How do you perceive a crisis that arises in therapy? Is it always a threat to treatment, or can it instead serve as a key to the deepest levels of the patient’s psyche? Should it be regarded as a destructive factor, or rather as a breakthrough point that allows hidden mechanisms of the patient’s inner world to come to light?

Treatment challenges occur when the acting out of an underlying conflict threatens to overwhelm the treatment and derail or end the therapeutic process. Although these moments in treatment have the potential of rendering the therapist so anxious that it is difficult to pursue exploratory therapy, they also offer important opportunities to advance the work of therapy. In managing challenges the therapist may, on a practical level, become more proactive in the sense of calling the patient at home or communicating with a family member and, on a technical level, increase the speed of interpretations or make deeper interpretations. Dealing with crises may involve reinforcing adherence to the treatment frame or may involve temporarily deviating from technical neutrality. 

In the early phase of therapy, the patient’s participation—that is, discussion of problem areas (interpersonal conflict, self-destructive behavior, depression, etc.)—generally consists mostly of thoughts of which the patient is already aware. The character pathology—in particular, the internal splitting—so fundamentally underlies and determines the patient’s experience in the world that he or she is not aware of it; the structure of the pathology is the structure of the patient’s subjective reality. This deeper level of disturbance—the disorder of psychic structure—is initially most evident in the patient’s actions, creating the need to pay special attention to actions and the therapeutic interaction. When the patient’s actions threaten to derail or end the treatment, the opportunity for deeper understanding goes hand in hand with the threat because it is a sign that intense affects have been activated in the treatment, usually at a time when the patient’s internal splitting is less effective in keeping a disturbing self or other representation from consciousness. To a large extent, it is in dealing with treatment crises that the patient’s inner world becomes available for observation and exploration. 

Crises, especially in the early phase of treatment, may include a component of challenging the treatment frame to see whether the therapist will adhere to or abandon the parameters set up in the treatment contract. Adherence to the parameters by the therapist is generally reassuring to patients who at some level are aware of a need for containment. Crises may also occur after the patient has settled into the treatment frame. Crises may correspond to moments when therapy has disrupted the precarious balance of primitive defense mechanisms or when the chaos of the patient’s life has calmed down enough for the patient to consciously experience the identity diffusion that leaves him or her feeling empty and lost in the world. The patient may feel less anxious in a storm of crises than in the awareness that he or she has no clear sense of self or direction in life.

Crises often represent enactments of feelings aroused in the transference, so a first question for a therapist to consider when a crisis develops is the following: 

“What is going on right now in the patient’s experience of me and the therapy that would lead to a threat to drop out (noncompliance with contract, psychotic regression, etc.)?” 

It may be that in order for the patient to avoid a painful selfawareness, the projection of an undesired internal representation becomes so intense that the patient’s experience of the therapist is overwhelmed by the projected negative affect. 

Because these challenges in treatment tend to elicit strong reactions in the therapist (e.g., anxiety, frustration, despair, hatred), the exploration of these episodes requires careful management lest the therapist get drawn into a pathological mutual enactment with the patient, leading to abandonment of the exploratory effort or the therapy altogether. 

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(c) Yuliia Holopiorova,

Ukrainian Association of Transference-Focused Psychotherapy