Psychodynamic Therapy and the “Difficult” Patient

SPECIAL REPORT: PSYCHOTHERAPY

We have all encountered patients we experience as “difficult” who do not respond to our best efforts. They may be caught in cycles of recurring crisis, stuck in impasses, or earn the label of treatment resistant. While there are patient- and disorder-specific contributors to the experience of patients as difficult, the problem may come from limits in our understanding of their struggles as they pursue recovery. According to the Substance Abuse and Mental Health Services Administration, recovery is a process over time that leads to a self-directed life. Psychodynamic therapy within an overall psychodynamic perspective may be useful when we experience a patient as difficult. Here, I describe some of our unwitting contributions to the experience of patients as difficult and offer 5 helpful psychodynamic concepts.

Beyond the Biomedical Model

Former National Institute of Mental Health leader Thomas Insel, MD, noted in 2017 that, despite numerous studies emerging from the field’s shift from a biopsychosocial model toward a biomedical one, all that science failed to “move the needle in reducing suicide, reducing hospitalizations, [or] improving recovery for the tens of millions of people who have mental illness.” The biomedical model overvalues 3 false assumptions that contribute to the experience of patients as difficult or treatment resistant when it is the model that is failing.¹

Genes, Environment, and the Illusion of Simplicity

The reductionist notion that “genes = disease” has not held up under scrutiny. Genome-wide association studies and research on copy number variations (mutations) show that hundreds of genetic markers (single nucleotide polymorphisms [SNPs]) account for a small fraction of the variance in mental disorders. Moreover, many of the same SNPs are shared across multiple disorders, further complicating the hope of precision treatment based solely on genetics. Similarly, the brain’s connectome is not disease specific. What has emerged is a gene-by-environment model; genes and environment interact in disease and health. Early adverse experiences—such as abuse, neglect, and deprivation—are now recognized not merely as risk factors, but as epigenetic agents that methylate DNA and alter gene expression.

Gene-by-environment interaction is just another way of saying biopsychosocial. There are complex interactions at play between genes and environmental factors in the messy reality that best fits the complex data. Such environmental factors as relationships arguably play a major role in causation—and in cure, as a psychotherapeutic relationship can be valuable.

The Myth of the Single Disorder

A second flawed assumption is that patients present with single disorders that respond to specific evidence-based treatments. The reality is that there are high rates of comorbidity and treatment failure even with evidence-based treatments. In the large, multisite STAR*D study, 78% of patients with depression had comorbid conditions or suicidal ideation that would have excluded them from randomized controlled trials (RCTs).² Only 22% of STAR*D patients with depression were selected for RCTs, while the less responsive individuals with comorbid conditions were the vast majority.

The Collaborative Longitudinal Personality Disorders Study demonstrated that personality disorders, especially borderline personality disorder (BPD), strongly predict poor treatment outcomes.³ The presence of often undiagnosed BPD contributes to the problem of treatment resistance or difficult patients. While the mainstay of BPD treatment is therapy rather than medications, psychiatrists are doing less therapy.⁴ BPD and other personality disorders are often overlooked as we evaluate patients, who may then be misdiagnosed and inappropriately treated with medications rather than psychotherapy.

Recognizing high rates of comorbidity and shared genetics across disorders, the replicated work of Caspi et al points to a single underlying psychopathology factor (“p”) accounting for an individual’s risk of developing a mental or substance use disorder.⁵ The Figure summarizes the cascade of factors that may lead to a difficult or treatment-resistant patient.

FIGURE. The Difficult Patient and the Descent Into Treatment Resistance

The Limits of Pharmacology

The third questionable assumption is that the best psychiatric treatment is medication. While there is no doubt that medications are effective, they have high failure rates (especially when measuring clinically meaningful rather than statistically significant change), and high placebo response rates, with the difficult or treatment- resistant patients least likely to benefit from medication^1,2 and least likely to have a positive placebo effect.⁶ Overreliance on medications helps create difficult patients. In the real world, comorbidity, trauma, the impact of early adversity, and personality disorders are frequent, and biomedical tools alone are often insufficient.

Psychodynamic Contributions

Psychodynamic concepts are valuable tools for understanding and engaging the so-called difficult or treatment-resistant patient. Five psychodynamic concepts are especially helpful, as follows:

