In pursuit of psychic change: The Betty Joseph workshop Edited by Edith Hargreaves and Arturo Varchevker New Library Series (Editor: Susan Budd). London:  Brunner-Routledge and Institute of Psychoanalysis. 2004.  206 pp.

British analysts who cohere into a group around the work of Betty Joseph have a consciousness that they may be on to a paradigm shift in psychoanalysis. Joseph (1975, 1988) pioneered an approach to working with particularly resistant patients. This has inspired a number of Kleinian analysts, of whom I have to say I count myself one. A number of those analysts have met with her as a research workshop over many years to discuss their struggles with difficult patients who persist in being suspicious of, and antagonistic to, the very existence of help and change.

In something of a tribute to Betty Joseph, those analysts have produced a volume of their papers: ‘With differing styles and some difference of theoretical emphases, all the contributors to this book illustrate … the spirit of enquiry in the workshop’ (p. 8). The kinds of patients under discussion tend to view negatively, and avoid, anyone who wishes to care and treat. Hence these patients are particularly hard to reach, and the field of interest is one concerned with negativity, resistance and avoidance of what the caregiver thinks is most necessary. They can view caregivers with extreme suspicion and sense of threat, and most in the helping professions find them so impossible they pass them on to psychoanalysts and psychoanalytic psychotherapists as a last resort. The discovery and increasingly widespread use of anxiolytic medication and antidepressants have led to those patients of old—the anxiety states, hysterias and milder depressives—no longer finding their way to the doorstep of the analytic consulting room. Instead, we analysts tend to be restricted to the struggle with more ‘resistant’ cases. Psychoanalysis is fortunate that it is founded in an understanding of resistance in its various forms. There is pragmatism in specialising in these patients.

The really important question is what to do with these treatment-resistant cases. And Betty Joseph has put her hand up with an idea. This book demonstrates th