Therapeutic Aggression

Over 20 years' practice in psychiatry and psychotherapy I have been impressed by the difficulties experienced by mental health staff in general (and psychotherapists in particular) when dealing with aggression in treatment relationships. As a young trainee I observed that colleagues who were competent in dealing with their own aggression handled aggression in patients more skilfully than those whose relationship with their own aggression was ambivalent, and speculated that aggressive competence was a necessary skill to be acquired in training. I was, however, struck by the almost complete absence of any mention of this aspect of therapeutic behaviour in textbooks, seminars or case discussions. A subsequent observation was that mental health staff and psychotherapists seemed uncomfortable to acknowledge their aggression, much less to use it. Discussion of overt or covert aggressive strategies in case management often provoked agitation and defensiveness, and led me to speculate that people with anxiety or ambivalence about their own aggression might select themselves for careers in mental health. A third observation was that patients, especially those who had been the subject of ill treatment or abuse, had a tendency to provoke re-enactment of that experience in treatment relationships, and that the process was often handled clumsily by the therapist with negative therapeutic consequences. Over the years, experience both as a practitioner and as a supervisor has reinforced these observations and led to the speculations that therapeutic aggression may be an important skill which psychotherapists are reluctant to use because of the personal dynamics which originally brought them into the profession.

The Existing Literature

Freud (1910) originally referred to countertransference as the analyst's unconscious resistance to dealing with areas of the patient's pathology which the analyst himself found difficult. Forty years later, Paula Heimann (1950) was ‘struck