Discussion of Harold F. Searles, Jean M. Bisco, Gilles Coutu, and Richard C. Scibetta's Article, Violence in Schizophrenia

Much of what is written about the psychoanalysis of psychotic patients is extrapolated from work with borderline patients who may show psychotic mechanisms but are able to manage their lives outside of a hospital. Searles is one of the very few who have written about long-term psychoanalytic treatment of severely disturbed hospitalized schizophrenic patients.

This paper is very rich in concrete assistance for anyone working with severely disturbed patients, in or out of a hospital setting. For example, Searles's way of handling his patient's demand to be released from the hospital is most helpful. The patient seeks freedom from environmental restraint, which can reflect internal restraint, and Searles presents a good example of the kind of inner restraint from which a patient may need release. His patient's inner restraint is derived from anxiety over infantile helplessness and from domination by an archaic maternal introject with which the patient was partially identified. In The Ethics of Psychoanalysis, Thomas Szasz (1965) points out that not only the paranoid patient but also society and the hospital administration regard the psychiatrist in a mental hospital as the opponent of the patient rather than his agent or advocate. Searles shows us how he handles this crucial issue. He accepts the patient's view of hospitalization as something imposed upon him by others for their own protection, while searching for an area in which he and the patient can work together toward a shared objective.

Searles has pioneered in the use of countertransference as a diagnostic and therapeutic instrument. Everyone talks and

writes about the importance of self-knowledge, but Searles shows us what this can mean and how to use it.

I have had psychiatric residents misuse Searles's writings to justify burdening patients with their own emotional reactions, which are disruptive to the treatment. Interpretation of countertransference anxieties is fraught with dangers. This is particularly tr