2022:

Past and present of clinical research on individual psychoanalytic therapy of psychoses

[see the Italian version]

On November 5, 2021, I have been invited to give a lecture at the “Center of Psychoanalysis Raymond de Saussure” of Geneva (the local section of the Swiss Psychoanalytic Society [SSPsa]) for a meeting entitled “Mythes et réalités du traitement psychanalytique des troubles psychotiques” (“Myths and realities of the psychoanalytic treatment of psychotic disorders”). The title that the organizers gave to my talk was “Passé et présent de la recherche clinique dans le domaine du traitement psychanalytique individuel des troubles psychotiques” (“Past and present of clinical research in the field of individual psychoanalytic treatment of psychotic disorders”), in other words they had asked me to trace the history of the empirical studies on psychoanalytic treatments of psychoses in order to show also the critical aspects (“myths and realities”), and reflect on what we can really mean today for “psychoanalytic” treatment of psychoses. I thought that maybe this lecture (that I have read in English, and was simultaneously translated into French) could be of interest also for the readers of these columns, and for this reason I copy it below (parts of this paper are taken from chapter 6 of my 1995 book Terapia psicoanalitica [“Psychoanalytic Therapy”]). There is also an Italian edition.

As is well known, Freud (1915) stated that paranoia and schizophrenia (which he called “narcissistic neuroses”) were not treatable with psychoanalysis since patients could not develop a transference on the analyst. But despite these indications, many of his followers, in the wake of the enthusiasm generated by the therapeutic perspectives that the “new science” seemed to open up, did not hesitate to apply psychoanalysis to psychotic patients as well (Müller, 1963). The greatest developments in this direction took place in the United States, where psychoanalysis soon saw a notable growth and “dynamic psychiatry” became dominant until about the mid-1960s. Regarding the therapy of schizophrenia, it was thought that one of the reasons for the failure of institutional and custodial therapy, implemented in a grand style in the previous century, could have been due to the absence of individual psychotherapy. For this reason, there was a flourishing of experiences of psychotherapy of schizophrenia, often under the guidance of charismatic figures such as Harry Stack Sullivan (1924-35, 1926, etc.), Frieda Fromm-Reichmann (1950), Silvano Arieti (1955), Harold Searles (1965) and many others (very touching is Joanne Greenberg’s [1964] account of her own therapy with Frieda Fromm-Reichmann). In Switzerland, we can mention Gaetano Benedetti (1979, 1987, 1988) and Madame Marguerite Sechehaye (1947, 1950) – Nelo Risi’s 1968 movie Diary of a Schizophrenic Girl was inspired by Sechehaye’s (1950) case of “Renée”, with the apparent cure of a young schizophrenic girl through the technique of “symbolic realization” (Sechehaye, 1947). Also in England there were important psychoanalysts of schizophrenia, for example the Kleinian Herbert A. Rosenfeld (1965) and, from a more phenomenological-existential than psychoanalytic perspective, the experiments of Ronald Laing (1955) became well known. Nor should we forget Carl Gustav Jung, the true pioneer of the psychotherapy of schizophrenia, who as early as 1903 tried to treat schizophrenia with psychoanalysis (Freud studied the Schreber case in 1910, but never saw the patient, he used his diary to study, among other things, the theme of paranoia).

Although later there were those who raised serious diagnostic doubts about the cases treated (North & Cadoret, 1981), in the literature there were reports of impressive cures of the schizophrenic picture produced by individual psychoanalytic therapy. Thus, while in the previous century it was believed that the response to schizophrenia therapy might consist in setting up a good number of efficient insane asylums, possibly located outside the cities, the opinion of the following generations was that the response to schizophrenia could be a good number of trained, analyzed, and highly motivated therapists for schizophrenic patients (Gunderson & Mosher, 1975).

But, as we know, even this era of dynamic psychiatry, characterized by a confidence in the psychoanalytic therapy of schizophrenia, declined, first of all due to the discovery of antipsychotic medication which took place in the 1950s and allowed for a rapid discharge policy in many hospitals and which significantly shifted the cost/benefit ratio, forcing public administrations to change direction: the prescription of psychiatric medication was extremely less expensive than the multi-year and complex training of psychotherapists of schizophrenia. At the same time, the entire ideology of North American (and later European) psychiatry was changing to go in a more biological direction and move away from the psychodynamic orientation that had characterized roughly the first seventy years of the twentieth century (very few American psychoanalysts still engage in the therapy of schizophrenia today, one of them is Michael Robbins, 1993, 2019). All these major transformations had a powerful negative impact on the psychotherapy of schizophrenia. But they were not the only ones to affect the enthusiasm in the individual therapy of schizophrenia: even some empirical studies cast shadows on the real effectiveness of this method of treatment. Let’s see them briefly.

