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Working with difficult patients can result in a variety of psychological stresses for the therapist. These may not relate to the therapist's unresolved conflicts or to the specific countertransferences evoked by the patient's use of projective identification. Although certain characterological vulnerabilities may not interfere with the therapist's capacity to do the work appropriately and effectively, they may nevertheless lead to a gradual erosion of the therapist's enthusiasm and energy for the work if not of his or her overall health. The requirements of doing analytic work, whether it be the ability to function as a needed selfobject for the patient, or the stamina to contain, neutralize, and survive noxious projections, may, over time, simply wear a therapist down, leading perhaps to emotionally distancing defenses. Discouraged by the demands of the analytic method and the nonspecific stress it creates, the therapist may turn to other less emotionally demanding techniques.
Abend (1986) describes how the demands of the analytic work—instinctual restraint, evenly hovering attention, neutrality, patience, confidence, and narcissistic balance—place a constant, rather than an intermittent, strain on the analyst's psychic functioning. He notes:
Our hard-earned ability to perform analytic work is subject to pressure during every hour we spend with patients. On the face of it, it is inconceivable that any one of us can sustain an optimum level of functioning in anything remotely like an absolutely unvarying state. Why, then, [he asks] do we appear so prepared to expect it of ourselves and to believe it of our peers? (p. 565)
Abend is addressing one of the factors contributing to burnout: persistence of unrealistic and unrealizable analytic ideals. And, he reminds us: