'Everyone who analyzes psychoses is doing pioneer work', says Fenichel in his Outline of Psychoanalysis. An alert and courageous group of such pioneers have headquarters at Chestnut Lodge, Rockville, Maryland. The physician-in-charge, Dr. Bullard, sketches in this paper some of the basic and elementary
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principles in a specifically psychoanalytic approach to psychotic patients. History taking is enriched by the physician's psychoanalytic understanding. Attention is then devoted to what the sick patient unwittingly reveals about himself by attitude, behavior, and speech, it often being necessary to read between the lines for the significance. Equally important perhaps, is a similar awareness of the attitudes of relatives: 'One may occasionally anticipate the concealed hostility of some relatives by being alert to the implications of their wishes in regard to patients… The husband of an agitated, suicidal patient said he felt so sorry for her he wanted her to get some rest, so he sent her drugs in a carton of cigarettes. She achieved a very long rest and now he is attempting to set aside a will which disinherited him.'
Especial care is taken in the approach to patients lest a nontherapeutic transference be set up, as when a physician's naïvely superior or judging manner serves as a barrier to the tentative pseudopodia put forth by a shy personality. The mental status is obtained gradually and informally without any probing of such sore spots as details of sex life or any questioning that might be regarded as an accusation. Questions about sensorium such as absurdities are omitted lest they distort the relationship. 'Rather, we ask the patient to tell us what he can of his difficulties—mindful of the fact … we may not be the person he can confide his innermost feelings to in a first interview. It is often helpful in establishing rapport, to say to the patient, that we know it is difficult to reveal much of himself to a person he knows but slightly and that we do not expect him to talk about anything that he doesn't wish to. This may result in much more being elicited than can be a bland assurance that the physician is his friend and everything he says will be held in confidence. Past experience may have taught him quite the contrary.' Likewise with the physical examination great care is needed that it may not violate the psychotic ego, as by taking a rectal temperature in case of panic, or by lightly assuring a patient with somatic complaints that 'there is nothing the matter with him', thus, as he may indignantly conclude, making him out a liar.
With such pathologically sensitive patients as the psychotics are, chance remarks may be unintentionally barbed. A friendly nurse remarked jokingly to a paranoid who was watching a bridge game, 'Are you the fifth wheel?' and set off a long-lived fury at the alleged insult. Even the failure to greet each patient in a group individually may be regarded as a slight by one with excessive feelings of inferiority. One might conclude that the personnel must have to learn to be pretty adept at tiptoeing around the psychotic ego, but fortunately a fundamentally good attitude towards these patients, informed by some understanding and instruction, automatically guides one's steps.
The paper does not go into the more detailed aspects of psychoanalytic technique with psychotics, since this would have been inappropriate to Dr. Bullard's audience, the Southern Psychiatric Association. For further descriptions of the Chestnut Lodge approach, reference might be made to Bullard's paper, Organization of Psychoanalytic Procedure in the Hospital, presented in San Francisco in 1938, and Fromm-Reichmann's recent paper, Transference Problems in Schizophrenia.1
1 Transference Problems in Schizophrenia. Psychoanal. Q., VIII, 1939.
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Chassell, J. (1941). The Application of Psychoanalytic Psychiatry to the Psychoses. Psychoanal. Q., 10:360-361