Some early experimental studies

In the 1960s, two studies were made (May, 1968; Grinspoon, Ewalt & Shader, 1967, 1972) which showed that psychotherapy had limited efficacy on schizophrenia at best. These studies were influential, but if we look at the methodologies used, we are struck by their naivety: for example, May wanted to demonstrate the effectiveness of a six-month psychotherapy practiced by psychiatrists in training on hospitalized schizophrenics; Grinspoon, Ewalt & Shader wanted to demonstrate that individual psychotherapy was more effective than neuroleptics in chronic hospitalized schizophrenics.

In reality, two other studies were made, less influential, but which reported more optimistic results: Rogers et al. (1967) found some results from psychotherapy of chronic schizophrenics even if done by inexperienced therapists, but the results appeared only after about a year and a half; O’Brien et al. (1972; see also Mintz, O’Brien & Luborsky, 1976) compared individual and group therapy, not finding major differences, with the implication of the importance of group therapy as more cost-effective; Karon & VandenBos (1981) did a study in Detroit of a relatively small group of schizophrenics, taking great care to select experienced supervisors and therapists (the fact that inexperienced therapists had been used in previous studies raised a lot of criticism), and found that intensive psychoanalytic therapy conducted by experienced therapists had positive effects when compared to drugs and normal hospital milieu; in the group treated with psychotherapy there were fewer thought disturbances and greater adaptation, moreover psychotherapy was more cost-effective because, due to the lower number of hospitalizations, it costed 20% less in the first 20 months and 43% less during the two years of follow-up. According to Karon, who was influenced by John N. Rosen (1902-1993), a psychiatrist who in the 1950s and 1970s had achieved some popularity for a technique for schizophrenia called “direct analysis”, «the treatment of choice for schizophrenia is psychotherapy, which can be as effective for schizophrenic patients as it is for neurotics, with the difference that for schizophrenia the process can be much longer».

However, as Gunderson et al. (1984, 1988) observed, the conclusions of these first studies, made with a methodology not always rigorous, may be the following: 1) the addition of a psychodynamic therapy to the therapeutic armamentarium for schizophrenic patients does not give the certainty of obtaining results superior to those of medication alone; 2) in any case, a possible benefit of psychotherapy is not impressive.

However, those who still believed in the efficacy of psychotherapy for schizophrenia had strongly criticized these studies, and the main critiques were essentially of four types: 1) as mentioned, expert and motivated therapists were almost never used, but only psychiatrists in training; 2) the psychotherapies were not long enough to be effective (for example they lasted six months); 3) too severe, almost incurable patients were chosen; 4) the instruments for measuring outcome were not sensitive enough to the “psychodynamic” or “intrapsychic” changes produced by psychoanalytic therapy.

For these reasons, a group of researchers from Boston, originally led by Alfred Stanton and then by John Gunderson, designed an impressive study on the psychotherapy of schizophrenia, with more rigorous criteria this time, to shed more light on this field. Let’s briefly see the methodology and results of this research (Stanton et al., 1984; Gunderson et al., 1984, 1988). Later on, other researches will be reviewed, also on non-individual therapies, to give a more complete picture of the psychological treatment of schizophrenia, which in fact has increasingly abandoned individual therapy and moved towards family and psychosocial approaches. I recall in this regard that at the Tenth International Symposium for the Psychotherapy of Schizophrenia (ISPS) (Stockholm, August 11-15, 1991), organized by the ISPS – which, as will be recalled, was founded by Christian Müller and Gaetano Benedetti in Lausanne in 1956 – discussions began to change the name of the association, considering that most of the therapies were no longer individual but family and psychosocial, and then in 2012 the change of the name of the ISPS was voted, while maintaining the same acronym: from International Society for the Psychological Treatments of the Schizophrenias and Other Psychoses the name became International Society for Psychological and Social Approaches to Psychosis.

The Boston study by Stanton and Gunderson

This research was planned in 1972 and completed in 1984. Particular attention was paid to selecting experienced and motivated therapists who were paid. The patients were neither too severe nor too mild and all diagnosable with what were to become the DSM-III criteria (American Psychiatric Association, 1980).

