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Rosenfeld, H. (1969). On the Treatment of Psychotic States by Psychoanalysis: An Historical Approach. Int. J. Psycho-Anal., 50:615-631.

(1969). International Journal of Psycho-Analysis, 50:615-631

On the Treatment of Psychotic States by Psychoanalysis: An Historical Approach

Herbert Rosenfeld


In this paper I have tried to show the main trends in the development of the treatment of the psychoses. After Freud's pessimism about the analysis of psychotic patients, due to his belief that they formed no transference, two main trends in the approach to the treatment of psychotics have appeared. There were those who believed that the narcissism of the psychotic patient presented a complete obstacle to analysis unless the analyst changed his usual analytic attitude. Analysts who held the view that the narcissism of the psychotic patient was caused by an environmental failure attempted to provide the patient with a new and better mother in the form

of the analyst, to make up for the deficiency of the early environment. Exponents of this approach were particularly Pearce Clark, Fromm-Reichmann in her early period, and Winnicott in his later work. Searles' approach is closely related to this, as he recommends the analyst's intense involvement with the psychotic patient, particularly in the symbiotic phase of the analysis. Waelder and Jacobson have also altered their analytic attitude. They do not analyse the transference but maintain a predominantly positive one and use it as a vehicle to sublimate the patient's narcissism or psychosis by relating it to object libido and the external world. Federn similarly encouraged the positive transference and avoided any analysis of transference manifestations. However, he differed from Waelder and Jacobson by training the patient to repress or split off the psychotic parts of his personality. Searles and Fromm-Reichmann in her later work differ from others in this group in so far as they analyse both the negative and the positive transference.

The second group of analysts attempted to deal with the narcissism and other psychotic manifestations of the patient by the classical psychoanalytic approach with only minor changes. First came Abraham, who found that the narcissistic defences of his patients were markedly diminished by interpretations. Then Stern, Cohn, Stone and Bullard described characteristics of the positive and negative transference of psychotic patients, which they felt could be analysed by verbal transference interpretations.

Segal, Bion and Rosenfeld stressed that no change in the analyst's attitude and only minor changes in technique were necessary, and that the psychotic productions attached themselves to the transference, which could be interpreted in both its negative and its positive forms to the patient. They also relied exclusively on interpretations to deal with the serious language and thought disorder of the schizophrenic patient, and saw these difficulties as part of the malfunctioning of the psychotic ego with its disturbed relationships to both external and internal reality and objects. The development of the treatment of psychosis over the last 50 years suggests that Freud's hope that some approach to the treatment of psychosis might become possible is now justified.

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