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'Everyone who analyzes psychoses is doing pioneer work', says Fenichel in his Outline of Psychoanalysis. An alert and courageous group of such pioneers have headquarters at Chestnut Lodge, Rockville, Maryland. The physician-in-charge, Dr. Bullard, sketches in this paper some of the basic and elementary
principles in a specifically psychoanalytic approach to psychotic patients. History taking is enriched by the physician's psychoanalytic understanding. Attention is then devoted to what the sick patient unwittingly reveals about himself by attitude, behavior, and speech, it often being necessary to read between the lines for the significance. Equally important perhaps, is a similar awareness of the attitudes of relatives: 'One may occasionally anticipate the concealed hostility of some relatives by being alert to the implications of their wishes in regard to patients… The husband of an agitated, suicidal patient said he felt so sorry for her he wanted her to get some rest, so he sent her drugs in a carton of cigarettes. She achieved a very long rest and now he is attempting to set aside a will which disinherited him.'
Especial care is taken in the approach to patients lest a nontherapeutic transference be set up, as when a physician's naïvely superior or judging manner serves as a barrier to the tentative pseudopodia put forth by a shy personality. The mental status is obtained gradually and informally without any probing of such sore spots as details of sex life or any questioning that might be regarded as an accusation. Questions about sensorium such as absurdities are omitted lest they distort the relationship. 'Rather, we ask the patient to tell us what he can of his difficulties—mindful of the fact … we may not be the person he can confide his innermost feelings to in a first interview. It is often helpful in establishing rapport, to say to the patient, that we know it is difficult to reveal much of himself to a person he knows but slightly and that