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During this discussion I will make an effort to interweave some of the shame themes from Dr. Lansky's innovative and well-organized presentation with Drs. Travin and Bluestone's intriguing look at “impossible” patients.
Drs. Travin and Bluestone speak of these disturbing patients as being erratic, noncompliant, impulsive, desperate, angry, unpleasant, annoying, abusive, violent, irritating, rejecting, irresponsible, hateful, confused, frightening, and frightened. Many of them are noted to be character-disordered, acting out and dangerous. They also speak of staff reactions to these patients, including actual withdrawal from them or becoming anxious, fearful, angry, frustrated, hostile, contemptuous or, finally, indifferent. Although at times these reactions may be appropriate to the danger encountered, at other times they are not, being inappropriately founded on ignorance of cultural differences, prejudice, intolerance, countertransference bias, or overreactions. In response to threatening patient behavior the first staff efforts are understandably containment, but later they need to provide support, validation, involvement, and structural limits as identified by Gunderson (1978).
The authors quote Ogden (1983) who describes mental aspects of development. From early on the ego is perceived as splitting into two unconscious suborganizations in order to develop an “internal object relationship,” one identified with the self and the other with the object. Each can stimulate thinking, feeling, and perceiving. If patients are disposed to project their internal objects