The Construction of the Psychoanalytic Setting with a “Difficult” Female Patient through an Intersubjective Process: The Use of “Anticipatory Interpretations”

The technique of dealing with the “difficult” patient is now a problem common to both private analytic practice and dynamic psychotherapy as conducted in public clinics.

A brief examination of recent psychoanalytic contributions from various countries highlights some important aspects of this technical

problem: dealing successfully with the clinical reality of contemporary practice. First, there is the importance from the outset of analyzing the patient's unconscious defenses which may lead him to avoid analysis (Rothstein, 1996). Second, there is the advantage of making the “working alliance” something within and not outside the transference and countertransference dimension (Deserno, 1992). Third, there is the need for the analyst to come to terms with the fear, agitation, confusion, paralysis, and petrification of affective life that characterize many patients today, by constantly working through these problems as they come to the fore in the transference-counter-transference (Holderegger, 1993). Fourth, there is the vital importance for the analyst to be aware of his way of relating to the patient as it is influenced by his own personality, analytic style, and theoretical framework (Harsch, 1994; Stolorow, Atwood, and Brandcraft, 1994).

An approach based on an intra- and intersubjective analysis of the transference-countertransference dimension (seen as an unconscious intrapsychic relational continuum), can contribute both to diagnosis, understood as the evaluation of the therapist-patient couple's potential for shared psychodynamic activity, and to treatment, understood in its broadest sense as the unfolding and realization of shared potential.

Extrinsic factors such as the institution, the therapist's training, the time at disposal, the patient's economic resources, and so forth, must, in my opinion, be seen in constant and strict relation to the intra- and intersubjective meanings these factors have for the patient and the therapist.

In the clinical case report