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Eissler, K.R. (1945). Psychoanalysis of Psychoses. II. Transference. III. the Psychoanalytic Process: Paul Federn. Psychiatric Quarterly, XVII, 1943, pp. 246–257, and 470–487.. Psychoanal Q., 14:130-132.
Psychoanalytic Electronic Publishing: Psychoanalysis of Psychoses. II. Transference. III. the Psychoanalytic Process: Paul Federn. Psychiatric Quarterly, XVII, 1943, pp. 246–257, and 470–487.

(1945). Psychoanalytic Quarterly, 14:130-132

Psychoanalysis of Psychoses. II. Transference. III. the Psychoanalytic Process: Paul Federn. Psychiatric Quarterly, XVII, 1943, pp. 246–257, and 470–487.

Kurt R. Eissler

The essential differences in psychoanalytic technique in treating neuroses and psychoses are discussed. Psychoanalysis of the psychoses is different not only in such details as an avoidance of the use of the couch, but also in more important ways. The analyst may, for instance, cease treatment temporarily and be replaced by a sympathetic member of the family guided by the analyst. Nevertheless, the method sponsored by Federn is 'not mere psychotherapy with

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psychoanalytical knowledge. It is true psychoanalysis… The application of the economical, topical and dynamic viewpoints while using free association and coping with transference and resistance.' Indeed, throughout the paper one gains the impression that the author consistently adapts the psychoanalytic method to the requirements of the individual patient. His main goal is to restore the functioning of a deeply injured ego, and he never sacrifices the ego of the patient to a therapeutic principle or abandons a rational therapy for the sake of a cheap transference success.

Federn was one of the first to recognize that the transference of the psychotic is the chief problem of the psychoanalysis of psychotics, opposing those who thought that there is 'no transference in psychosis'. However, the transference has a different meaning to the psychotic than to the neurotic and therefore requires different handling. The main difference is that in the psychotic patient the positive transference should never be permitted to change into a negative one. Whereas the neurotic patient is able to continue treatment in spite of phases of negative transference, the psychotic cannot be treated by a physician who has become an object of negative transference. Since temporary or even long-lasting periods of negative transference are unavoidable, the treatment must be supplemented by the coöperation of a helper, preferably a woman who may be a nurse or a member of the family. According to Federn, the dynamism of treatment is different in the two groups due to the difference of ego structure: in neuroses, repressions must be dissolved, in psychoses, 're-repressions' must be created. 'In neurotics, transference is used to make repressed material free; in psychotics, to make free material repressed.'

The peculiarities of the psychotic's ambivalence are emphasized. Whereas the neurotic's ambivalence results in a reaction towards the loved and hated objects, the psychotic's ambivalence tears his ego into parts, thus creating a 'split ego'. If these contradictory parts of the ego continue to work simultaneously, and with equal force, a catatonic reaction results. If alternation occurs, manic-depressive psychoses or cyclothymia will result. Special attention is given to the complications in the marriages of cyclothymic persons, and to the technique of their treatment. Although the author agrees with Freud's concise formulations of the basic structural differences of neuroses and psychoses, he reminds us that damage and restitution are not kept apart, but occur intermixed in the course of the disease. Whereas Freud considered the loss of reality as the decisive central occurrence in the psychoses, the author attributes primary importance to 'the gaining of reality by what has previously been mere thought'. Loss of reality is a consequence of an interpretation of external reality by that internal reality which is externalized by the patient.

Thus the representation of reality is not really lost during the psychosis, but is overshadowed by 'the establishment of a false reality conception'. The author's metapsychological description of the psychoses is based on the concept of the 'ego boundaries' and their cathexes. Withdrawal of ego-cathexis from some thoughts makes them appear to be outside reality, since 'what happens outside the ego boundaries is felt to be truly real and really true'. If, however, only libidinous cathexis is withdrawn from an ego-boundary, the experience

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of estrangement results. If the patient realizes that one part of his ego is no longer reliable because he confounds thoughts and reality, his illusions lose power.

The idea of a 'perfect analysis and the hope for a clinically perfect cure' have to be abandoned. 'The patient returns to active life, sometimes without psychic residues, sometimes capable of permanent dissimulation of such residues', but in no case should potential postanalytic care be disregarded.

One must carefully avoid hindering the self-expression of the patient in favor of discipline. 'Logical understanding has little therapeutic effect, while the same explanation produced by the analysand through his own experience has curative value.'

Throughout the paper there is a wealth of most pertinent clinical suggestions which are indispensable to everyone who ventures into the psychoanalysis of psychoses. The author had to present a huge topic in a brief space, and his paper therefore requires most careful reading. Some short paragraphs cover the scope of a chapter in a book, and the paper reads like the abstract from a voluminous book on the theory and therapy of psychoses.

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Article Citation

Eissler, K.R. (1945). Psychoanalysis of Psychoses. II. Transference. III. the Psychoanalytic Process. Psychoanal. Q., 14:130-132

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