Int J Psychoanal 2003;84:3–15

Psychoanalytic Controversies
The relationship between psychoanalysis and
schizophrenia
Richard Lucas
63 Ossulton Way, London N2 OJY, UK — Richardnlucas1@aol.com

In this article, the author considers psychoanalysts’ current attitudes towards schizophre-
nia. After early optimism of a psychoanalytic approach, interest has waned, other than in
the Ž eld of Ž rst-onset psychosis. This was because of poor outcome Ž gures and regarding
schizophrenia as now having a biological, rather than psychological, base. The author
argues that there is a paradox, because only psychoanalysis offers a framework for relating
to psychotic patients in a way that helps them to make sense of their experiences. A
framework is described, with clinical examples, to illustrate the application of analytic
thinking to patients with schizophrenia. Psychoanalysis needs to revitalise its attitude to
psychosis, as it has a signiŽ cant contribution to make within general psychiatry, not least
in the training of the next generation of psychiatrists.

Keywords: psychoanalysis,schizophrenia,frameworks of understanding,psychotic wave-

length, ideographs,hallucinations and delusions, teaching aspects

Introduction
In a recent article entitled ‘Psychoanalysis and schizophrenia: A cautionary tale’ (2001),
Willick cites the history of psychoanalysis and schizophrenia as an example of psychoanalytic
theories that have not stood the test of time.
Analysts have imposed their theoretical views of aetiology, attributing schizophrenia to early
trauma linked with an emotionally unresponsive mother, rather than accepting an underlying
biological causation. It was therefore not surprising that the outcome Ž gures from Chestnut
Lodge, where they had employed a purely analytic approach to schizophrenia, were
unfavourable, in contrast to the results with more borderline states (McGlashan, 1984).
In a review of British object-relations theorists, with the exception of Rosenfeld, Willick
(2001) reported that he was unable to Ž nd a single well-documented case of schizophrenia in
the work of Klein, Winnicott, Fairbairn, Guntrip and Bion. Without any clinical supportive
evidence, they had all lumped together schizophrenia, schizoid personalities and other severe
character disorders as examples of failures to adequately overcome the paranoid-schizoid
position.
Bion, in fact, did see patients with schizophrenia analytically and, from his clinical
experience, he developed a whole new way of approaching schizophrenia, as shown in the
clinical illustrations I present below.
Willick does not express a view as to where that now leaves analysis in relation to
schizophrenia, if it has a biological basis. Does psychoanalysis still have a useful contribution
to make?
A review of the analytic attitude to schizophrenia is long overdue and carries important