Two techniques were compared, defined EIO (Exploratory Insight-Oriented, that is, we could say a “psychoanalytic” technique) and RAS (Reality-Adaptive Supportive, that is, a more “supportive” technique, not interpretative and therefore not psychoanalytic). The EIO therapists were expert psychoanalysts, they saw patients three times a week (in rare cases two), they believed in the psychological causes of the disease and in the usefulness of analyzing the past, conflicts, the unconscious, the transference, etc. The RAS therapists were mainly psychopharmacologists, they saw patients once a week (in some cases less), believed in the biological causes of the disease and tried to adapt the patient to daily life. It was possible to demonstrate through independent judges that the two groups of therapists were different in fact and not only in name, even if certain functions were performed by everyone (a certain support and adaptation to reality, attention to interpersonal problems, etc.).

164 suitable patients were found, of which only 60% remained in treatment beyond 6 months (minimum time to be included in the study), and 30% beyond two years of follow-up. Therefore, the research was conducted on 95 patients (age 18-35 years), of which 51 for 2 years (28 RAS and 23 EIO). All patients also received regular medication and milieu therapy as needed.

The results were the following. Over time, the patients who remained in supportive therapy (RAS) were different from those who remained in psychoanalytic therapy (EIO): the former had above all the positive symptoms of schizophrenia (delusions and hallucinations) and greater optimism in improvement, while the latter had mainly negative symptoms (social isolation and apathy), greater pessimism in improvement, greater education and a history of previous psychotherapies.

In this regard, it is worth opening a brief parenthesis to comment on this finding – and precisely the fact that patients who benefit from “expressive” therapies (that is, introspective or “psychoanalytic”) are different from those who benefit from “supportive” therapies – because it will be amply corroborated by the researches of Sid Blatt (2004, 2006, 2008; see Migone, 2015) on “anaclitic” and “introjective” personalities (terms taken up by Freud, 1905, 1915): anaclitic personalities are more dependent on interpersonal relationships (in case of depression, for example, they suffer from the fear of being abandoned), while introjective personalities are characterized by a sense of autonomy, responsibility, ability to tolerate loneliness, etc. (and in case of depression they suffer from guilt, not abandonment). Blatt demonstrated that anaclitic patients improve more with supportive techniques while introjective patients improve more with psychoanalytic or introspective techniques. He reached this conclusion, which has obvious therapeutic implications, by re-examining the most important studies on the efficacy of psychotherapy (such as that of the Menninger Foundation [Kernberg et al., 1972; Wallerstein, 1986, 1993], the well-known Treatment of Depression Collaborative Research Program [TDCRP] of the National Institute of Mental Health [NIMH] [Elkin et al., 1989], etc.) and correlated the results to personality types using his model of the “fundamental polarity” of personality (see Blatt, 2006, pp. 754-757).

Returning to the Boston study, all the patients improved, even if not in the core of schizophrenia, but the RAS-patients (supportive therapy) improved more in work functioning, in the number of hospitalizations and to a lesser extent also in social adaptation, while the EIO-patients (psychoanalytic therapy) improved, albeit modestly, in cognitive and ego functions (for example in the disorganization of thought).

One of the implications of this research is – in the words of Gunderson et al. (1988) – that for many schizophrenic patients «individual psychotherapy, at best, would be only a waste of time» (p. 261), and that sociotherapy (social skills training, etc.) is more advisable; it is preferable a supportive, directive and reassuring attitude, such as the “authoritative attitude typical of the family doctor”, which diminishes fears and gives hope, and pays  attention to the practical things of daily life. Another implication of this research is that it is not true that the best results are obtained by the so-called “most gifted” therapists, but only by a good “matching” between patient and analyst; in other words, even less gifted therapists can produce good results if they are matched well with certain patients. Psychoanalytic therapy should be limited to cases in which negative symptoms prevail (which among other things are not usually modified by medication), and in any case should never be considered as a first choice intervention, and perhaps not even second choice. Jerry Klerman (1984), commenting on these results, even went so far as to affirm that «scientific evidence does not justify any further research on individual intensive psychotherapy of schizophrenia (...) based on psychodynamic or interpersonal principles» (p. 611).

In conclusion, according to Gunderson, for the vast majority of schizophrenics the first choice should be medication, the second choice sociotherapy, and, if both fail, the third choice intervention should be psychotherapy, especially with those patients in whom negative symptoms prevail. Other studies also reached similar conclusions, including those by Michael Stone (1986) and McGlashan (1984b), that we present now.

