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Modern Psychoanalysis of the Schizophrenic Patient: Theory of the Technique

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I was privileged to study modern psychoanalytic technique under Dr. Spotnitz who taught this subject on the U. of PA campus. It was a required course for those of us who were studying at the Philadelphia School for Psychoanalysis. For years, as a psychoanalytic psychotherapist, I have used Dr. Spotnitz's techniques in private practice, in a social agency and when I worked as a therapist at the maximum security State Correctional Institute in Graterford, PA.

In brief, there are two categories of mental illnesses: one, oedipal conditions, which we refer to as neuroses; two, preoedipal conditions, which Dr. Spotnitz calls "narcissistic neuroses". Etiologically, when children suffer severe problems before the oedipal stage, they are predisposed to a narcissistic neurosis.

Other reviewers mention transference/countertransference. The entire point of treating narcissistic patients is that they do not transfer and there is no typical countertransference. There is, however, "narcissistic countertransference" - to use Dr. Spotnitz's terms. A common form of NCT, narcissistic countertransference, is when, without realizing it consciously, the therapist gives up on a patient becuase he/she has been influenced by the patient to give up.

Dr. Spotnitz specifies that Freud's "talking cure" is inadequate for the narcissistic patient. The narcissistic neuroses lie on a spectrum of severity with catatonia being its most severe form and with paranoid schizophrenia being its least severe form. The verbal strategies analysts use for neurotic patients are useless with the narcissistic patient. Dr. Spotnitz lays out three basic rules for using nonverbal strategies with narcissistic patients.

#1: Dosage: The modern psychoanalyst knows patients respond to words on an oral level. You can only feed them as much as they choose to ingest. You only speak as much as they need or request speech. Example: The modern analyst would say, "Am I talking too much?" One young lady was very comfortable with my using five questions in fifty minutes. So that is what I did for months until she wanted more psychic nutrition/support.

#2: Joining. You join their defense. The only way to be allowed inside their circle of narcissism is to join their defenses - with sincerity. Example: You only contact them as much or as little as they choose to be contacted. E.G.: a paranoid-schizophrenic inmate said to me: "The guard told me I have to come back but I don't want to." I said, "OK, you don't have to come back." He: "I don't have to." I: "No, come back if you choose to." He: [comfortable because he is in control]"How often should I come back." I: "How often should we meet?"
He: "Oh, I guess, once a week." I: "Ok, once a week." With touching solemnity, he wiped his hands on his trousers and shook my hand.

I would not have shaken his hand if he had not offered it - that, too, is "joining".

Dr. Spotnitz's principle #3: Object oriented questions - narcissistic patients have extremely fragile egos. A modern analyst never would do what untrained psychiatrists and fictitional caricatures do and ask, "How are you feeling?" The Spotnitzian analyst does not use the pronoun "you" but he/she uses "I" a lot because if things do not go well, "I" the analyst am at fault. Until I get to know how severe their illness is, I ask "object oriented questions", i.e., questions that are far away from injuring their ego. I say: "Is the light too bright?" or "Am I talking too much?" of "Should I talk more?" or "What should I ask questions about?"

You can not underestimate the revolutionary value of Dr. Spotnitz's book and of these three principles. After Freud's work itself, all 23 volumes, two of the largest contributions to mental illness are this work and Erik Erikson's Childhood and Society.

Exellent book for anyone, novice or experienced therapist, interested in the theory and practice of modern psychoanalysis. As an experienced psychotherapist, I have found it very useful to enhance my repetoire of skills and techniques in working with patients with preverbal issues. It is clearly written and easily understandable.

What Freud called the "stone wall" was first breached by this pioneering psychiatrist and psychoanalyst with this seminal work in 1969. This substantially revised and enlarged edition is the comprehensive and definitive handbook for practitioners of the talking cure of the disorders that arise before speech.

In his most comprehensive writing Spotnitz outlines 50 years of his Modern Psychoanalytic approach to treatment of schizophrenia. Freud's concept of the transference is advanced in order to fit the needs of the analyst in eliciting the 'constructive emotional interchange' necessary to reverse the effects of the schizophrenic reaction. This work serves as an essential handbook to the clinician interested in applying psychoanalytic techniques proven to be successful in treating schizophrenic disorders.

When looking for technical information about treating the pschotic patient using modern psycoanalytic technique this is the place to go. Spotnitz explains in explicit detail the use of transference, counter-transference and resistance. The application of technique and its ramifications on communicating emotionally with the patient is especially helpful when the patient or analysis is blocked.