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This short book is a considerably expanded version of a lecture given at the New York Academy of Medicine in 1965. It touches on many important factors concerning the psychopathology and treatment of psychotic patients. Dr Jacobson concentrates, as the title of the book suggests, on the relation of the psychotic patient to reality. She follows Freud's formulation that in psychosis there is a conflict between the ego and reality and that the main mechanism used by the psychotic is the denial and displacement of reality.
In examining the intrapsychic psychotic conflict she talks about the struggle
between active and passive, sadistic and masochistic, destructive and self-destructive tendencies and in general between sexual and aggressive impulses, which at certain stages of the illness may be used as a defence against each other.
She feels that the rise of aggression at the expense of the libido may be the primary agent that induces the psychotic process with its fear of 'an impending dissolution of the psychic structure'. Dr Jacobson is impressed by the puzzling features of the schizophrenic's ego structure. Some delusional psychotics, despite their impairment of reality-testing in certain areas, are able, at least temporarily, to engage in highly intellectual work, while others are unable to do any work without suffering from overt psychotic symptoms, such as delusions or hallucinations. For this reason she feels that any generalization about the psychotic's relations to the external world, to personal objects as well as to reality in general, must be regarded as very doubtful. She explored the different relations to the external world of florid and mild schizophrenics and believes that the study of the acting out behaviour, object relations and attitudes to work of such patients can help to throw light on the psychotic's complex relations to the external world. She observed that some types of psychotic patients will not immediately break with reality but will