The follow-up by McGlashan at Chesnut Lodge

In the mid-1980s, the well-known follow-up by McGlashan (1984a, 1984b, 1986; McGlashan & Keats, 1988) was done on schizophrenic, bipolar and borderline patients hospitalized at Chesnut Lodge, the famous psychoanalytic hospital in which Frieda Fromm-Reichmann, Harold Searles and others had worked, influenced by the pioneering work of Harry Stack Sullivan who gave his seminars there. McGlashan followed up for 15 years 446 seriously ill patients treated at Chesnut Lodge from 1950 to 1975. It turned out that about 2/3 of schizophrenics – just as Kraepelin observed – had either not improved or had gotten worse. On the other hand, only 1/3 of bipolar patients had gotten worse, and the same thing could be said of borderline; borderline patients, however, showed some improvement in the second decade after discharge.

The research on “Expressed Emotion”

These studies are interesting because they show that a psychological approach to schizophrenia aimed at involving the patient’s family members can be very effective (Leff & Vaughn, 1985; Leff, 1988; Hoo¬ley, 1985; Kanter, Lamb & Loeper, 1987). According to a review (Kavanagh, 1992), studies on Expressed Emotion are “the most significant advance in the treatment of schizophrenia since the discovery of neuroleptic medication” (p. 616). Let’s see them briefly. &&&

These studies, initiated by Brown in England in the 1950s and 1960s, were then continued by other researchers, including Leff (1988), Vaughn, Hogarty, Anderson, Goldstein, Falloon, Tarrier, etc. The context in which these studies developed was the great movement of deinstitutionalization that took place in England in those years. What was discovered was that the patients who after discharge had a higher number of relapses of schizophrenia lived in families with a high rate of “Expressed Emotion” (EE), i.e., characterized by an atmosphere full of high emotional tension, over-involvement, criticism and hostility towards the patient, excessive physical proximity (also measurable with a high number of hours per week “face-to-face” with over-involved family members), and so on. A technique was then formalized, called “psychoeducation” (Anderson et al., 1986), aimed at lowering the Expressed Emotion in family members by clarifying the symptoms of the schizophrenic family member, “educating” them on the causes and course of schizophrenia. For example, some parents may accuse their son of being lazy while they do not understand that he is simply unable to change because he is ill, or might feel responsible for the illness of their son (and might project their intolerable sense of guilt onto him), and they are taught that it is not their fault; and so on. The results have been extremely promising: relapses of schizophrenia one year after discharge drop from about 50% to a percentage ranging from 0% to 12% depending on the studies.

From the psychoanalytic point of view, it can be said that with this technique it is interrupted the vicious circle of anxiety and disturbing feelings which, in a continuous feed-back of projective identifications, are rebounded from the patient to the family and vice versa (Migone, 1991b, 1993, 1995 ch. 7). If family members learn to contain these anxieties, showing the schizophrenic relative that it is possible to live with them without being overwhelmed by them, they behave in a way like a therapist, allowing the patient to introject new adaptive abilities, or to modify his archaic super-ego through new introjections. It can be said that this therapeutic modality, well known to those analysts who today refer to the concept of projective identification (Ogden, 1979, 1982), is not very far from that described by Strachey in 1934.

Hogarty’s contributions

An important place in this review deserves Gerard E. Hogarty (1935-2006), who devoted his life to studying schizophrenia while also performing rigorous controlled studies (Hogarty, 2002; Hogarty et al., 1986, 1995, 1997, etc.). He developed four methods in succession, each of which based on an attempt to improve the previous ones, and always paying attention to keeping the scientific and human approaches together (for a review, see Eack, Schooler & Ganguli, 2007):

1) Major Role Therapy (MRT) was a precursor of clinical case management. Its effects on relapse rates were analyzed in the NIMH Collaborative Outpatient Study in Schizophrenia, a randomized study involving 400 patients (chlorpromazine+MRT, chlorpromazine only, MRT+placebo, placebo only). 20% of standard doses of antipsychotic drugs were as effective as regular doses, with the advantage of having fewer side effects. Major Role Therapy provided pragmatic and compassionate care that helped patients in key life roles, such as completing school, engaging in paid work, and/or doing household tasks.

2) Family Psychoeducation, an approach to educate – and ally with – family members to reduce family distress, has been shown to be highly effective. At the University of Pittsburgh, Hogarty joined the well-known family therapist Carol M. Anderson in this project.

3) Personal Therapy (PT) was an individualized and flexible psychotherapy aimed at teaching stress management and emotional regulation techniques. In fact, the prodromal signs of a relapse are more often manifested with affective dysregulation rather than with positive symptoms of psychosis. The goal of the PT was to reduce relapses in the 2nd and 3rd year after discharge. Previous psychosocial treatments focused only on changing the environment, either directly (e.g., family psychoeducation) or indirectly (e.g. social skills training), rather than teaching patients to manage internal distress: consequently, when there was external stress, there was often a relapse.

4) Cognitive Enhancement Therapy (CET) is a comprehensive approach for the improvement of cognitive deficits. The program combines individual neurocognitive training with cognitive exercises to improve attention, memory and problem-solving, and group meetings to improve socio-cognitive skills such as taking the perspective of others, reading non-verbal signals and learning about rules of conduct. The improvements compared to control group (which was a supportive therapy) occurred also at one year of follow-up.

Loren Mosher’s Soteria Project

It is worth mentioning the Soteria Project of Loren R. Mosher (1933-2004), who was a schizophrenia researcher and director of the Center for Studies of Schizophrenia at the NIMH from 1968 to 1980, dedicating his entire professional career in search of a humane and effective treatment for patients with schizophrenia. This innovative project consisted of residences similar to normal homes, therefore very different from hospitals, where patients could stay, even without medication, in a quiet environment and supported by non-medical personnel. The Soteria Houses spread to various countries, for example in Bern Luc Ciompi had founded Soteria Bern.

The meta-analysis by Malmberg, Fenton & Rathbone

Malmberg, Fenton & Rathbone (2001) twenty years ago published in the Cochrane Library a review on the efficacy of psychoanalytic therapy in schizophrenia to try to settle the question. They found only four randomized studies that could fit in their review, for a total of 528 patients and 5 comparisons between different treatments. Comparing individual psychotherapy versus drugs, psychotherapy patients took longer to be discharged; there was no difference between the two groups in the number of patients who were re-hospitalized long-term, but at 12 months, psychotherapy patients needed fewer drugs than those treated with drugs. If one compared individual psychotherapy plus drugs versus drugs alone, there were no differences between suicide rates and improvement to allow discharge. Data on long-term re-hospitalizations were equivocal. In the Boston study (Gunderson et al., 1984), EIO and RAS patients were the same in terms of re-hospitalizations, but EIO-patients stayed longer in therapy. There were no differences between individual and group therapy. The conclusion is that there is no strong evidence that psychoanalytic therapy is more effective than other interventions, and in any case it would not be indicated in hospitalized patients.

The Finnish Open Dialogue approach

An interesting approach to the prevention of psychotic episodes is the Open Dialogue approach, practiced for more than thirty years by Jaakko Seikkula’s group in Western Lapland (Finland). Various countries are working to apply this method, and interest is very strong also in Italy: eight Departments of Mental Health of various Italian Regions (two in Rome and two in Turin, and in Catania, Modena, Savona, and Trieste) have launched a pilot project funded by the Ministry of Health, in collaboration with the National Research Council (CNR), to verify the possibility of integrating this approach into the Italian mental health services (see Putman & Martindale, 2021, chapters 17 and 20).

The theoretical background of this approach is extremely interesting because it is interdisciplinary, with references also outside to our field. In fact, its points of reference are in the studies of Lev Vygotsky on the development of language and of the Russian linguist Michail Bachtin on the work of Dostoevskji, in which dialogue is identified as a constitutive element of being: «At the center of the artistic world of Dostoevskji there is dialogue, and dialogue is not a means, but an autonomous end. (…). To be means to communicate dialogically. When the dialogue ends, everything ends» (Bakhtin, 1929, p. 331). Dostoevskji’s primary intention is choral dialogue, «to convey the theme through numerous and different voices» (Bakhtin, 1929, p. 351, italics in the original).

Seikkula’s team was originally inspired by the “need adapted approach” of the well-known Finnish psychoanalyst Yrjö Alanen (1997), from whom it then became autonomous, approaching systemic therapy (very useful in schizophrenia) to finally arrive to Open Dialogue. Unlike the Milan Approach of systemic therapy, i.e., Mara Selvini Palazzoli’s famous “Milan school” (Selvini Palazzoli et al., 1975) which operated mainly outside the hospital, Open Dialogue is also used in hospitalized patients; in addition, the idea of the therapist who “from above” brings about a change in the family was abandoned, and now the aim is to listen to the different voices present in the meetings.