#2003 Institute of Psychoanalysis

4 PSYCHOANALYTIC CONTROVERSIES
consequences for the contribution of psychoanalysis to the Ž eld of general psychiatry
(Freeman, 1988; Jackson & Williams, 1994).
One might list a whole range of controversial issues meriting further debate, for example, the
question of acceptance or repudiation of the death instinct (Black, 2001; Lucas, 2002), and the
existence or otherwise of transference in psychosis, with its implication for analytic technique
(Rosenfeld, 1969). Also does one make a clear distinction in one’s mind between borderline
states and schizophrenia, both in terms of psychopathology and prognosis (Rey, 1994)?
However, the biggest question to be confronted when approaching schizophrenia is the
aspiration to cure. After all, we refer to analysis as ‘the talking cure’.
Current research concentrates on attempts to prevent the development of schizophrenia
through vigorous treatment of Ž rst-onset psychosis. Optimistic reports have been published in
relation to both a combination of C.B.T. and family therapy and an analytically based approach
(McGorry, 2000; Jackson, 2001). Time will tell whether this optimism proves to be well
founded.
Many analysts hold the view that, once patients have established schizophrenia, they come
into the domain of ‘no hopers’. These are cases we cannot cure, cases who remain resistive to
offered therapeutic measures, cases with recurrent episodes of disturbed behaviour and cases
demanding of long-term care.
In analytic terms, these are hardly rewarding candidates for treatment, especially if there
proves to be an underlying organic rather than psychological substrate.
However, a paradox remains. Speaking as a practising psychoanalyst, who also works in the
Ž eld of general psychiatry in a busy, socially deprived area of North London, I have found that
only applied psychoanalytic knowledge and technique provide the tools to gain understanding
and talk meaningfully to these patients about the working of their minds and their emotional
experiences. Psychoanalytic thinking provides the framework to help the individual, their
relatives and the professional staff in making sense of, and living with, the condition of
schizophrenia.
Psychoanalysis needs to rethink its way in relation to schizophrenia. At one point there was
much interest in an analytic approach, both in the US and in the UK, related to emerging
Kleinian theory. With the initial optimism not resulting in cures, enthusiasm has waned and the
special interest units in the UK, at Shenley and the Maudsley Hospitals, preceded Chestnut
Lodge in their closure.
Psychoanalysis can be viewed in three ways. First, it is an accumulated body of knowledge
of the working of the mind, especially focusing on the unconscious origins to emotional drives.
Second, it is a method of treatment of mental disorders through utilisation of the transference
and countertransference. Third, it is a research tool, through individual cases seen analytically,
four to Ž ve times a week. Detailed case studies of disturbed patients continue to contribute to
our overall knowledge of how the mind operates in psychosis (Sohn, 1997; Lucas, 1998).
However, here I am referring to an under-appreciated area: the importance of the applied use of
analytic insights in thinking about problems and sharing thoughts with staff, patients and their
relatives in everyday psychiatric practice.
There is a neuronal network, a biochemical pathway and a psychological level underlying
the expression of emotional drives (Rey, 1994). Approaching problems at one level does not
contradict a simultaneous approach at another level. In other words, administration of
medication and talking to patients with psychotic disorders are not contradictory, provided one
has sorted out the reason for one’s actions in one’s mind and can explain the reason to the
patient. In the case vignettes presented below, all the patients were receiving anti-psychotic
medication with the aim of helping to calm them down. However, this did not prevent analytic
 Richard Lucas 5
understandings of the patient’s behaviour, in each case, being of crucial importance to their
management.
The time has come to revitalise an analytic approach to schizophrenia, applied in a realistic
way, in the relevant setting, i.e. within general psychiatry. To do this successfully, one must
develop a robust and coherent framework. I will end this short review article by outlining some
aspects to this framework that I have developed in over twenty-Ž ve years of working in this
area.

Developing a framework
The basic philosophy
When we grow up, we all have to live with ourselves and our own psychopathology and ‘make
the best of a bad job’ in life. Some have to live with more severe psychopathology that might at
times completely dominate, adversely affecting the individual and his/her family. Learning
about these experiences and how best to cope with them can be a lifelong process.
A patient on admission angrily said, ‘I am God’s older brother’. I replied that he must really
be fed up with his younger brother getting all the publicity! The patient stopped, smiled and a
mutual warmth developed between us from that time onwards. Previously, he had taken his
brother’s car and driven it into a wall, fortunately without any resulting serious injury. He
thought he was omnipotent; that, at the time, he could do anything. My point is the need to relate
meaningfully to our patients to start an ongoing, shared lifelong experience, even if at times the
rapport may be temporarily overwhelmed, like a tidal wave, by the psychosis. Bion referred to
this as the never decided con ict between the life and death instinct in schizophrenia (1957).

Tuning into the psychotic wavelength

Bion produced a grid, which invited us to question, whenever we are dealing with a patient
with a major psychiatric disorder, whether we are receiving a communication from a non-
psychotic part or a psychotic part masquerading as normal (Bion, 1957). After all, the
commonest symptoms of schizophrenia are not auditory hallucinations or paranoid delusions,
encountered in some 60 per cent of cases, but denial and rationalisation, found in over 95 per
cent of cases (Lucas, 1993). The following are everyday examples.
A patient was admitted having smashed up his place, in a psychotic state. When I saw him
on the ward the next day, he was quite calm. He denied having any mental problems. His only
problem was that he didn’t know if I was Dr Lucas or an impostor. He thought of ringing the
police about this. His awareness of his disturbance was projected on to me, so I was the
impostor rather than himself, as if he was not the same person who only the previous night had
smashed up his  at.
A more serious case was of a man, who, in a state of psychotic relapse, had thrown bleach in
the face of a stranger: a young woman. He had wanted to project his problems into her and scar
her. His mother had contacted the professionals, as she was concerned that he was relapsing.
However, when seen the day before the incident, he had managed to convince the approved
social worker that he was all right and that it was his mother who was the problem.
The above case illustrates how the capacity to be aware of denial and rationalisation is of
crucial importance in risk assessment.

