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413 The Difficult Patient – 4 seminars

Course Leaders: D. Carveth, PhD and R. Ruskin, MD

Course Description

The seminar will study difficult cases in analysis by means of presentation and discussion. Patients with severe psychopathology can be impulsive, act out, suffer extreme mood shifts and have more difficulty in reality testing than is typical of hysterical and obsessional neurosis. The seminar will examine difficulties presented by their diagnosis and treatment and evaluate results. The seminar will explore whether such patients have a unique etiology or whether it is a question of the degree of their severity.

Difficult patients can often also be patients who present risks of harm, either to themselves or others. Students will learn to identify and evaluate situations involving potential risk of harm. These are complex situations requiring mature judgement, including the judgement of when to seek consultation from a supervisor and/or legal advisor. We will explore how a deeper psychoanalytic understanding can be integrated with the need to make judgments about risk, and to act on these risk assessments, and what actions need to be taken.

Course Objectives

Candidates will learn to:

  1. Formulate the problems of the “difficult patient”: provocative, homicidal, narcissistic, masochistic, suicidal (1.1, 1.2, 4.5c, 4.5f)  .
  2. Observe the commonalities and differences in a broad range of psychopathologies (1.3).
  3. Understand the technical problems posed by patients who are difficult to treat, and to integrate into practice appropriate treatment strategies (4.5).
  4. Observe in themselves the impact of the difficult patient on their countertransference, and to respond appropriately (1.4, 4.2, 4.3).
  5. Expand their exploration of the therapeutic potentials of psychoanalysis (1.2, 1.3).
  6. Learn how to construct a risk assessment to determine risk of client self-harm, harm to others, and harm to analyst, including distinguishing between passive suicidal ideation and active planning. (4.4)
  7. Learn in relation to risk assessment, the limits of confidentiality and when there is a duty to report (for instance to the Children’s Aid Society), and in relation to this, when to seek consultation. (4.4)
  8. Review CRPO (2018) guidelines on “Disclosing Information to Prevent Harm” (4.4)

Seminar 1

The Hateful Patient

Required Reading

Epstein, L. (1977). The Therapeutic Function of Hate in the Countertransference. Contemp. Psychoanal., 13:442-460.

Seminar 2

The Deeply Masochistic Patient

Required Reading

Joseph, B. (1982). Addiction to Near-Death. Int. J. Psycho-Anal., 63:449-456

Seminar 3

A Homicidal Patient

Required Readings

Hanly, C.  (1992). On narcissistic defences. The Psychoanalytic Study of the Child, 47: 139-157, pp.148-156.

Hanly, C.  (1998). Reflections on the analyst’s self-disclosure. Psychoanalytic Inquiry, 18: 550-565.

Hanly, C.  (2009). On Truth and Clinical Psychoanalysis. IJPA, 90: 363-73.

Porter, M. (1998) On Beginning with a Borderline Patient. In On Beginning an Analysis Ed. Jacobs T. and Rothstein, A. IUP Press pp. 163-178.

Seminar 4

A Suicidal Patient

Required Readings

Ruskin, R. (2010). The Tragic Impact of Failure and Dread: Therapists Whose Patients Suicide. Fifth Joint International Conference. Failure: Psychoanalytic Explorations. Edinburgh Scotland.

Hanly, C. (2018).  Narcissism, realism and the analytic process.  (Unpublished; copies to be provided by teacher).

Calef, V. Weinshel, E.M. (1979). The New Psychoanalysis and Psychoanalytic Revisionism.  Psychoanal Q., 48:470-491.

CRPO (2018) guidelines on “Disclosing Information to Prevent Harm”

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