The Hateful Patient: Difficult Patients in Psychotherapy


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By: Dr. Sam Vaknin

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In 1978, a medical doctor by the name of J.E. Groves published in the prestigious New England Journal of Medicine an article titled "Taking Care of the Hateful Patient". In it he admitted that patients with personality disorders often evoke in their physicians dislike or even outright hatred.


Groves described four types of such undesirable patients: "dependent clingers" (codependents), "entitled demanders" (narcissists and borderlines), "manipulative help rejectors" (typically psychopaths and paranoids, borderlines and negativistic passive-aggressives), and "self-destructive deniers" (schizoids and schizotypals, for instance, or histrionics and borderlines).


Therapists, psychologists, social workers, and psychiatrists report similar negative feelings towards such patients. Many of them try to ignore, deny, and repress them. The more mature health professionals realize that denial only exacerbates the undercurrents of tension and resentment, prevents effective patient management, and undermines any therapeutic alliance between healer and the ill.


It is not easy to cater to the needs of patients with personality disorders. By far the worst is the narcissistic (patient with Narcissistic Personality Disorder).

(continued below)

This article appears in my book "Malignant Self-love: Narcissism Revisited"

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From my book "Malignant Self Love - Narcissism Revisited":

"One of the most important presenting symptoms of the narcissist in therapy is his (or her) insistence that he (or she) is equal to the psychotherapist in knowledge, in experience, or in social status. The narcissist in the therapeutic session spices his speech with psychiatric lingo and professional terms.

The narcissist distances himself from his painful emotions by generalising and analyzing them, by slicing his life and hurt and neatly packaging the results into what he thinks are "professional insights". His message to the psychotherapist is: there is nothing much that you can teach me, I am as intelligent as you are, you are not superior to me, actually, we should both collaborate as equals in this unfortunate state of things in which we, inadvertently, find ourselves involved."

In their seminal tome, "Personality Disorders in Modern Life" (New York, John Wiley & Sons, 2000), Theodore Millon and Roger Davis write (p. 308):

"Most narcissists strongly resist psychotherapy. For those who choose to remain in therapy, there are several pitfalls that are difficult to avoid ... Interpretation and even general assessment are often difficult to accomplish..."

The third edition of the "Oxford Textbook of Psychiatry" (Oxford, Oxford University Press, reprinted 2000), cautions (p. 128):

"... (P)eople cannot change their natures, but can only change their situations. There has been some progress in finding ways of effecting small changes in disorders of personality, but management still consists largely of helping the person to find a way of life that conflicts less with his character ... Whatever treatment is used, aims should be modest and considerable time should be allowed to achieve them."

The fourth edition of the authoritative "Review of General Psychiatry" (London, Prentice-Hall International, 1995), says (p. 309):

"(People with personality disorders) ... cause resentment and possibly even alienation and burnout in the healthcare professionals who treat them ... (p. 318) Long-term psychoanalytic psychotherapy and psychoanalysis have been attempted with (narcissists), although their use has been controversial."

Read more about therapy of personality disorders


Many additional Frequently Asked Questions (FAQs) about Personality Disorders - click HERE!

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