The resolution of impasses in long-term intensive, inpatient psychotherapy

Selected literature is reviewed, and clinical material is presented to discuss the phenomena of negative therapeutic reaction, interaction, and impasses in psychotherapy. It is suggested that certain seriously ill patients, in whose therapy an impasse develops, suffer from both the primitive superego pathology or other intrapsychic conflicts that have been described in the literature on negative therapeutic reaction and from a tendency to act so as to recreate these struggles in the external field, often in the form of negative therapeutic interactions. In some such cases, outside assistance for the therapist is necessary in order for the treatment to move beyond a stalemate. In seriously disturbed, hospitalized patients, interventions by the entire treatment team, not simply the therapist alone or the therapist and supervisor, are sometimes required to enable the treatment to proceed. This may be due to the primitive and extremely violent nature of such patients' conflicts, which may strain the limits of a dyadic relationship.