Establishing thirdness. Overcoming an impasse in the treatment of a patient with a delusional disorder

The author discusses the difficulties that arose in the analysis of a female patient suffering from a delusional disorder, where traditional criteria of suitability for psychoanalytic treatment were initially lacking and had to be established as part of the process. The transference-countertransference interaction came to a deadlock, understood by the analyst as due to the patient’s pathological dyadic relating. She was lacking in her capacity of reflective functioning, and there was no potential space to foster a fruitful therapeutic dialogue between analyst and patient. The analyst adopted a bystander perspective as a vantage point from which to comment on the patient’s narrative, whereby she succeeded in gradually altering the dysfunctional dyadic exchange into an interaction where a triadic perspective was introduced as a means to making possible meaningful communication between patient and analyst. Substantial changes were achieved with this procedure as a point of departure. The case study highlights aspects of dyadic versus triadic functioning of the analytic pair, and serves to illustrate theoretical points pertaining to the ongoing debate between professionals on how the basic structural elements of the analytic relationship should be conceptualised.