Differentiation of the psychotic from non-psychotic personality

In addressing patients with schizophrenia, as Bion pointed out, we always need to think in
terms of two separate parts, the psychotic and non-psychotic, not one person (Bion, 1957;
6 PSYCHOANALYTIC CONTROVERSIES
Lucas, 1992). The psychotic part is intolerant of frustration and attacks thinking arrived at by
the work of the non-psychotic part. The following case serves as an illustration.
A young woman was admitted to our mental hospital in a thought-disordered state. While on
the ward, for months she kept denying having any problems. One weekend, she went home to
her mother and jumped out of her bedroom window, fracturing her leg. While still on the
orthopaedic ward, she came to see me in my out-patient clinic. She was in a frightened state
and asked to be readmitted to the mental hospital, on medical discharge.
When she returned to the mental hospital, she reverted to a denial of any problems. Anti-
psychotic medication was having no effect on her mental state. I then realised that she hadn’t
jumped out of the window in a state of adolescent despair, she had been pushed out by an
intolerant part.
When I put this to her, her mental state suddenly changed. She made out that she was
religious and that I was bigoted and intolerant towards religion. She also began to speak for the
Ž rst time in ward groups, saying that patients should be given holidays. However, at least the
murderous part was now in the open for us—and her mother—to appreciate. It also explained
why another part of her, the non-psychotic part, was in a frightened state when coming to see
me, asking for readmission, as she felt on the end of a murderous attack.

Ideographs, hallucinations and delusions

The aim of the psychotic part of the mind is to relieve itself of emotional pain through
projection. If a painful feeling arises, it will evacuate it to produce an hallucination. If the
sensation is projected into an object, it becomes a delusion. The characteristic of the object’s
behaviour will be determined by the nature of the hallucination, for example, a television may
be experienced as spying or talking depending on whether the projected hallucination was
visual or auditory in origin (Bion, 1958).
According to Bion, the psychotic part has attacked and fragmented all parts of its mind to do
with registration and differentiation of internal and external reality. The psychotic part stores
past events, which Bion termed ideographs, for later use for the purposes of either emotional
evacuation or communication. I think of these past events stored in the mind like mugs on
pegs, to be taken down and used when needed. The challenge to decipher ideographs brings
interest into general psychiatry, into what otherwise threatens to remain just very demanding
and soul-destroying work, leading to premature retirement.
The following case serves as an illustration of deciphering an ideograph. A young man, of
Asian background, came into hospital saying that he was Prince Edward, son of Henry the
Eighth! He had no associations to his belief. The next day, he was behaving in a grandiose
manner demanding cigars from the nursing staff. In frustration at his lack of associations, I said
that he couldn’t have a cigar as they didn’t come into the country until brought by Walter
Raleigh when his sister Elizabeth was on the throne. The humour was completely lost on him.
Later, at a ward review, we learned from a social worker how there had been an arranged
marriage to a young woman who had come from abroad. He had beaten her up and she was
now in a women’s refuge. She didn’t want to leave him for fear of deportation. We could now
understand the ideograph. It was an attempt, by the psychotic part, to disown awareness arrived
at by the work of the non-psychotic part through use of the ideograph.
Henry the Eighth made up his own religion and was not to be contradicted in the way he
treated his wives. Our awareness of its meaning, at least, opened up the potential for relating to
the patient about his behaviour.
 Richard Lucas 7
The countertransference
If dreams are the royal road to the unconscious in neurosis, then the countertransference is the
‘via regia’ to understanding in psychosis (Rosenfeld, 1992). When patients in psychotic states
disown troublesome feelings into others, this is an unconscious process, not immediately
understandable to the patient or recipient. However, the countertransference experience may be
crucial in trying to make sense of an overall situation (Garelick & Lucas, 1996).
At a psychosis workshop, a junior doctor presented a problem of a patient who had
developed a delusional belief that he would be cured if the doctor sneezed. As a result, the
doctor became very careful not to sneeze in a session, fearing that it would have a catastrophic
effect. The patient seemed to centre all hopes of a quick cure on the doctor’s sneeze!
The doctor feared that, if he sneezed, he might lose his patient as a potentially responsive
person, through giving him a magical cure. The fear was that the patient would remain forever
in a manic unthinking state and that he would have been responsible for producing it.
Understanding his countertransference fear of sneezing led to the doctor being freed to think
and address the patient, namely, on the con ict of his aim of being in an isolated omnipotent
identiŽ cation versus being with others as supportive human beings.

