This paper was written in an attempt to process extreme counter-transference reactions to an 'absent' patient, i.e. one who attended her twice-weekly sessions only sporadically. At times she did not come for up to several months, thus incurring a serious debt. However, it was not so much the amount owing but rather the constant cancellations, with seemingly 'rational' excuses about her non-attendance that would provoke an intense frustration accompanied, at times, by furious, almost sadistic countertransference feelings in the therapist. The author attempts to make sense of these feelings in the light of the patient's early relationships, reaching a hypothesis that the absences have been necessary to convey, very powerfully, experiences that may not have been communicated by regular attendance.

The difficulties and anxieties involved in working with patients who self-harm or are suicidal are striking and, as is appropriate, frequently discussed. The difficulties involved in working with chronically, often quietly, depressed patients receive less attention, yet many counsellors and psychotherapists describe these patients as those with whom they feel least effective.

This presentation will consider the phenomenology of chronic depression. Drawing on clinical material, the presenter will explore the unconscious dynamics behind the feelings of frustration and self-doubt so often reported by counsellors and psychotherapists working with this patient group.

I will begin by outlining the multi-disciplinary assessment procedure of complex clinical case - a woman who had been described as unable to benefit from psychotherapeutic or psychiatric treatment. She suffered from a severe head injury, language and memory impediment as well as PTSD. I will describe the use of sensorimotor therapy and a modified EMDR approach as part of a full picture of the methodology and outcome. The seminar will offer participants a hands-on understanding of both the assessment issues and therapeutic approaches used.

Taking as read the therapeutic usefulness of a therapist's remaining able to survive long-term work with patients who make little progress and who attack themselves and the therapeutic process, this talk describes how the author examined the relationship between depth therapy and Dante's Divine Comedy, reflecting on questions of containment and of "what is the good" as a means of survival in her work with a borderline patient.

I shall present the story of a 10 years weekly psychotherapy I undertook with a woman patient, who despite achieving enormous progress at times, developed a powerful negative therapeutic reaction that included manic behaviour and criminal activity. Despite many positive achievements these episodes signified a most consistent and insidious way attempt attack and destroy me, and all what had been accomplished with her infantile-dependent self. I will explain how I attempted find and rescue the "dependent sane part of the self from its trapped position inside the psychotic narcissistic structure" (Rosenfeld) and how the therapy eventually led a new born, emerging self.

Impossible patient or patient therapist misfit? Impossible in terms of what? What is the aim in therapy and who decides? How do we think about relief of symptoms and gain of insight? Is "getting worse" a bad sign or part of every therapeutic process? Is the therapy to be adapted to the patient or formulaic? Do we think in terms of diagnostic categories or individuals? Is severe psychosis contraindicated when selecting patients for therapy? These questions and many more need thinking through. This is a good time to do it.

As therapists we hope that the work we do may be of some benefit, so it is sobering when we face the limitation that our skills and experience are simply not enough. Whether or not we believe in the concept of 'the impossible patient', or the idea that psychotherapy is just not suitable for some people, most of us have struggled with particular clients, where nothing seems to work. What do we do when we encounter extreme negativity or when we feel incapable of finding a way out of the relational bind we become stuck in? What do empathy and compassion mean in practise, if as therapists, we experience relentless attack from our patients? Is it holding to endure this, or is the setting of firm limits and boundaries a better approach? This talk will attempt to explore these and other questions.

With reference to Freud's assessment that only "worthwhile persons" could benefit from psychoanalysis, and the reality that the alternative to psychotherapy might be drug treatment on a psychiatric ward, I will argue that all too often the judgement of "impossible to work with" is informed by class bias, a fear of psychosis and an ignorance of the great strides taken in the effective treatment with psychoanalysis. At the same time most of us have patients for whom psychotherapy doesn't work, or least, doesn't work with us. Now what? I suggest that we have patients who are intractably alone, for whom psychotherapy can't be helpful because they are unable to enter into enough of a relationship for the talking cure to be effective. This is a profound disorder. I will offer examples for discussion.

Andrea has anorexia, Betty is borderline, Brenda has bulimia, Cheryl has conduct disorder, Don is drug addicted, Donna is a dominatrix, Erin is exhausted, George is a gay slave, Harry is homicidal, Lara is lifeless, Mary is manic-depressive, Nora is a novelist, Penny is Psychotic, Paula is promiscuous, Susan is schizophrenic, Sarah is suicidal, Tara is a teacher, Vera is violent, Wanda is a worker. And all, together with many more children, adolescents, adults, creatures share the same body. How can a single therapist work with Dissociative Identity Disorder? Where there is a whole group, community or world in one person as a result of enormous trauma how does the therapist manage?

PDF brochure of full programme.