1Freud's concept of the negative therapeutic reaction limited its etiology to a sense of guilt, or a need for punishment. I have found it clinically useful to add the following etiologies: (a) a masochistic ego responding to a special psychopathology

of the ego ideal; (b) a defense against the regressive pull back to symbiosis with a depressed preoedipal object, and (c) an extension of Freud's original category of "unconscious guilt," to include preoedipal "crimes," such as responsibility for birth trauma to mother, mother's castration, etc.