Correspondence

Kudos to Carsky and Yeomans for their article (2012) on countertransference problems with “overwhelming” patients who derail treatments and create therapeutic standstill. They succinctly summarize these problems: excess therapist effort, affects of guilt, shame, entrapment, or irritation, slippages of frame that start with well-intentioned efforts to manage engagement of the patient flexibly and are undermined by projective identifications, therapist problems such as isolation, lack of training, difficulty with aggression, or personal stress, and many other helpful illustrations of clinical pitfalls.

I wanted greater clarity, however, about two issues in particular: One, what happens once a treatment has gone wrong and consultation is sought? And two, when and how does one terminate a treatment that will not work? I particularly noted examples in their cases and my own where it becomes clear that the patient does not wish to work or change pathology, for example, to stop a substance problem, take a necessary medication, or adopt an interpersonal change necessary to feel better. For example, I had a masochistic patient disabled by an undiagnosable painful arthritic syndrome that began around the time of her mother's death who wanted me to replace her mother's indulgent unquestioning support (“you and me against the world”) of all her demands and behaviors despite the devastating impact of her personality on her marriage, rehabilitation and occupation. How would the authors handle a stalemate such as this? What does one do when proper clarification, frame, and interpretation repeated tolerantly over a period of time lead to no benefit? At what point does the therapist decide to end or change treatment, and what techniques for doing so would be recommended?

Previous psychoanalytic articles on interminable analysis have described unconscious wishes for an interminable relationship, erotic cycles of guilt and reparation, and excess “castration” anxiety, death