The crisis is observed early in vivo in the natural environment in which it originated, even at the patient’s home (Anderson & Goolishian, 1988), and the family is never seen as the object but as the agent of change. The meetings are attended by at least three team members, the patient, his family and other important figures of his social network, such as sometimes neighbors (here the technique of the French ethno-psychoanalyst Tobie Nathan comes to mind, who – however in his work with immigrants and in different ways – in Paris it included in the sessions different staff members and various people of the patient’s social context). The goal of the meetings, in which everybody sit in a circle, is to create a new language and give new meanings to the symptomatic behavior (Seikkula, 2014, p. 99), just as happens in the psychodynamic tradition; furthermore, on the part of the team there is no planning of the topics of the meeting, as in a sort of free association in a group.

To avoid hospitalization, the intervention must be immediate, within 24 hours of the initial contact, because in the very first days it is possible to talk to the patient about things that later can become inaccessible (for example the contents of hallucinations and delusions); a diagnosis of schizophrenia can often be avoided as the symptoms soon subside. They try not to use antipsychotic medication, preferring anxiolytics to promote sleep. Important is the ability of the team to tolerate situations of uncertainty, therefore not to quell the crisis with drugs and not to be in a hurry to make decisions. This fundamental team capacity is facilitated by a real training based on reflective discussions and mutual listening, as well as personal psychotherapy for all team members (including nurses and doctors).

Thanks to this approach, 5-10% of the population is involved each year in Western Lapland, and stigma decreases consistently, causing, with a feed-back, positive effects on possible new cases of schizophrenia, which per 100,000 inhabitants have passed from 33 in 1985 to 2 in 2000 (Seikkula, 2014, p. 95).

For an in-depth look at this approach, see Seikkula (2014), Bessone & Tarantino (2015), Tondi (2015), Putman & Martindale (2021) and the documentary film by Daniel Mackler (2011), which shows very well the way of working of the Open Dialogue approach (in this film there is also an interview to Robert Whitaker, author of the 2010 book Anatomy of an Epidemic, which is discussed also in Marcia Angell’s [2011] well-known essay on the current crisis of psychiatry).

From the psychoanalytic point of view, this technique allows the construction of a “mentalizing” or metacognitive pole, of an observing ego, in which the patient no longer identifies with a single voice, his reality is not the only one but is enriched by different points of view, by the choral and polyphonic character of the dialogue, just like in Bakhtin’s (1929) Dostoevskian reading. The patient expands his reflective capacity by reflecting himself in the words of the other members of the meetings, that is, favoring the development of a new psychological function, as Ernst Kris (1956) had already conceptualized in the middle of last century when he underlined the importance of the function of insight with respect to the content of the insight.

In a psychiatry dominated by a “technological paradigm” (Bracken et al., 2012) – in which drugs now represent the main variables of treatment, devaluing the role of listening and dialogue, and in which the propaganda of pharmaceutical companies penetrates every aspect of our field – these “good practices” of our Finnish colleagues in their “simplicity that is difficult to make” represent a breath of fresh air and hope.

Two naturalistic studies at the Austen Riggs Center

Finally, two naturalistic studies deserve to be mentioned, the first in 1994 and the second just completed, in 2021, on patients of the Austen Riggs Center (Stockbridge, Massachusetts), which is a psychoanalytic hospital with a prestigious tradition (among those who worked at the Austen Riggs Center there were Erik Erikson, David Rapaport, Robert Knight, Otto Will, Merton Gill, Roy Schafer, etc.). It can be said that the Austen Riggs Center is the only psychoanalytic hospital left in the United States, after the closing of Chestnut Lodge (founded in 1910 and closed in 2001) and the Menninger Foundation (founded in 1919 and moved to Houston in 2003).

In the first study, Blatt et al. (1994) verified a moderate efficacy of psychoanalytic therapy at four sessions per week in 90 hospitalized patients followed for nine months and examined with a battery of tests including the Rorschach, the Thematic Apperception Test (TAT), the Wechsler Adult Intelligence Scale (WAIS), the Human Figure Drawing Test, etc.

The second study has been just published in Psychiatry (the journal founded by Sullivan in 1938) by Chris Perry & J. Christopher Fowler (2021), who followed for 14 years patients who had been in hospital for two to three years. It is a study on treatment-resistant patients, with multiple diagnoses, and the goal was to see if they improved and in how long. They focused on the concept of psychodynamic recovery, that is, looking not only at symptoms change but at global improvement, and they validated it with 12 convergent scales that measured symptoms and functioning. As a result, these severe patients can improve if treated over the long term. The patients were 226 adults, of which 75.2% were women. A subgroup of 54 patients were periodically screened with the Psychodynamic Conflict Rating Scales (PCRS), resulting in 12% of these having fully recovered after a mean of 11.63 years, and 14.81% also achieved good adaptation. There were also improvements in symptoms (64.29%), social functioning (87.50%), and psychodynamic functioning (50%). The conclusions show that it is possible to achieve an improvement, albeit in the long term, in global functioning and social adaptation.

