Choice of Treatment versus Treatment of Choice

From the time of Freud's early “Papers on Technique” and his later Introductory Lectures on “Transference” and on “Analytic Therapy”, most analysts have agreed that the transference must be, as Freud put it, the “playground” (Freud, 1914, p. 154) or the “battlefield on which all the mutually struggling forces of the personality should meet one another” (Freud, 1917, p. 454). But all of us have encountered patients who are difficult to treat because we cannot seem to engage them in the transference. Melanie Klein, in her 1946 paper “Notes on Some Schizoid Mechanisms”, describes these patients in the following way:

“Their withdrawn, unemotional attitude, the narcissistic elements in their object relations, a kind of detached hostility which pervades the whole relation to the analyst, create a very difficult type of resistence … The patient himself feels estranged and far away, and this feeling corresponds to the analyst's impression that considerable parts of the patient's personality and of his emotions are not available. Patients with schizoid features may say: ‘I hear what you are saying. You may be right, but it has no meaning for me’ … The expression ‘no meaning’ in such cases does not imply an active rejection of the interpretation but suggests that parts of the personality and of the emotions are split off. These patients can, therefore, not deal with the interpretation; they can neither accept it nor reject it.” (Klein, 1946, p. 313)

Mrs. Klein attributes these patients' difficulties to an excessive use of splitting and projective identification. She and many other analysts have described the detailed, long-term analysis of the transference and countertransference that is necessary for the gradual integration of previously split off and projected parts of the self.

In my experience, there are certain child patients, as well, who are difficult to treat because there is no vitality in the transference relationship. The lack of energy is surprising, sinc