Along history of psychoanalytic work with psychotic patients, especially those with schizophrenia, belies the cur-rent reliance on "assembly-line" treatment modalities, said psychiatrist Ann-Louise S. Silver, M.D., president of the U.S. Chapter of the International Society for the Psychological Treatments of Schizophrenia and Other Psychoses (ISPS).

"Psychoanalysis," said Silver, who spoke at the annual meeting of the ISPS’s U.S. chapter last month in Washington, D.C., "aims at continuing a very long tradition of working with individuals suffering from psychotic illness, getting to know them and their life stories as fully as we can, offering treatment specifically tailored to that person’s needs, and building on his or her strengths and hopes."

Despite Freud’s distaste for working with psychotic people, the connection between psychoanalysis and schizophrenia goes back more than a century, said Silver, who is also a member of the medical staff at Chestnut Lodge in Rockville, Md., and an adjunct professor of psychiatry at the Uniformed Services University of the Health Sciences. She dismissed the familiar view that the American interest in psychoanalysis only began with the 1909 convocation at Clark University in Worcester, Mass., when Freud, Jung, and 23 other leaders of psychology were given honorary degrees. In fact, she said, Adolf Meyer, the Swiss-born psychiatrist, had articulated a number of ideas about diagnosis and treatment consistent with psychoanalysis at least as early as 1906.

Meyer cautioned against Kraepelin’s catchall definition of dementia praecox, as schizophrenia was then termed. "As one gets into ill-defined facts, the diagnosis becomes a name for what one would like to do," he wrote, "an expression for a substitutive attitude rather than for the actually demonstrated facts."

By 1908 Meyer had called for at least attempting psychoanalysis in each case of schizophrenia. And in his lecture at the Clark University symposium in 1909, Meyer (who also picked up an honorary sheepskin) minimized the role of heredity in the etiology of schizophrenia. Instead, as a contemporary account reported, he "stressed ‘habit-conflicts’ that affect the balance of the personality."

This at least implied some hope for treatment, a view in opposition to the then-current belief that saw psychiatric illness as a disease of the brain rather than the mind.

Such thinking had led to the warehousing of psychiatric patients by the end of the century. That policy had seemed benign earlier, said Wayne Fenton, M.D., deputy director of clinical affairs at the National Institute of Mental Health, and had led to the founding of state mental hospitals, "an orderly alternative to the disorder of ordinary society." But with waves of late 19th century immigration (especially Roman Catholic Irish), the asylum movement changed the prevailing view from "We take care of our own" to "You take care of your own problem."

Meyer’s option of using psychoanalysis to treat people with schizophrenia at least opened the possibility of cure, said Silver. However, another major figure in early American psychiatry believed that psychoanalysis might not cure but nonetheless could be useful.

Smith Ely Jelliffe, M.D., Ph.D., met and studied the works of leading European analysts in the first decade of the century, helping to spread their findings on this side of the Atlantic. A prolific writer, his influence spread beyond the therapeutic community, said Silver. Playwright Eugene O’Neill, for instance, relied on Jelliffe’s work in creating the characters for "Long Day’s Journey Into Night," said Silver. She noted that Jeliffe treated O’Neill, and the book that may have informed the character of Mary was Psychopathology by Edward Kempf.

Jelliffe, said Silver, was dubious about the benefits of psychoanalysis for schizophrenia patients, but hoped that analysis would at least help the psychiatrist understand the case before him.

Analytic concepts and techniques were also part of the operating philosophies at St. Elizabeths Hospital in Washington, D.C., Sheppard and Enoch Pratt Hospital in Towson, Md., Menninger in Kansas, and others. Knowledge of this history, said Silver, might help present-day therapists in understanding a variety of treatment approaches to schizophrenia.