. (1966). Projective identification in the therapeutic process.International Journal of Psychoanalysis, 47, 26–31.
Modell, A. H. (1979). The conceptualization of the therapeutic action of psychoanalysis: The action of the holding environment.Bulletin of the Menninger Clinic, 42, 493–504.
Racker, H. (1953). A contribution to the problem of countertransference.International Journal of Psycho-Analysis, 34, 313–324.
Racker, H. (1957). The meanings and uses of countertransference.Psychoanalytic Quarterly, 26, 303–357.
Rey, J. H. (1979). Schizoid phenomena in the borderline. In J. Le Boit and A. Capponi (Eds.),Advances in psychotherapy of the borderline patient. New York: Jason Aronson.
Searles, H. F. (1955). The informational value of the supervisor's emotional experiences. InCollected papers on schizophrenia and related subjects. New York: International Universities Press, 1965.
Segal, H. (1964).Introduction to the work of Melanie Klein. New York: Basic Books.
Shapiro, E. R. (1978). The psychodynamics and developmental psychology of the borderline patient: a review of the literature.American Journal of Psychiatry, 135, 1305–1315.
Singer, J. (1985). Transference and the human condition: a cognitive-affective perspective.Psychoanalytic Psychology 2(it3), 189–219.
Solomon, I. (1985). On feeling hopeless.Psychoanalytic Review, 72, 55–69.
Winnicott, D. W. (1935). The manic defense.Through paediatrics to psychoanalysis. London: Hogarth Press, 1978.
Winnicott, D. W. (1947). Hate in the countertransference.Through paediatrics to psycho-analysis. London: Hogarth Press, 1978.
Winnicott, D. W. (1954). Metapsychological and clinical aspects of regression within the psycho-analytic set-up. InThrough paediatrics to psycho-analysis. London: Hogarth Press, 1978.
Winnicott, D. W. (1960). The theory of the parent-infant relationship. InThe maturational processes and the facilitating environment. New York: International Universities Press, 1965.
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Fiore, R.J. Toward engaging the difficult patient. J Contemp Psychother 18, 87–106 (1988). https://doi.org/10.1007/BF00946359
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DOI: https://doi.org/10.1007/BF00946359