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This chapter had its origin several years ago, when after a long period of apparently effective therapeutic work, a patient became convinced I was causing him great harm, indeed had destroyed whatever chance he had for a satisfying life. For some time the patient and I attempted to understand this alarming turn of events, but our efforts failed. Though I could empathize with his feelings, and he with mine, we could not bridge the gap between our respective views; the affective state worsened and his treatment foundered.
The problems faced with this patient are not unique and have drawn the attention of psychoanalysts and psychotherapists since the work of Breuer and Freud (1893-95) almost a hundred years ago. They noted that patients develop strong feelings and attitudes about us, the transference–seemingly inappropriate to the present and assumed or inferred to be related to past expectations and experiences (Freud, 1917). Though Breuer and Freud's observations are well known, we, and our patients, continue to be beset by the same difficulties. Patients are not readily freed of their painful affect states, and occasionally their intensity becomes so alarming that we flee, as did Breuer; or the patient flees, as did Dora (Freud, 1905) or the patient to whom I referred.
In the attempt to understand this phenomenon, several possibilities present themselves. We may simply assume that the problem lies with the patient, that the attraction of past patterns was so strong that he could not relinquish his preformed expectations, that is, that his