A View From Riggs: Treatment Resistance and Patient Authority—Introduction to Paper IV

As we have noted throughout this evolving series of articles, efforts to approach the problem of treatment resistance generally focus on the development of biological treatment algorithms, with little attention to psychosocial factors or to meaning. The preferred logic of the field is that of evidence-based medicine, with the gold standard of evidence the randomized controlled trial. This series of articles has introduced alternative points of view to the conceptualization and understanding of the treatment resistant or treatment refractory patient drawn from our experience at Riggs. My first article in the series (Plakun, 2006) surveyed the scope of treatment resistant patients and defined a subgroup who benefit from an alternate approach, and then emphasized the importance of attending to and utilizing negative transference and countertransference in work with such patients. The second article by Jerry Fromm (2006) focused on the way trauma from a previous generation may lead to what appears to be treatment resistance in a patient. In the third series article, David Mintz and Barri Belnap introduced “psychodynamic psychopharmacology” to the field, noting the importance of including careful attention to the meaning of medication along with knowledge of pharmacological effects, particularly in work with treatment resistant patients. Now, in the fourth series article, John Muller offers a conceptual article explicating and further developing the notion of the “Third” in psychoanalytic treatment, and explains how this notion plays a role in treatment resistance.

Muller introduces us to the notion of the Third and its origin, and then differentiates the developmental, relational, and structural thirds as a way of clarifying what has sometimes seemed a hard to define and shifting concept. Among other points he makes is to show how representative clinical interventions from the earlier series articles by Fromm and by me may be understood as clinical applications of his no