The exoskeleton
Patients with chronic psychoses need, above all else, provision of an exoskeleton, a supportive
environment that can think and care for them. This dynamic often goes unappreciated when
planning the needs of patients with the closure of the asylums. Certainly, the quality of care
and expertise developed at Chestnut Lodge seems to have been forgotten, when everything is
reduced to mere outcome Ž gures (Silver, 1997).
Finally, mention should be made of the function of the currently overburdened acute
psychiatric ward, as both container and safety net if a patient relapses. Since psychotic patients
tend to fragment and project, it is important for all carers, professionals and relatives to gather
together to see who might have the vital piece of the jigsaw to appreciate the whole picture. For
example, it was the social worker who brought the vital piece of information to understand the
patient’s delusion of being the son of Henry the Eighth.
While medication may prove essential in calming down and controlling an excitable
psychotic state, it is the analytic framework that helps to provide the container to make overall
sense of the presenting situation in a needs-adapted way (Alanen, 1997).

The challenge for the future

In the UK, junior doctors start psychiatry with no real knowledge of psychoanalysis. With
schizophrenia, they are only taught to look for Ž rst-rank symptoms when performing a mental-
state examination. If you provide informal clinical seminars for them, things start to happen!
A junior doctor described how a patient, in her Ž rst psychotic breakdown, made an outline
with her hands of the junior doctor as he was leaving the room. She then gathered up the
outline in her hands and put her hands on her head. For the next three months, she walked
around with both hands on her head.
Clearly, she had created some idealised phantasy Ž gure of the junior doctor and put it into
her head. While words such as projective identiŽ cation, at this stage, have no meaning to the
junior doctors, such cases light an interest in an analytic approach. The doctors may start to
realise that analytic thinking is anything but passé when trying to make sense of the working of
the mind in schizophrenia. Our challenge is to excite the minds of the junior doctors.
Despite Willick’s cautionary tale, the analytic contribution to schizophrenia is anything but
8 PSYCHOANALYTIC CONTROVERSIES
redundant. The requirement now for psychoanalysis is to gather together like-minded
interested parties from the UK, Scandinavia, the US, South America and elsewhere through the
aegis of the IPA.
Analytic thinking may yet have its greatest impact for the general public in what may appear
to be the most unrewarding of terrain: the world of established psychoses.

Translations
Die Beziehung zwischen Psychoanalyse und Schizophrenie. In diesem Artikel betrachtet der Autor
derzeitige Haltungen von Analytikern bezüglich Schizophrenie. Nach anfänglichem Optimismus eines
psychoanalytischen Ansatzs hat das Interesse nachgelassen, abgesehen vom Feld der Psychose beim ersten
Auftreten. Dies ist auf schlechte Behandlungsergebnisse und dass Schizophrenie nun mit einer biologischen
statt einer psychologischen Basis gesehen wird, zurückzuführen. Der Autor argumentiert, dass darin ein
Paradox besteht, weil nur Psychoanalyse einen Rahmen bietet, um sich auf psychotische Patieten so zu
beziehen, was ihnen hilft, ihren Erlebnissen Sinn zu geben. Es wird ein Rahmen mit klinischen Beispielen
beschrieben, um die Anwendung analytischen Denkens bezüglich Patienten mit Schizophrenie zu illustrieren.
Psychoanalyse muss ihre Haltung zur Psychose wiederbeleben, da sie einen wichtigen Beitrag innerhalb der
allgemeinen Psychatrie leisten kann, nicht zuletzt in der Ausbildung der nächsten Generation von Psychiatern.

