Psycho-Analytic Treatment in a Sanatorium1

In considering the cases of patients about whom we are consulted we psycho-analysts have this peculiar advantage that, when we have made our diagnosis, we have also a reliable prognosis for our therapeutic work. We know that difficulties lie before us, the degree of which increases according as we are dealing with a case of hysteria, an obsessional neurosis, a narcissistic neurosis or a true psychosis. By the measure of regression underlying the clinical picture in these different diseases and the extent to which the libido has been shattered by that regression we are enabled to draw conclusions as to the duration, the laboriousness and the prospects of our treatment in each case. If a neurosis conforms more closely to the transference-type we call it 'slight': if to the narcissistic type we call it 'severe'.

And yet we not infrequently meet with patients from whom we have, hitherto, had to withhold our help for reasons quite independent of the degree of 'severity' of their cases in the psycho-analytical sense. We could not attempt their treatment or have had to break it off prematurely, because their illness was too 'severe' in another sense—I mean, from the general clinical standpoint. In these neuroses the clinical picture has either persisted or has been so unsuitably handled that the symptoms have reached a point at which the patient's condition is markedly asocial. For instance, in this stage of illness the hysteric or obsessional neurotic may be suffering without intermission from anxiety-states or their equivalents or else his defensive measures (in phobia) or his 'ceremonial' (in obsession) may be restricting within increasingly narrow limits the radius of his personal activities. The result is that he is for practical purposes as incapable of orientation in reality as is the psychotic. We can understand that these patients become an intolerable burden not only to themselves, but to those around them, and are a menace to the stability and security o