Carsky presents details from a case to illustrate the problems encountered in the treatment of a severely disturbed psychotic young woman in an inpatient setting. She describes the dynamics involved in the impasses that developed, and how the hospital staff helped her and the patient resolve them, particularly by helping them experience and deal with the severe and primitive rage reactions being stirred up in the treatment. Carsky reviews some of the literature and offers ideas about negative therapeutic reactions and interactions, not only as they occur in the patient-therapist dyad, but in the larger social system of the hospital setting.