Academic journal article American Journal of Psychotherapy

Barely Here to Begin with and Not-So-Goodbyes: Keeping the Faith When Working with Turbulent Patients

Academic journal article American Journal of Psychotherapy

Barely Here to Begin with and Not-So-Goodbyes: Keeping the Faith When Working with Turbulent Patients

Article excerpt

Some patients are unable or unwilling to step into the difficult and uncharted explorations that psychoanalytic work entails; in this paper the author shows how the effort to establish analytic contact with each individual can provide a level of valuable support, containment, and growth for many patients. Such patients may display great resistance to the challenge of psychoanalytic treatment, subtly inviting the analyst, through projective identification processes, to succumb to countertransference acting out.

These turbulent patients often leave treatment in very abrupt and unprocessed manners. It is suddenly all over and that is that. This abrupt dismissal is usually a continued expression of the remaining pathology and conflictual phantasies that had been played out in the transference throughout the span of the analytic process. We cannot always prevent this. Rather than seeing this as a complete failure, we can try to maintain ourselves within the depressive position by realizing we are being used by turbulent patients as provisional placeholders and temporary containers. This is a model of grieving in which we acknowledge and accept what we cannot have, what we are not, and what should be but is not. Struggling with these issues in the countertransference is critical to our ability to help such patients because these are the exact issues the patients cannot bear in their lives. And, if we cannot bear them, then the patient has no hope of ever surviving them.

KEYWORDS: turbulent patients, treatment resistance, countertransference, projective identification, therapist challenges


Patients with whom we have difficulties typically have spent their lives cultivating, maintaining, and then enduring intense internal and interpersonal turbulence through excessive reliance on destructive projective identification processes. As a result, the analyst must be constandy aware of these shifting and complex dynamics. Turbulent patients, by definition, create a vicious internal cycle of projecting toxic mental conflict, reacting to it as if it is an outside force were threatening them, and then creating more defensive projections to protect themselves.

In the Kleinian approach (Segal & Britton 1981), the understanding of projective identification has led to a greater attention to the interaction between analyst and patient. Historically, this has added to those sources of information already available for interpretative use, such as the patient's verbal and nonverbal behavior. Now, interpretation can include the analyst's perception of himself through his patient's view, his own emotional experience of the session in the countertransference, and both his and die patient's tendencies to action. Often, die core of the transference with such patients will be projective based phantasies that pull the analyst into very narrow roles the patient expects, desires, and fears. The case presented in this paper illustrates many moments of this type of uncertainty, a misstep on the analyst's part, and the struggle to regain balance.

Slow-to-thaw patients, such as the one followed in the clinical material, struggle with enormous levels of anxiety concerning conflicts about love and hate and the psychological meaning of knowing more about themselves or their objects. For example, the patient in this paper unconsciously felt that knowing more about his mother and learning about his own feelings toward his mother were very dangerous and, therefore, to be denied, avoided, or eliminated.

In response to these internal threats regarding knowledge, love, and hate, these patients tend to excessive and destructive methods of projective identification, manic denial, and splitting, which provides temporary psychic shelter or pathological retreats (Steiner, 1993). These methods of relating and reacting create intense transference and countertransference climates. Joseph (1978) pointed out how the more the patient uses primitive defenses against anxiety, the more die analyst is used by the patient unconsciously, which, turns the analysis to a scene for action rather than understanding. …

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