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Munich, R.L. (2011). The Psychoanalytic Approach to Psychosis: Commentary on Kafka. J. Amer. Psychoanal. Assn., 59(1):49-57.

(2011). Journal of the American Psychoanalytic Association, 59(1):49-57

The Psychoanalytic Approach to Psychosis: Commentary on Kafka Related Papers

Richard L. Munich

Perhaps the most salient fact to describe the dramatic reduction in dynamically oriented, therapeutic community-based hospital treatment for patients with psychotic disorders is that there are fewer than a handful of facilities that still provide it as their mainstay. Even if one includes patients with concurrent Axis I and Axis II diagnoses, a significant percentage of that original hospital population, today there are far fewer admissions with a length of stay longer than six weeks. Pharmacological advances, so-called evidence-based treatments, economic factors, and longer-term outcome studies have provided various rationales for this reduction.

John Kafka has elegantly reviewed the contributions of the pre-reduction era at Chestnut Lodge, contributions echoed by those from similar institutions including Sheppard and Enoch Pratt Hospial, McLean Hospital, the Yale Psychiatric Institute, the Menninger Clinic, the Westchester Division of New York Hospital, the Austen Riggs Center, and the Institute of Living, among others. It is notable that he cites no papers on the issue of extended inpatient treatment for psychotic disorders after the early 1990s. With the exception of the International Society for the Psychological Treatments of the Schizophrenias and Other Psychoses, there is no organized academic or research support for the dynamically oriented psychotherapeutic treatment of these disorders. Current treatment of the most profound psychotic disorders is in the main organized around psychopharmacology, cognitive-behavioral therapies, psychiatric rehabilitation, psychoeducation, and assertive community treatment. Efforts to provide and shape inpatient treatment options for seriously disturbed patients in the current environment have been addressed elsewhere (Munich 2003; Munich and Allen 2003).

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