On Working with 'Unwanted' Patients

The 'unwanted' patient often goes through similar trials in trying to find a therapist who can and will work with him as he does in trying to find people who are able to sustain benign interactions with him in his daily life. These patients tend to drive therapists away as they do people in general. They generally present severe narcissistic character deformations which are more than usually exasperating or repulsive. They may oscillate between an over-cloying and obnoxiously negativistic manner in apparently endless repetition of extreme forms of hostile dependence. They can appear needy and demanding yet seem to present intractable resistances if one tries to help them. In some instances they may appear snake-like and cynically chilling. If they are vegetative, they are also wilful and proud, even when in seemingly masochistic and silent ways. They are very sensitive to slights but seem to have long ago accepted that the best they can do is just manage to get through things. They carry a hope tinged with resentment, made heavy with an accusing sense of deprivation and self-pity. They seek relief from pain but have a high tolerance for feeling that things will never change and nothing good can happen to them. However, all this despair seems part of an atmosphere of muted want and rage. Their identity is formed by a chronic sense of injury together with a primitive union with the phallic mother—male or female—who injured them. Thus one moment they may enact the role of helpless victim and then become a terrifying active mass, impulsive, tyrannical or biting. Their personality deformations, further, frequently express themselves in physically unappealing ways, such as unkempt obesity or severely distorting facial and postural rigidities. In these cases the actual body has become closely identified with and formed by a negative self image.

In general, these patients tend to evoke some sense of distaste in the therapists who try to treat them. Their basic