Discussion

From the studies reviewed on the individual psychoanalytic therapy of psychosis it clearly emerges that a supportive psychotherapy, therefore not psychoanalytic in the strict sense, is more effective. A therapeutic relationship based on reassurance and on an identification with the therapist who also provides corrective experiences (Alexander et al., 1946) would lead to better results than a work aimed primarily at the search for insight, arriving at the conclusion that in the psychoses the “pure gold” of psychoanalysis is less valuable than the “copper” of psychotherapy (Freud, 1918, p. 28; see McGlashan & Nayfack, 1988).

Moreover, Freud, as mentioned at the beginning, believed that psychoanalytic technique based on interpretation and analysis of transference was not suitable for psychotics. Not only that, but it must also be said – as many authors have pointed out – that the technique that can be defined as “orthodox” or “classical”, that is, based on the privileged use of verbal interpretation and the tendential elimination of relational aspects, was not practiced by Freud, who was very flexible, not at all rigid with his patients, also placing himself as an object of affective identification. In short, Freud, if we can say so, was never a “Freudian”, as can be clearly seen from various reports of his patients and also, for example, from the symposium on curative factors held at the International Psychoanalytic Association (IPA) congress of Marienbad in 1936 when Freud was still alive and made his influence felt. The turning point came 25 years later, at the Edinburgh congress in 1961, when with a curious backtrack the majority of the analysts who intervened (Segal, Kuiper, Garma, Heimann, etc.) did not want to hear about curative factors that were not interpretation (insisting further that it must be a “true” interpretation). In vain Sacha Nacht (1962) tried to underline the importance of the analyst’s “presence” and “humanity” as a source of identification, and Max Gitelson (1962), proposing the concept of the analyst’s “diatrophic” function (that is, nourishment, support), had to defend himself from the attacks received by saying, as in a sort of concession, that it could possibly be useful only in borderline patients or at the beginning of therapy and then move on to “real” psychoanalysis. In Edinburgh it was emphasized the importance of eliminating the “impurities” of the emotional relationship with the analyst, who, as I defined it years ago (Migone, 1995 ch. 6, 2004 p. 151), had undergone a sort of “personectomy”, that is, the surgical removal of his person from the relationship with the patient (the metaphor of the surgeon here may be appropriate also because it should not be forgotten that American analysts were only physicians, since psychologists will gain the right to access training only after the lawsuit that was concluded at the end of the 1980s; for an account of this lawsuit, see Migone, 1987).

Larry Friedman (1978, pp. 536-537; see Migone, 1995, ch. 6) has shown very well that this “orthodox” turning point, which officially took place at the Edinburgh congress in 1961, was actually due to sociological factors: in the middle of the century, psychoanalysis no longer dominated the market unchallenged, and its monopoly had been broken by the siege of a vast movement of psychotherapies, many of which were not only effective but also cheaper and therefore more attractive (one of the main threats was coming from the so-called “psychoanalytic psychotherapy”, and the eternal debate on the difference between psychoanalysis and psychotherapy has never been resolved unanimously – I believe that Gill, in his 1984 revision, was the only one to clarify this problem in a coherent way; see Migone , 1991a, 1995 ch. 4, 2000). The psychoanalytic community felt threatened and needed to differentiate as much as possible the specificity of the psychoanalytic method, and of course only interpretation lent itself to serve as a “strong concept” suitable for this purpose (Galli, 1985, 1992, 2006, 2012). The identificatory and affective components, linked to the relationship with the therapist, risked being included in the so-called “non-specific” or “common” factors present in all psychotherapies (Frank, 1961), diminishing the originality of psychoanalysis.

