Psychoanalytic Institutions and Treatment Resistance: Commentary on Kafka

John Kafka offers us a retrospective on an extraordinary institution committed to working with severely troubled patients who could not be treated elsewhere. The opportunity at Chestnut Lodge for psychoanalytically trained clinicians to see psychotic and characterologically disturbed patients intensively and over extended periods opened new understandings of the edges of human experience. The work of these clinicians demonstrated that the profound isolation inherent in psychosis could be overcome if someone was there to listen. Kafka underlines what it takes for clinicians to be “trained” by these patients to be listeners. Fromm-Reichman, Searles, Will, Pao, Kafka, and others from the Lodge unpacked patients' seemingly bizarre transferences and clinicians' often troubling countertransference feelings evoked in the context of prolonged and extensive psychotherapy. These discoveries opened the patients' efforts to communicate and illuminated their terror about being lost in the obliterating other through their intense longing. These ideas—and the related understanding of unconscious, nonverbal, interpersonally evoked communication—expanded the boundaries of psychoanalytic knowledge. Kafka's notion of “atmospheric objects” points to these patients' relatedness to their environment. The re-created childhood context that interfered with their psychological development was opened for examination and perspective.

Chestnut Lodge and other psychoanalytically focused hospitals were centrally important in expanding the understanding of severe disturbance. However, they left many issues unaddressed that offer opportunities for the next generation of psychoanalytic institutions. For example, Kafka does not speak to the impact of psychoactive medications in managing the acute phase of schizophrenia. Once the positive and, to a lesser extent,