Establishing a Transference

In my work at the Austen Riggs Center-and in the reflections of my colleagues in a series of 12 papers published in the Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry-I have encountered patients for whom establishing a usable transference is complicated by intrapsychic, familial, social, and iatrogenic factors. These patients likely make up a significant subset of those labeled “treatment resistant,” as treatment relying on transference takes for granted the patient's-and the therapist's-ability to organize, tolerate, and maintain a transference. Unreflectively, the label “treatment resistant” positions the problem in the patient, rather than in treatment relationships and interventions. In this essay, I will reconsider these patients, their needs, and the needs of therapists working with them; furthermore, I will suggest team-based milieu treatment as one means of addressing the factors contributing to disorganized, intolerable, or otherwise unusable transferences. For these patients, milieu treatment-wherein the patient is surrounded by potential transference objects and known across time and contexts, and the treatment is provided by a team-may be a useful precursor to outpatient treatment, providing a space within which to organize, tolerate, maintain, and, ultimately, establish a usable transference.

As a group, patients labeled “treatment resistant” generally carry multiple diagnoses, have a history of self-destructive behaviors, and have tried multiple psychotherapies and medications without lasting positive effect. The therapists working with them often feel beleaguered, concerned about risk management, and very much alone. Of the patients admitted to the Austen Riggs Center, a psychodynamic residential treatment center in Stockbridge, Massachusetts, where “treatment resistant” patients are often referred, patients have an average of six diagnoses upon admission, and 40% have made near-lethal suicide attempts. On the psychological te