All therapists have a vision of the “good” patient or therapy — cooperative, trusting, mutually beneficial, and productive. Most of us have also had experiences with the “difficult” patient or therapy, which can feel adversarial, guarded, non-mutual and unproductive. Historically, difficulty in therapy relationships has been seen as the “fault” of the patient, who is conceptualized as resistant to change. As the field has come to encompass the co-constructed crucible of both therapist and patient subjectivities, more has been written about the contribution of the therapist’s inadequacies and vulnerabilities to impasse in psychotherapy.

This course will explore the intersection of patient and therapist when the therapy relationship stalls, implodes, or explodes. How do we understand relational “k(nots)” (Pizer, 2003)? The way some aspect of therapy becomes seemingly impenetrable — who said what to whom, and what was meant. These distressing conversations are often at the heart of a treatment but can feel excruciating. When is a diagnosis of a personality disorder an evacuation of blame, and when is it a useful tool? How might the problem be located in the therapist’s lack of skill or confounding countertransference? What unconscious material is being enacted?

Senior clinicians approach this topic from multiple theoretical perspectives, varying definitions of “difficulty,” and years of clinical experience with working through — or not working through — problematic intersections of subjectivity. Join a group of seasoned colleagues in an intensive study of this topic through reading, didactic discussion, and case presentations.

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