Problem patients or troublemakers? Dynamic and therapeutic considerations.

The article addresses itself to patients who are of above-average difficulty to deal with and who set up a variety of therapeutic obstructions. The scale of disruptive and counterproductive actions on the part of certain patients is extremely broad and represents a psychopathology per se rather than a specific psychiatric diagnosis. A grouping of ten categories covering clinical manifestations seen in problem patients is offered. Dynamic factors pertaining to the described symptoms are discussed. Brief reference is made to Sullivan's construct of malevolent transformation and Freud's tenet of the negative therapeutic reaction. Several case illustrations are offered indicative of a variety of problem-patient situations in the process of psychotherapy. Finally, a few general considerations about working with particularly difficult patients are added. Special reference is made to various ways of setting limits as well as to the particular role of countertransference in the broadest sense of the term.