The Difficult Patient or the Difficult Dyad?—Some Basic Issues

IN A PAPER ENTITLED "The Unreasonable Patient, " Giovacchini (1985) refers to the general situation in which a patient's psychopathology clashes with the treatment process, as a psychoanalytic paradox. He puts it that "transference repetition is essential for analytic resolution but with some patients, its very nature seems to preclude analysis" (p. 8). Taking as an example, patients who seem to enact their right to be unreasonable during the course of treatment, he sees their need for enactment dominating the analytic situation, and the patient's ego as having lost its self-observing function. Clinically, this frequently results in a situation where the therapist, because he feels helpless and unable to maintain his analytic role, experiences the patient as "difficult." The paradox to which he refers is in the fact that a central part of the analytic process is for the patient to be able to experience his primitive affects and mental states in the treatment itself, and that insight formulations always contain the potential of depriving the patient of fully experiencing an affective state to its ultimate resolution. "To some extent every interpretation is potentially premature,