The therapist may be able to enlist these patients' need to be correct by praising them about how they seem to usually be on the mark and that the challenge now is to see if they can be on the mark about the analysis of their own deficits.
The invisible patient. These patients use the composite defense of obedience and passive defiance to protect themselves from the aggravation of being controlled or belittled. They may have had belittling or authoritarian parents. They seem to be very compliant and cooperative on the surface, but on deeper interaction they are withholding and uncooperative and seem to have a wall around themselves against real intimacy. They tend to not show up for important events, are late for work, do not complete chores they agree to do at work or with significant others, and have conflict with people in these areas; this usually being the reason they have come for therapy.
Patients may often be late for sessions, not show for the sessions and often be in arrears with fees. They set up relationships so that they can relive a pattern of being oppositional to a scolding person in authority (e.g., spouse, boss, therapist). They will often use intellectualization and rationalization to describe their behavior, and while they ostensibly agree with everything the therapist has said, there is no effective change in their life strategy. If the therapist does not terminate the therapy because of either reasonable or oversensitive (countertransference) reactions to these patients because of their invisibility (e.g., poor attendance, late fees), these patients may eventually terminate the therapy using an excuse such as "work or family duties" that are only more displays of passive defiant behavior.
Standard approaches to gain insight may be of help. In some patients, however, the passive defiance may be so ingrained that a paradoxical approach, where the therapist tells the patient that the problem is unfixable and that the therapy should focus on how to live with the defiance, will engage this patient in a defiant stand to fix the problem.
The rubber cement patient. These patients use the defense of clingy "object hunger" (intense persistence to avoid separation from significant others) in order to protect themselves from the fear of being alone. They may have had some childhood experiences of feeling abandoned or, in reverse, of never practicing being on their own. Some children are also born with intense dependency needs that can develop into a maladaptive style when mixed with a particular upbringing.
These people often get into and/or stay in relationships that are clearly unhealthy from the start, causing conflict that brings them to therapy; or they may present to therapy when their partner proposes a breakup. They may get involved with partners who are inappropriate for them (e.g., violent, alcoholic, promiscuous). It is not necessarily that these patients are "looking for" difficult people, but because most people would avoid entering or continuing in these unhealthy relationships, these potential partners naturally do not realize relationships until they come across a dependent person willing to cross these hurdles and stick with them. The patients also tend to have trouble realizing relationships because the intensity of their neediness pushes people away. They may have a repertoire of rationalizations for their behavior.
These patients will implore the therapist to help them find ways of improving a destructive relationship or try to get the therapist to convince their partner not to break up with them rather than change their maladaptive defensive strategy. They may request phone calls or e-mails from the therapist between sessions to hold on to a connection with the therapist to tide themselves over their pain. They may push for the therapist to give them the answer on how to prevent a breakup.
These patients are mainly interested in having their defense of object hunger work better for them and will terminate the therapy when they sense that the therapist cannot or will not collude with their determination to promote their defense of clingy dependency. The therapist may react by trying to save these patients too much and thus break boundaries by trying to give too much concrete help, or the therapist may devalue these patients because their clingy behavior becomes annoying to the therapist.