• Therapeutic Alliance as Goal, Not Precondition. The therapeutic alliance (TA) is the most robust predictor of outcome and is especially important in working with difficult patients.⁷ It is the one part of the therapeutic relationship that requires careful and explicit negotiation, while the other 2 parts (the real relationship and the transference relationship) will always be present. It is wise to negotiate the alliance as an agreement between patient and clinician to collaborate in a task to which each is committed and subservient, even when the going gets tough. This includes an agreement to explore the patient’s mind and meaning. However, a difficult patient often has good reasons not to trust medical authorities. With such patients, the TA is an initial goal of treatment rather than a precondition; we begin our work with a proto-alliance. Inevitable ruptures in the proto-alliance, and their repair, and the sorting of each enactment raises the level of mutual trust and moves the work toward an authentic alliance.⁸ Achieving a trusting TA can be transformative with a difficult patient.
• Transference and Countertransference. These are inevitable therapeutic phenomena that we ignore at our peril as they enter the room with our patients. Understanding how patients unconsciously reenact past relationships in the treatment dyad helps clinicians stay grounded, particularly when the clinician or patient experiences difficult emotions. Indeed, our experience of a patient as difficult or treatment resistant may be a signal about issues within ourselves. Sorting this out can help us see our own influence on the experience of a patient as difficult.
• Psychodynamic Psychopharmacology. Mintz has described this approach to prescribing as attending not only to the biochemical effects of medications but also to their meanings to the patient and prescriber.⁶ Attending to these can illuminate issues contributing to impasses, nonresponse, and countertherapeutic overprescribing.
• Immature Defenses.: Splitting and Projective Identification. In splitting, patients oscillate between idealization and devaluation and thus evoke powerful feelings in the clinician and treatment team. That may be part of what makes work with such patients feel difficult. In projective identification, a patient unconsciously projects disavowed aspects of themselves into the clinician, who may then feel, think, or act in accordance with those projections. These projections are unwitting invitations to play a role in the patient’s internal drama. Such unconscious invitations are often hard to refuse. Indeed, projective identification is the pathway to enactment.
• Enactment. Projective identification is a defense used by all humans to varying degrees. Since there are 2 humans in a therapeutic situation, clinicians may also unwittingly deploy this defense mechanism in work with patients—especially with difficult or challenging patients who are prone to projective identification. When we unwittingly accept or refuse a patient’s projective identification because of our own early life vulnerabilities, we find ourselves in a mutual and complementary set of projective identifications.¹ The patient projects an unwelcome bit of their inner world into the clinician, while the clinician unwittingly accepts this and projects a bit of their inner world into the patient. This may lead to an impasse or repeating patterns of rupture, with authentic engagement required for repair. For instance, clinicians with discomfort around anger may find themselves extending sessions or becoming overly accommodating with patients whose transference to them is that of an abuser.

The therapeutic task is not simply to avoid enactments. With difficult patients, enactments are inevitable, but we can learn to detect, analyze, and utilize them to repair treatment ruptures and strengthen the TA. This work is part of moving from a proto-alliance toward the goal of an authentic TA. Experienced psychodynamic clinicians, like skilled skiers, do not avoid the slippery slope of enactment—they learn to find their edges so they can remain in balance and under control on the slippery slope. While these unconscious, mutual interactions can derail treatment, they also offer an opportunity to deepen the alliance and resolve impasses.

Conclusion: A Call for Integration

The recent American Psychiatric Association (APA) report The Future of the Psychiatrist asserts that the future work of psychiatrists is treating difficult patients, and that psychotherapy skills will remain a cornerstone of our work.⁹ Psychiatrists’ work with difficult and treatment-resistant patients, and their leadership of treatment teams, are enhanced by mastery of psychodynamic therapeutic skills, whether the psychiatrist is in the role of therapist, prescriber, or team leader. Familiarity with immature defenses, such as splitting and projective identification, attending to transference, countertransference, and the meaning of medications, utilizing enactments, and skills in negotiating an authentic TA, all advance the treatment of difficult patients. Psychodynamic therapeutic skills are a powerful complement to biomedical approaches to our patients. Integrating knowledge of brain, mind, and relationships is our best hope to address the full complexity of human suffering.

Dr Plakun is a senior consultant at the Erikson Institute for Education, Research, and Advocacy at the Austen Riggs Center. He is also the past chair of the APA Committee on Psychotherapy by Psychiatrists and the founder and past leader of the APA Psychotherapy Caucus.

The views expressed in this paper are those of the author and do not necessarily represent those of the APA or any other entity.

References

1. Plakun EM, ed. Treatment Resistance and Patient Authority: The Austen Riggs Reader. W.W. Norton & Company; 2011.

2. Wisniewski SR, Rush AJ, Nierenberg AA, et al. Can phase III trial results of antidepressant medications be generalized to clinical practice? A STAR*D report. Am J Psychiatry. 2009;166(5):599-607.

3. Skodol AE, Gunderson JG, Shea MT, et al. The Collaborative Longitudinal Personality Disorders Study (CLPS): overview and implications. J Pers Disord. 2005;19(5):487-504.

4. Mojtabai R, Olfson M. National trends in psychotherapy by office-based psychiatrists. Arch Gen Psychiatry. 2008;65(8):962-970.

5. Caspi A, Moffitt TE. All for one and one for all: mental disorders in one dimension. Am J Psychiatry. 2018;175(9):831-844.

6. Mintz D. Psychodynamic Psychopharmacology: Caring for the Treatment-Resistant Patient. American Psychiatric Association Publishing; 2022.

7. Horvath AO, Del Re AC, Flückiger C, Symonds D. Alliance in individual psychotherapy. Psychotherapy (Chic). 2011;48(1):9-16.

8. Bach S. On treating the difficult patient. In: Ellman CS, Grand S, Silvan M, Ellman SJ, eds. The Modern Freudians: Contemporary Psychoanalytic Technique. Jason Aronson Inc; 1999:185-195.

9. Potash JB, McClanahan A, Davidson J, et al. The future of the psychiatrist. Psych Res Clin Pract. Published online March 27, 2025.