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Many patients resist engagement in the therapeutic relationship because they fear the traumatic consequences of the mobilization of thwarted selfobject needs in what they fear will be a faulty, nonempathic environment. At times this resistance is manifest in “narcissistic rage” as described by Heinz Kohut. Providing opportunities for selfobject experience in work with these patients can be challenging. In his 1971 paper The Use of the Object, D.W. Winnicott described a developmental process in which the state of omnipotent merger with important objects undergoes a transformation in which the other is increasingly recognized as not only outside the self, but also in possession of a subjectivity of its own and thus can be made use of. In work with some seriously and persistently mentally ill, the client’s capacity to make use of the clinician is poorly developed or highly conflicted. Given this the clinical process in which the client achieves the recognition of the worker and trust in their intentions—and hence can make use of them as a selfobject, is often prolonged and stormy. A case is discussed at length that illustrates this. The report documents the importance of holding, containment, management of the countertransference, and survival strategies for the clinician. It also shows the patient’s growing ability to make use of the clinician as a selfobject as she struggles to understand and cope with changes in her life world and self-experience.

Destruction, survival and the use of the clinician: Preserving opportunities for selfobject experience in work with challenging patients