A challenge to psychoanalysis: a review of the negative therapeutic reaction

In this paper, I have summarized the large body of literature on the N.T.R. and noted that the term has been broadened from Freud's original definition of deterioration following improvement or correct analytic work to include a negativistic, ongoing narcissistic reaction with failure to recover. Like Freud, Klein became very pessimistic about reversing this phenomenon. The N.T.R. is a multidetermined but not unitary clinical phenomenon that has generated much controversy. Its dynamics involve interpersonal and intrapsychic elements. Aggression, revenge, and oppositional reactions interfere with analytic progress and may range from temporary to a characteristic way of responding in the analysis. Aggression, the reaction to early frustration and deprivation, plays a large part in the narcissistic organization. Patients who experience N.T.Rs. are shown to have strong narcissistic features. Interpersonally, conflict between longings for fusion and the wish for separateness is central. The transference-countertransference is made difficult by projective identification. Envy and narcissism are critical in the N.T.R. patient's intrapsychic dynamics. Clinical material illustrated the difficult interpersonal and intrapsychic factors that prevailed in a severe N.T.R. patient. The N.T.R. is an insidious obstacle to analytic success and one that requires mastery of the interpersonal and intrapsychic dynamics of the patient and the treatment situation.