Meetings of the New York Psychoanalytic Society

May 11, 1965. PSYCHOTIC CONFLICT AND REALITY (Fifteenth Freud Anniversary Lecture). Edith Jacobson, M.D.

Dr. Jacobson, expressing her admiration for the genius of Freud, selects a subject she feels might have held his interest—the relationship of the psychotic to the external world and the role of reality in psychotic conflict. She refers to Freud's attempt to apply his structural concepts to a comparison and contrast between the neuroses and psychoses. His inferences regarding conflict, narcissistic fixations in psychotics, and their use of primitive defenses have been amply confirmed, but there is still controversy about the psychotic's capacity for object relationships. Contradictory observations emphasize the need for further study of different psychoses and different stages of each disorder.

The author has found it revealing to explore relations to the external world in mild psychotics, patients showing psychotic potential, and those in a state of remission after a psychotic episode. She was inspired by Freud's comparison of the psychotic's efforts to alter reality with the normal person's alloplastic endeavors. She wondered how the psychotic might attempt to alter reality to adapt it to his very special needs and purposes. Profound hostility, narcissistic vulnerability, and fragility of defense organization prevent his toleration of frustration and withstanding the assault of instinctual forces. The external world is employed as an aid in replenishing libidinal resources and resolving narcissistic and instinctual conflicts. In contrast to neurotic patients, psychotics use the external world for the purpose of preventing ego and superego dissolution, which would threaten them with a manifest psychotic break.

Clinical material is presented to illustrate a patient's relations to the external world. The patient, an attorney in his thirties, was the oldest of seven children. His mother was a chronic schizophrenic who gradually deteriorated; his father was