Patients who are severely inhibited in their capacity to free associate and reflect on their associations present a technical challenge. Such inhibitions threaten the treatment with a form of communication breakdown. There is often a sense of futility and a sense that someone must be to blame for the treatment impasse. Efforts to interpret such severe inhibitions often result in intensification of the impasse. Working through such enactments is facilitated not only through accurate psychodynamic understanding but also through a willingness to engage in some degree of spontaneous emotional engagement, self-disclosure, and mutual analysis. When the patient is in a state of psychic equivalence, a particular quality of relational experience is sometimes required for the patient to perceive how external and internal reality are not necessarily equivalent.