The basic issue here is what is meant by “psychoanalysis”, a problem that has been debated countless times in the history of the psychoanalytic movement without being resolved unanimously (cf. Migone, 2011, 2020). As I have argued on several occasions (Migone, 1991a, 1995 ch. 4, 2000, etc.; Green, Kernberg & Migone, 2008), a big mistake made by the psychoanalytic movement was to identify with the term “psychoanalysis” not a general theory but only a specific technique, and precisely the “classical” technique (couch, high weekly frequency, privileged use of interpretation, etc.). In other words, and to better explain what I mean, it could be argued, for example, that the Boston study was not on the efficacy of psychoanalysis of schizophrenia, but on the efficacy of a particular technique that had been taught to a group of colleagues in a specific historical period and in a specific country (the United States), and that this was not the right psychoanalytic technique for schizophrenia; it was therefore a study with also sociological implications. For the sake of brevity, I quote from a debate I had years ago with André Green and Otto Kernberg:

«Freud (1922, p. 439), when he gave a definition of psychoanalysis, said that it was three things at once: a research method, a therapeutic technique, and a psychological theory. However, what many forget is that these three aspects were conceived as inseparable from each other. The problem arose when over the years the theoretical pole had been increasingly fragmented due to the creation of different schools (some in opposition to each other), so that it has become increasingly difficult, if not impossible, to maintain a unitary identity of the movement. As the theoretical pole is fragmented, there has therefore been the natural tendency to find a common denominator in the technical pole (couch, high weekly frequency, etc.), also because it is more visible, concrete and functional for the pressing needs of a professional group now well organized also at the international level. The problem, however, arose to the extent that the relationship between theory (which was diversified) and technique (which curiously remained the same, the classical one, also sanctioned by IPA rules) no longer became completely clear. By breaking the close link between theory and technique, the scientific status of the discipline is threatened. What I mean is that, if we want to keep the link between theory and technique, we must necessarily argue that even a supportive (or “psychotherapeutic”) technique is “psychoanalysis” if at a particular moment it is the only possible intervention that an analyst can use with a particular patient in light of his or her defenses. On the contrary, if a psychoanalyst treats a severe patient with an “unmodified psychoanalysis”, this is not psychoanalysis but “bad psychoanalysis”» (Migone, in: Green, Kernberg & Migone, 2008, pp. 217-218).

The term “psychoanalysis” therefore should not be used to refer, in a reductive way that also leads to dead ends, only to a specific technique but, as was also in Freud’s intentions, to a general theory that can be declined in different techniques according to the various clinical situations (borderlines, psychotics, institutions, groups, families, children, etc.). Moreover, this was the program of Ego Psychology, which gave importance to the respect of defenses, the adaptive point of view and the developmental level, and which on closer inspection implied that, in a way, the difference between psychoanalysis and psychotherapy is dissolved (not by chance, the debate on the difference between psychoanalysis and psychotherapy never existed within schools other than Ego Psychology, such as the Kleinian one, where the same technique was also used for psychotics and children) (see Gill, 1984; Migone, 1991a, 1995 ch. 4, 2000). If by psychoanalysis we mean a general theory that can be declined in different techniques – as it is in medicine – the relationship between theory and technique is not broken, thus maintaining the scientific status of the discipline.

In this regard, it is worth mentioning the revision of the theory of technique “beyond interpretation” suggested by John Gedo (1979), who proposed a “hierarchical scheme” which envisages five “modes” that follow a progressive maturation, each with five variables: mode of functioning, regulatory principle, typical defense, typical problem or danger, technical intervention (for further information, see Migone, 1985). Thus different therapeutic modalities fall within what we can define “psychoanalysis” (an alternative proposal on how to handle multiple models in psychoanalysis made in the 1980s, as is well known, was that of Fred Pine [1988, 1990], which I cannot discuss here).

In 1988, on the occasion of the 900^th Anniversary of the University of Bologna, we organized a conference on schizophrenia (Migone, Martini & Volterra, 1988), to which we invited various researchers, including John Gunderson, Gaetano Benedetti, Loren Mosher, Julian Leff, Michael Robbins, Luc Ciompi, Mario Maj, Georges Lanteri-Laura, Carlo Perris, Norman Sartorius, etc. In the debate after Gunderson’s paper, in which he presented the results of his Boston study published four years earlier, there was a confrontation between Gunderson, Benedetti, Leff, Galli and others on the psychoanalytic therapy of schizophrenia; in order not to make my presentation too much, I cannot report it here, so I refer to another work (Migone, 1995, ch. 6).

I would like to end with a quote from Freud (1910a), which clearly shows what psychoanalysis was for him:

«Informing the patient of what he does not know because he has repressed it is only one of the necessary preliminaries to the treatment. If knowledge about the unconscious were as important for the patient as people inexperienced in psychoanalysis imagine, listening to lectures or reading books would be enough to cure him. Such measures, however, have as much influence on the symptoms of nervous illness as a distribution of menu-cards in a time of famine has upon hunger» (SE, 11, p. 225; p. 329 of the Italian edition).