Clinical Commentary on Psychotic Processes

I must play their game, of not seeing I see the game.

Although Sigmund Freud wrote extensively about the unconscious meanings underlying manifest symptoms, behaviours and speech, he remained sceptical about the possibility of treating people suffering from psychotic illness by means of psychoanalysis. He believed that psychotic process led to a withdrawal of all libidinal cathexes from the object and the external world, resulting in lack of transference relationship to the analyst. Today we know that this is not the case and even Freud's position evolved over time, and in his interpretation of Schreber's memoirs (1911) the idea of transference is already present. Moreover, in the posthumously published An Outline of Psychoanalysis, Freud says:

The problem of psychoses would be simple and intelligible if the withdrawal of the ego from reality could be carried through completely. But that seems rarely if ever to happen. Even in conditions so far removed from the reality of the external world as hallucinatory confusional states, one learns from patients after their recovery that at the time in some corner of their minds, as they express it, there was a normal person hidden, who watched the hubbub of the illness go past, like a disinterested spectator. (Freud, 1946, pp. 114-15)

Here I think lie the origins of the questions raised today by Dorothée Bonnigal-Katz, that is, what is the place of psychoanalysis in the understanding and treatment of psychoses, what is the appropriate setting and analytic technique, what is the relationship between psychosis and neurosis, and the fate of symbol formation? What are the dominant defence mechanisms and the significance of unconscious phantasy?

Following the contributions of Karl Abraham (1911) and Melanie Klein (1946), Hanna Segal (1950) described her work with a schizophrenic patient treated in a largely traditional psychoanalytic setting, that is, five sessions per week and on the couch, making a strong case