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Wexler, M. (1965). Working Through in the Therapy of Schizophrenia. Int. J. Psycho-Anal., 46:279-286.

(1965). International Journal of Psycho-Analysis, 46:279-286

Working Through in the Therapy of Schizophrenia

Milton Wexler

SUMMARY

Working through in the analytic situation involves overcoming resistances to structural change within the id, ego, and superego. The

working alliance is an essential precondition to successful working through since it involves the continuing operation of identificatory processes without which the potential threat to object constancy might lead either to increased resistances or to psychosis. The deepest anxiety of the patient lies in the fear of loss of object representation without corresponding replacement, of which the continuing working alliance stands as guarantor. Such processes as the development of insight, the abreaction of affects, the testing of the reality of insights through their conjunction with emotional responses, and the mastery of anxiety within the analytic situation are all affective elements in the working through process, but only in the situation where new identifications are available to replace old object ties and investments which must ultimately be abandoned or radically altered if analysis is to be successful. And under ordinary circumstances the analytic situation in itself, without educative, restrictive, or overtly supportive atmospheres, provides adequate opportunity for safeguarding structural integrity in the patient.

The schizophrenic, having already suffered a structural holocaust, clings to his shadowy, unreal, and fragmented identity and restitutional objects with the greatest tenacity. The problem is perhaps less one of structural change than one of reconstruction or replacement. Identificatory processes and a working alliance cannot be counted on and the therapeutic task, even with respect to interpretation, centres on contact, communication, and understanding in order to facilitate the operation of primitive imitation, incorporation, introjection, and ultimately identification.

Working through here means a more direct emphasis on those approaches which, in the infant and child, tend to build psychic structure, including education, restriction of destructive impulses, support, affection, and the provision of effective models for thought, feeling, and action. Even the bolstering of the defensive organization, e.g., the provision of compulsive, ritualized tasks, represent more directed efforts at structure building than is true of the working through process in psycho-analysis. In all likelihood the term 'working through' should be reserved for classical psycho-analytic procedures with neurotic patients. In the treatment of schizophrenia the emphasis is so largely on the tactics for developing and deepening the 'working alliance' that the process of 'working through' proper must necessarily play a very secondary role.

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