Reflections on Training

My return to the study of the psychoses after 30-odd years which had been devoted chiefly to studying the neurotic process was the beginning of an exciting re-education. It shook me out of many preconceptions, changing my ideas about almost everything. (15)

One of the lessons I learned was that the sequence of steps in training for psychiatry should be reversed and much of the content changed. For this there are many reasons.

In the first place one of the facts which I learned after returning to the psychiatric hospital was that episodes of psychotic disorganization always precipitate out of the neurotic process under certain quite specific types of impasse. Furthermore, no patients are psychotic all the time. Even within a brief interview, interludes of neurotic reorganization

occur. The road to health leads back to and finally through the prepsychotic neurosis. Consequently the student and therapist of the psychosis must be prepared by previous experience and training to utilize these moments of neurotic reorganization. Clearly the inexperienced resident, who knows nothing about the neurotic process or how to deal with it, is unprepared for this. The young student of psychiatry must first understand how to relate to the neurotic process in himself and in others. He can start this best by studying the complex processes of growth, observing the subtle early neurotic deviations from normal psychological development. He must learn that once such deviations arise they are maintained primarily by unconscious conflicts which give rise to neurotic symptoms, which in turn feed back new distortions of life, which then give rise to new conflicts and new secondary symptoms to produce further distortions, out of which a third order of symptoms evolve, etc. It is this chain of reverberating reactions which constitutes the neurotic process; and it is out of this that psychotic disorganization may precipitate, but only under certain specific circumstances. (16)

Moreover, to confro