I will describe the psychoanalytic treatment of Mr. A, a man with a history of serious alcohol abuse and violent psychotic episodes. Mr. A was persecuted by numerous auditory and visual hallucinations. Sometimes, these command hallucinations resembled characters he had known and he would submit to their demands to keep them quiet. At other times, he would ‘cast spells’ on the voices in an attempt to make them disappear.

Patients who suffer from serious psychotic illnesses need support managing psychological pain. In this paper, I will show how Mr. A's reliance upon the therapy to support the non-psychotic aspect of himself lead to a ‘Catch 22’ situation since engaging with the severity of his illness threatened to overwhelm him with despair. Engaging with his depressing reality provoked murderous attacks from his ‘ego destructive superego’ (O'Shaughnessy, 1999). Mr. A believed that the therapist would find the psychotic aspect of himself unacceptable in the transference.

In an attempt to maintain the therapy, he tried to conform with what he imagined was my demand that he play the role of a non-psychotic patient. At other times, he played the role of a psychotic man or reminded me he was schizophrenic.