On the Treatment of Psychotic States by Psychoanalysis: An Historical Approach

In this paper I have tried to show the main trends in the development of the treatment of the psychoses. After Freud's pessimism about the analysis of psychotic patients, due to his belief that they formed no transference, two main trends in the approach to the treatment of psychotics have appeared. There were those who believed that the narcissism of the psychotic patient presented a complete obstacle to analysis unless the analyst changed his usual analytic attitude. Analysts who held the view that the narcissism of the psychotic patient was caused by an environmental failure attempted to provide the patient with a new and better mother in the form

of the analyst, to make up for the deficiency of the early environment. Exponents of this approach were particularly Pearce Clark, Fromm-Reichmann in her early period, and Winnicott in his later work. Searles' approach is closely related to this, as he recommends the analyst's intense involvement with the psychotic patient, particularly in the symbiotic phase of the analysis. Waelder and Jacobson have also altered their analytic attitude. They do not analyse the transference but maintain a predominantly positive one and use it as a vehicle to sublimate the patient's narcissism or psychosis by relating it to object libido and the external world. Federn similarly encouraged the positive transference and avoided any analysis of transference manifestations. However, he differed from Waelder and Jacobson by training the patient to repress or split off the psychotic parts of his personality. Searles and Fromm-Reichmann in her later work differ from others in this group in so far as they analyse both the negative and the positive transference.