Psychiatry is the medical specialty that focuses on disorders of the mind, especially disturbances in thinking, behavior, and emotions. Psychoanalysis refers here not to a form of individual psychotherapy, but rather to a theory of mind that attends to an individual’s unique developmental trajectory within a familial and cultural context, with attention to the important impact of unconscious factors on human thought and behavior. Given these 2 definitions, we can think of psychodynamic psychiatry as the area of intersection between the domain of psychoanalysis as a theory of mind and the domain of general psychiatry. Psychodynamic psychiatry offers a perspective that allows us to engage, understand, and be useful to difficult-to-treat patients.1 All of us have experienced work with patients we come to view as difficult to treat or, as they are sometimes called, “treatment resistant.”2 There are patient-specific and disorder-specific characteristics that make patients difficult to treat, but that which is difficult often resides not in them, but in us, and in the limitations of our treatments. This article is in 2 sections that each address different kinds of limitations that contribute to the experience of patients as difficult. The first section addresses limits inherent in the biomedical model that threatens to supplant the biopsychosocial model, which is better supported by research and more salient for understanding and treating mental disorders. The second section elaborates the way our inevitable human vulnerability to countertransference enactments contributes to the experience of patients as difficult.

LIMITATIONS OF THE BIOMEDICAL MODEL

Mathematician George Box noted that, “All models are wrong, but some are useful.”3 It was George Engel4 who proposed the biopsychosocial model, a model suggesting that understanding and treating people with mental disorders requires attention to the contributions of their biology, individual psychology, and social context. The biopsychosocial model is entirely congruent with psychodynamic psychiatry. However, over the last several decades, a narrower biomedical model has been in ascendancy and the biopsychosocial model has been in decline. Popular psychiatrist authors like Nasir Ghaemi, for example, have criticized the biopsychosocial model as lacking rigor.5 There was hope in the 1990s that the eventual decoding of the human genome and findings from brain research would confirm the value of a biomedical model. Current director of the National Institutes of Health, Francis Collins, who was then director of the National Human Genome Research Institute, suggested in 1999 that a genetic revolution throughout medicine would emerge from the Human Genome Project.

HISTORICAL ISSUES

Freud began his professional career as an academic physician whose career path was blocked because he was Jewish.5 Private practice was the way he could make a living—and he soon became a successful practitioner. This accident of fate seems to have wed organized psychoanalysis as it subsequently evolved to a private practice paradigm, rather than an experimentally based, empirical frame of reference. As academic psychiatry grew along an empirically validated path, psychoanalytic psychology gradually but somewhat disdainfully moved away from traditional academic research. This movement was not only because so many of the psychoanalytic patients were neurotic, unlike the predominately psychotic population treated by psychiatrists in the past. The movement also took place because of insistence by many psychoanalysts that consciousness was merely a layer of the mind that happened to be immediately accessible. Under conscious awareness, unconscious motives lurked, and these unconscious fears and desires were often different in their ultimate meanings than conscious recall indicated. For example, a person who allegedly loved another might unconsciously hate her. Given this ambiguity of meaning, it was difficult to assess the motivational significance of consciously experienced psychic material or its role in symptom formation. Much academic psychology, however, was based on quantification of consciously accessible thoughts, feelings, and memories. This information notwithstanding, it ultimately became necessary for psychiatrists to demonstrate that they could make diagnoses in a valid and reliable manner. Their poor capacity to do this contributed to the diminished influence of psychoanalysis in psychiatry.