ABSTRACT
Clinical practice is replete with challenges that can result in treatment gridlock or destruction of the therapeutic relationship. There are many junctures that are difficult for the therapist, and the author discusses a wide variety in this chapter. Therapeutic standstills come in a variety of packages: lack of momentum and relational resonance, lack of substance, disinterest, chronic boredom, missing necessary tension, and superficiality are ways standstills can manifest. Other standstills emanate from structural violations of the frame, such as chronic missed appointments, patient suggestions to take a break or dilute the schedule. Patient attitudes and behaviors should be discussed and sorted out; these types of interventions are explained with examples. The chapter discusses a defensive style that can be quite provocative: the devaluing narcissistic defense. This patient’s defensive style of attack and devaluation is described as well as various therapist’s reactions. Suggestions on working with this type of defense are included. Other challenging interludes are described. This chapter discusses various character types such as manic-depressives, paranoid types, and so on, and provides notes on how to approach their particular challenges.
