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Patients who suffer from severe psychotic illness, those who are severely narcissistic, and those who do not get better or even get worse as psychotherapeutic treatment progresses have always been a special focus of my interest. In this book, drawing on material from my own practice and from those of psychoanalysts and psychotherapists whom I have supervised over the last twenty years, I want to give an outline of the ideas I have developed about such patients. In Part Two of the book, I shall present my ideas about the specific contribution the analyst or therapist can make towards influencing the patient for better or worse. In Part Three, I will outline how I think a correct understanding and approach to the problems created by what we have come to term ‘narcissism’ are essential if the analyst is to function therapeutically. In Part Four, I shall discuss the complex ways in which aspects of projective identification can both assist and undermine the therapeutic relationship.
It is central to my thinking that analytic psychotherapy can be an enormous influence on very disturbed patients, but this influence can be for both good and ill. Some of the treatments I shall discuss did not end well, although not, I think, because the patients were beyond help. What happened was that an impasse developed in the relationship between patient and analyst, something which can happen very easily with a psychotic patient, and this could not be overcome. I believe that such impasses are often created by the therapist's response to the patient's communications and can be avoided by paying careful attention to what the patient is saying. It is my conviction that the psychotic patient's speech and behaviour (particularly in sessions) invariably make a statement about his