La relación entre psicoanálisis y esquizofrenia. En este artí́culo, el autor considera las actitudes actuales de
los psicoanalistas frente a la esquizofrenia. Después de un optimismo inicial respecto del enfoque
psicoanalí´tico, el interés ha decaí́do, con excepción de los casos de primer brote sicótico. Esto ocurrió por los
datos exiguos sobre resultados, y porque se ha pasado a creer que la base de la esquizofrenia es biológica más
que psicológica. El autor alega que hay una paradoja, pues sólo el psicoanálisis ofrece un marco que permite
relacionarse con los pacientes sicóticos de modo a ayudarles a dilucidar sus experiencias. Se describe un
marco, con ejemplos clí́nicos, para ilustrar la aplicación del pensamiento analí́tico a los pacientes con
esquizofrenia. El psicoanálisis debe revitalizar su actitud frente a la psicosis, pues tiene una contribución
signiŽ cativa que hacer dentro de la psiquiatrí́a general, en especial en la formación de la siguiente generación
de psiquiátras.

La relation entre la psychanalyse et la schizophrénie. Dans le présent article, l’auteur examine les attitudes
courants des psychanalystes face à la schizophrénie. Après une optimisme initiale d’une abord psychanaly-
tique, l’intérêt était tombé en déclin, sauf dans le domaine des psychoses des débuts. C’était ainsi à cause des
résultats décevants lié au concept contemporaine que la schizophrénie a une base biologique, plutôt que
psychologique. L’auteur propose qu’il y a un paradoxe, parce que seule la psychanalyse permet d’offrir aux
patients psychotiques la possibilité de comprendre leurs expériences. Avec des exemples cliniques, un cadre
est décrit pour illustrer l’application des idées psychanalytiques aux schizophrènes. La psychanalyse a besoin
de faire revivre son attitude envers la psychose, parce qu’elle a une contribution importante à faire en
psychiatrie générale, et en particulier dans la formation de la prochaine génération de psychiatres.

Rapporti tra psicoanalisi e schizofrenia. In quest’articolo l’autore prende in considerazione l’attuale

atteggiamento degli psicoanalisti nei confronti della schizofrenia. Dopo il primo ottimismo nei confronti di un
approccio psicoanalitico,l’interesse è diminuito, tranne che nel campo del primo insorgere delle psicosi. Ciò a
causa dei dati indicanti scarsi risultati e poiché ora si ritiene che la schizofrenia abbia una base biologica
piuttosto che psicologica. L’autore sostiene che ciò è paradossale, poiché soltanto la psicoanalisi offre una
cornice di riferimento per rapportarsi ai pazienti psicotici in modo da aiutarli a dare un senso alla loro
esperienza. Egli descrive mediante esempi clinici un’impalcatura metodologica per illustrare l’applicazione
del pensiero psicoanalitico a pazienti affetti da schizofrenia. Occorre che la psicoanalisi dia nuova vitalità al
proprio atteggiamento nei confronti della psicosi, poiché essa può offrire un contributo signiŽ cativo nel campo
della psichiatria generale, se non altro nella formazione della prossima generazione di psichiatri.

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The relationship between psychoanalysis and

schizophrenia by Richard Lucas—A commentary
Robert Michels
418 E. 71 Street, Suite 41, New York, NY 10021, USA — rmichels@med.cornell.edu

Psychoanalysis provides a framework for understanding human experience, which can be

of great value to persons suffering from psychiatric disorders, and to their caretakers.
There are also, of course, other useful frameworks. In past years, some have inferred that
the value of psychoanalysis with these patients implies that it helps us to understand the
aetiology of their disorders, that it may offer a ‘cure’, or that it has some special relevance
to their problems. There is no evidence for any of these. Further progress in this area
should be based on new evidence.

Keywords: schizophrenia, psychoanalysis

The history of the relationship between psychoanalysis and schizophrenia is complex. So-
called psychoanalytic theories of aetiology have not only been of little scientiŽ c value, their
application to the psychotherapy of schizophrenic patients or in discussion with their families
has often been demoralising and counterproductive. In the empiric arena of evidence and
science, they have largely lost out to biologic and psychosocial models. Most North American
psychoanalysts, exempliŽ ed by Willick, see the most important aspect of the story of
psychoanalysis and schizophrenia to be an example of how psychoanalysis can go so far astray,
with the hope of preventing similar misadventures in the future.