Issues of Technique where Patients Relate with Difficulty

Individuals who have had a serious misfit with key objects in their childhood tend to withdraw behind a 'shell', to remain unrelated and uncommitted in meaningful ways to real people, and to become intensely involved with their inner world. The shell precludes interactions with other individuals that would otherwise enhance expectable maturation and individuation. A model of the effects of this shell upon the development of realistic expectations and upon self-reflectiveness is presented. The model aims at highlighting the issues relevant to the various stages of treatment of patients with this condition.

Three stages in the treatment, each with its own therapeutic dilemmas for the analyst, are suggested. The first stage, before a transition from an unrelated to a more related involvement with the analyst has occurred, raises the issue of whether, when, and in what manner, the analyst might confront the patient with his unrelatedness. The second stage, where the now-more-involved patient manifests unrealistic expectations towards the analyst, presents the problems of how far and in what manner, if ever, the analyst should meet the patient's request for gratification or confront him and at what level of regression therapeutic progress will best take place. Where the analyst eventually believes himself in a position to be interpretative, the third stage of the treatment, he is faced with the question as how to make meaningful explanations to someone where understanding and capacity for reflectiveness have been impaired.