Treatment issues of patients who engage in power struggles

Patients who use a predominance of anal defenses pose particular problems in the first stage of treatment. The frame and structure of psychoanalysis (i.e., reserved session time, policy of missed sessions, frequency of sessions, use of the couch) and psychoanalytic psychotherapy often create and provoke intense defensive behavior. The defensive behavior can be expressed in a power struggle with the therapist. Premature termination of treatment is a significant threat particularly since a working alliance has not yet developed. Parameters may need to be introduced initially, in order to engage and keep the patient in treatment. A clinical case is offered to demonstrate treatment considerations.For all of us engaged in clinical work, it may be especially relevant to be reminded that one of the greatest indignities is regularly endured by our patients, no matter how gently we cushion the blow, or how much we strain our empathic resources. I am referring here to the indignity of being an adult in therapy, while simultaneously allowing the emergence in the transference of infantile aspects of ourselves that the adult part of ourselves experiences as so humiliating and demeaning, and further, having to share it with another adult. Segel, N. (1981), p. 474