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

During the last fifty years the psychoanalytic approach to psychosis has undergone very considerable change, and at the present time there is no unified theory of either the psychopathology or the technique of treating the psychoses. Many analysts working with psychotics have found it necessary to alter to some extent the classical technique of analysis developed by Freud in dealing with neurotic states, a technique which is based on a therapeutic alliance with the patient and on the capacity of the patient to come to treatment regularly and also to free-associate. Such a patient would be able to develop a transference neurosis and other transference manifestations which can be interpreted to a patient whose ego is sufficiently intact to co-operate in this way in an analysis. Freud himself thought that this technique was unsuitable for psychotics. The work of many analysts has been influenced by Freud's belief that psychotics do not develop a transference at all. However, an increasing number of analysts have tried to develop methods with the hope that eventually some contact with the psychotic, and with this some improvement of the psychotic condition, might be achieved. Freud (1933) discussed the intimate relations which exist in psychoanalysis between theoretical views and therapeutic treatment.

I believe that the changes in the therapeutic approach to psychotics have been certainly influenced by the theoretical views held by the therapist and by factors in the therapist's own personality. A clearly defined method of approaching psychotic states is important if we expect to conduct research to clarify the psychotic psychopathology rather than concentrating on symptomatic improvement. The therapist should ask himself whether he is inclined to change his