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Understanding the place of reality in the psychoanalytic relationship has been a vexing problem since Freud conceptualized that the cause of psychopathology was not traumatic events like sexual abuse that were generated in reality, but within the patient’s mind as fantasies. This proposition led to the exploration of the patient’s inner world and psychoanalysis as we know it was born.
Yet Freud, and almost every other analyst, was never satisfied with this explanation because, although fantasy is integral to psychopathology, the patient’s experiences of external reality in the present and past find their way into psychopathology and could not be ignored; there was both nature and nurture to consider, especially in the clinical situation where, for the patient, the external reality of the analyst was ever present. The problem is best seen in the difficulty over where to place trauma within the mind. When examining the mind in the analytic relationship the only actual reality is within the relationship between the patient and analyst in the present moment, the experience of many past realities are also expressed in the present moment. Memories of trauma become one of those difficult past realities which in the clinical situation is intra psychic and part of a repetition, i.e., the patient experiences the repetition of the trauma as if it is a new event and it is through the therapeutic action of an analysis that true change is possible.
In no other analytic situation can one follow as well the distortions of reality because of trauma as it appears in transferences, resistances, and repetition of severely traumatized patients because the experience of a trauma can be unbearable and the distortion of reality, which contributes to psychopathology is life saving.
With this in mind, we have planned two issues devoted to the question of how we explain psychoanalytic improvement in patients with severe psychopathology. Each of the next two issues will begin with a description o