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In the course of our work as psychoanalysts, we often encounter situations in which our patients appear to change slowly or not at all. These moments of partial or total impasse challenge the analyst and bring underlying theoretical assumptions into high relief. Most often, I think, contemporary psychoanalysts tend to see impasse as a reflection of a failure in understanding. The analyst may simply fail to understand the patient. Alternatively, impasse may reflect the replacement of insight by enactment, a process that may itself be variously understood, from different theoretical perspectives, as the patient's recruitment of the analyst to play the role of one of the patient's internal objects, or as the meshing unconscious for both participants of the internal worlds of patient and analyst.
A particularly confident psychoanalyst may argue, in a variant of the old joke that the operation was a success but the patient died, that he or she understood the patient well enough, but the patient did not make use of this excellent insight. This position, however, would itself raise the question of enactment: What drama would patient and analyst be playing out together if the analyst felt that he or she understood the patient, but the patient did not agree? Or, more subtly, what drama might be taking place if both parties agreed that everything important had been understood, but nevertheless no change had occurred?
From another perspective, however, impasse may be viewed as a demonstration of the limitations of insight in effecting change. Experienced clinicians from Freud onward have recognized that analytic change occurs slowly, and that some aspects of mental life cannot be changed at all. Analytic impasse may occur as a reflection of an underlying psychotic or affective disorder. In these cases,