A cost-effective psychoanalytic treatment of a severely disturbed woman.

Guidelines for the treatment of psychotic conditions currently emphasize psychopharmacology and supportive individual and family counseling as well as environmental approaches (American Psychiatric Association [APA], 1997). In the past three decades psychoanalytic therapeutic approaches to the treatment of these conditions have bccn regarded as ineffective, except in rare cases (Davis and Andriukaitis, 1986; Hogarty et al., 1986; Kane, 1987). The thrust of these guidelines is reflected by criteria that managed care organizations (MCOs) use to approve or disallow treatment services (Merit Behavioral Care, 1997). These criteria prescribe the use of medication combined with a psychotherapeutic approach that emphasizes brief treatment directed toward behaviorally measurable goals (United Behavioral Health, 1999). The uncovering of emotional life and the reconstruction of past experiences having emotional consequences in the present, characteristic of psychoanalysis and psychoanalytic therapy, are regarded as irrelevant in some cases and, in other cases, as disorganizing and therefore counter-therapeutic. Differences of opinion as to the relevance of psychoanalysis in the treatment of schizophrenia and related conditions goes back over 100 years. Freud (1911) did not attempt to treat primitive psychoses with psychoanalysis, and current biopsychiatry sees itself in the tradition of Kraeplin (1907), whose methods were descriptive and biological. Bleuler (1911), however, did apply psychoanalytic principles and a more intrapsychic approach to the understanding and treatment of patients with schizophrenia and other major mental disorders. In the first 65 years of the twentieth century, until the advent of effectivc psychopharmacology and cognitive and behavioral psychotherapies, psychoanalysis and psychoanalytic treatment were the only systematic treatments of mental disorders that had some effectiveness; therefore, these approaches continued to be used in the treatment of major mental illnesses. Such approaches remained controversial, but those who engaged in them reported strongly beneficial outcomes (Fromm-Reichman, 1948; Giovac