The negative therapeutic reaction.

Abstract

The negative therapeutic reaction is a unique case of negativism in which the patient demonstrates an inability to tolerate success in treatment. This results in the deterioration of the patient's condition shortly after progress is achieved. The NTR is distinguished from either a regression that accompanies a transference neurosis or a form of negative transference in psychotherapy. The hypothesis presented in this article suggests that the patient perceives her/his progress and approval by the therapist as a severe threat to the patient's autonomy. The fear of fusion with the therapist propels the patient into an extreme negativistic position which is expressed by her/his deterioration. Included is the report on the treatment of a middle-aged woman who reacts to improvement in treatment with a negativistic refusal to consolidate these gains and translate them into a more effective adjustment. The therapist must consider the NTR as a part of the larger process of therapy rather than to adopt the patient's view that it is a failure.

Kohut, Kernberg, and accusatory interpretations.

“…Analysts have long been puzzled by the "negative therapeutic reaction," the tendency of some patients to become worse rather than better following interpretations that are meant to free them from their problems (Freud, 1923). Several explanations have been offered for this phenomenon: a sense of guilt and need for punishment (Freud, 1937), a wish to defeat the analyst (Horney, 1948), a fear of change (Ivimey, 1948), a fear of success (Horney, 1948), an oversensitivity to criticism (Horney, 1936), an expression of the failure to achieve separation-individuation (Jaffe, 1981), and the therapist's inadequate technique for dealing with the latent negative transference (Reich, 1945). We now have a simpler explanation.…”

Negative Therapeutic Reaction

“…Attachments to exciting/rejecting internal objects would also account for the conflict between the wish for, and fear of, fusion. Jaffe's (1981) thoughts about the unconscious idea that there are only two alternatives (complete fusion or complete separation) may give therapists a better understanding of the magnitude of what the client fears -either a loss of his internal objects and therefore the loss of her/his self, or a merging with an internal object that is engulfing and devouring.…”

“…catastrophic reactions sometimes are due to not realizing that a fantasy of fusion has been dominating the transference and the patient has suddenly felt separate from us' (p. 387). Jaffe (1981) suggests that an unconscious idea that only two options are available (complete fusion or complete separation) plays a part in NTR. The patient fears fusion with the therapist, then feels guilty for destroying the perceived fusion, then believes he himself must deserve punishment for this.…”

The Role of Shame in Negative Therapeutic Reactions.

“…Every partial solution that ought to result and in others does result, in an improvement or temporary suspension of symptoms produces in them for the time being an exacerbation of their illness; they get worse instead of better. They exhibit what is known as a “negative therapeutic reaction.” (p. 49) Freud's (1923) original observation focused primarily on the paradoxical worsening of symptoms, but negative therapeutic reactions also include those instances in which individuals do not improve with seemingly appropriate treatment or exhibit an inability to tolerate success (Jaffe, 1981). This absence of improvement has been described as “resistance to recovery, interminable analysis, and…treatment impasses” (Finell, 1987, p. 487).…”