THE PSYCHODYNAMICS OF FAILURE IN THERAPY

This study of failures in psychotherapy indicates that successful treatment of the psychoneuroses necessitates a consideration of the following points.

(1)Motivation.—An adequate understanding of the individual's motivation incoming into treatment requires that the intake worker be constantly alert to the ways in which the treatment situation, particularly in public clinics, may be used for ulterior motives and not because of genuine internal anxiety. We have illustrated this by citing cases where the patient comes to the clinic because psychiatric treatment was made a condition of remaining in school, or of being placed on parole. Patients may come into treatment because of other types of external pressure, such as the family, or the treatment situation may be too threatening to the wife or husband of a patient already in treatment and cause them to seek treatment. Unless the ulterior quality is dealt with promptly and sufficiently at the very onset of therapy, our experience indicates it will remain as a blanket of resistance over any significant material that may be obtained and prevent any progress in these areas. Ideally, inner anxiety must be the motivation; individuals with secondary motivation should be accepted only on a trial basis, and the first therapeutic problem should deal frankly with their motivation or lack of it. Only when this can be removed as resistance and inner anxiety mobilized, can it be considered that treatment has actually started. Placing these individuals on a trial basis prevents them from feeling secure in their deception and helps to mobilize the anxiety necessary for progress.

(2)Dynamics.—A prerequisite to any successful treatment is a correct formulation of the psychodynamics of the disorder. The young girl in the second case illustrates the therapeutic confusion and failure due to incorrect evaluation of the psychopathology. If incorrect estimate of the ego strength is made, or if interpretations are made to persons with weak ego, treatment fails. Again this is best shown in treatment of the patient in Case 2. She suffered from a deep emotional disturbance of at least prepsychotic degree and did not have enough ego strength to form transference relationships.

(3)Transference and Countertransference Problems.—Regardless of the type of treatment, any therapeutic relationship contains transference and countertransference aspects. Any form of psychotherapy that ignores these elements can only be blind therapy. Although patients may benefit in therapeutic situations in which transference or countertransference elements are ignored or not perceived or both, it is only by awareness of these qualities that we can actually understand what is happening and what is not happening in therapy. Several of our cases cited illustrate how failure can be a direct result of ignorance of the transference or countertransference aspect of the relationship or of the inability to tolerate or work with these feelings. This is shown particularly well in the first and third cases. In the example of the veteran, the therapist's own attitude toward the army prevented adequate dealing with the patient's feelings as well as blinding him to the patient's deception. The third case illustrates therapeutic failure due to inability to cope with a patient's hostility.

The narcissistic need of the therapist to be loved frequently results in the therapist failing to encourage the patient to express hostility. Even more important is the therapist's inability to accept the libidinal aspect of the relationship because of his own anxiety.