Psychoanalytically Informed Psychotherapy of Psychosis: The Influences of American Psychoanalysis

Although Freud (1900, 1914, 1924) was fascinated by the psychoses, their relation to dreaming and to the profound alterations within the topographic and, later, the structural model, he thought their treatment was impossible because these were “narcissistic neuroses.” He was, no doubt, influenced by one of Bleuler's “four A's” of schizophrenia (1905), namely, “autism.” Finding in these conditions no libidinal cathexis of an external object, he concluded that the psychotic patient's inability to form a transference would thwart psychoanalytic work. Last spring in Washington, D.C., Eric Marcus assembled a diverse group of analysts who work psychoanalytically with psychotic patients to demonstrate that patients with psychosis can, contrary to this earlier view, make remarkable recoveries through psychoanalytic treatment. As we listen in on the panel, one can discern a decidedly “American” admixture regarding theory and technique when difficult challenges are encountered in the consulting room with this diverse and extraordinary group of patients.

Marcus opened the panel with a paper illustrating the use of the structural model to understand psychotic and “near psychotic” illness. His approach (Marcus 2003) focused on Hartmann's ideas of “the relatively autonomous ego functions” that help individuals distinguish between the emotional/cognitive, inside/outside, and fantasy/reality domains of psychic experience. Marcus looks to symbolic representation “signatures” that give each patient