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John Kafka's article is an extremely interesting musing upon the psychoanalytic treatment of patients with psychosis in the context of a psychoanalytic hospitalization, namely, at Chestnut Lodge. A hotbed of therapeutic and research activity, the Lodge provided therapists both a nurturing and a stimulating group process around treating patients with psychosis, a process that helped not only the individual patients but also the analysts and the field itself. Many interesting ideas arose in the context of work in this institution. Some of the prime questions raised remain with us today.
Rather than address Kafka's article point by point, I intend to discuss my own take on some of the issues he raises. I note also that I speak not as a researcher into the psychoanalytic treatment of people with psychosis, nor as a reader and purveyor of theories in articles by others on psychoanalysis of the psychoses. Rather, I speak as a patient with psychosis who has benefited enormously from psychoanalytic treatment, four or five times a week for over three decades (Saks 2007). I do this recognizing that I am an n of only one, so that my experience may not generalize to that of others; and that I may be wrong when I speculate even about my own case.
The first issue I'd like to address is whether there is a continuum between neurosis and psychosis. Kafka suggests this would be the case if the conflict theory of symptoms applies to both. But many think that conflict cannot explain psychosis—we must rather rely on the concept of deficit.