believe that their treatment is relevant to schizophrenia and who want to convince others oftheir convictions will have to meet the same standard. Examples of how psychoanalyticconcepts can enhance our understanding of experiences with patients with schizophrenia won’tsimply be unconvincing, they will be seen as irrelevant to the dialogue concerning thetreatment of schizophrenia.

TranslationsDie Beziehung zwischen Psychoanalyse und Schizophrenie—Kommentar. Psychoanalyse bietet einenRahmen zum Verstandnis des menschlichen Erlebens an, das fur Menschen, die an psychiatrischenStorungenund ihren P� egern grossen Wert besitzen kann. Es gibt naturlich auch andere nutzliche Bezugsrahmen. In derVergangenheit haben einige daraus geschlossen, dass der Wert der Psychoanalyse mit diesen Patienten darinliegt, dass es die Atiologie ihrer Storungen verstehen hilft, eine ,,Heilung‘‘ anbieten kann oder eine besondereRelevanz fur ihre Probleme bietet. Fur diese Behauptungen gibt es keinen Beweis. Weiterer Fortschritt indiesem Bereich sollte auf neuem Beweis basiert sein.

La relacion entre psicoanalisis y esquizofrenia. Comentario de Robert Michels. El psicoanalisis ofrece unmarco para entender la experiencia humana que puede ser de gran valor para quienes padezcan desordenespsiquiatricos, y para quienes los cuidan. Sin duda, tambien hay otros marcos utiles. En el pasado, algunos haninferido que el valor del psicoanalisis para estos pacientes esta en que nos ayuda a entender la etiología de susdesordenes, o que puede ofrecer una ‘curacion’ o tiene alguna relevancia especial para sus problemas. No haypruebas que sustenten ninguna de estas a� rmaciones. El avance futuro en este area debería de cenirse a lasnuevas pruebas.

Commentaire sur l’article de Richard Lucas. La psychanalyse fournit un cadre pour comprendrel’experience humaine, qui peut etre d’une grande valeur pour les personnes souffrant de troublespsychiatriques et pour leurs soignants; il y a bien sur aussi d’autres cadres utiles. Dans le passe, certainsavaient conclu que la valeur de la psychanalyse pour ces patients implique qu’elle nous aide a comprendrel’etiologie de leurs troubles, qu’elle puisse offrir une ‘cure’ ou qu’elle ait un rapport special a leurs problemes.Il n’y a pas de preuve dans chacun de ces elements. Des progres nouveaux dans ce domaine devraient etrefondes sur des nouvelles preuves.

Rapporti tra psicoanalisi e schizofrenia. Osservazioni sull’articolo di Richard Lucas. La psicoanalisifornisce un’impalcatura metodologica per comprendere l’esperienza umana, e cio puo avere grande valore perpersone sofferenti di disturbi psichiatrici e per chi si occupa di loro. Esistono, naturalmente, altre utili corniciinterpretative. In passato qualcuno ha avanzato l’ipotesi che il valore della psicoanalisi applicata a questipazienti implichi un aiuto nella comprensione dell’eziologia dei loro disturbi, che possa offrire una ‘‘cura’’ oche abbia una qualche particolare importanza rispettivamente ai loro problemi. Non esiste prova che cio siavero. Ulteriori progressi in questo campo dovrebberobasarsi su nuove prove.

The relationship between psychoanalysis andschizophrenia—A response to the commentary by

Robert Michels

Richard Lucas

In this section, the author responds to Dr Michels’s commentary. In contrast to the situationin the United States, there are far fewer psychoanalysts in the UK and very few indeedworking in general psychiatry to in� uence its practice. It is argued that psychoanalysisdiffers from all other psychological approaches with its recognition of the inner world and

12 PSYCHOANALYTIC CONTROVERSIES

its unconscious in� uence on the individual’s everyday life. Michels invites one to focus onoutcome studies to judge the effectiveness of psychoanalysis in schizophrenia. There is adanger of throwing the baby out with the bathwater in that psychoanalysis helps inunderstanding presenting clinical material and in risk assessment in everyday generalpsychiatry.

Keywords: schizophrenia,US/UK contrast, medication, multidisciplinaryapproach,analytic relevance, controlled trials

I am grateful to Robert Michels for the questions that he has raised, particularly as there maybe a contrast in the nature of analytic involvement with psychosis between the USA and theUK.

Michels reports that, compared to North American psychoanalysts, I, a follower of Kleinand Bion, have had more rewarding experiences in using psychoanalytic ideas in clinical workwith schizophrenic patients. He suspects that I am only familiar with psychoanalysis, that it ismy favourite system and that it is the only one that I have tried. This view may have arisenfrom the history of Chestnut Lodge where, for years, only intensive individual analytic therapywas given, without resort to medication or other psychological interventions. Such an analystmight well be ignorant of biological psychiatry.

The situation in the UK is very different from the United States. First, the number ofpsychoanalysts in the UK, as a presence to in� uence psychiatric practice, is much smaller thanin the USA. Second, the number of people possessing a psychoanalytic quali� cation workingin an adult general psychiatry post in the NHS is very small indeed.

In my case, having trained for seven years at the Maudsley Hospital, gaining experience inall approaches, I have spent the last twenty-� ve years working as a consultant in a very busypsychiatric post. It carries responsibility for in-patients, out-patients, a day hospital,emergencies in the community and regular CPA reviews with other team members.

We operate from a community mental health centre and work as a multi-disciplinary team.Anti-psychotic medication features centrally in managing psychoses. We use typical andatypical medication, depot medication and Clozaril where indicated. All systems of enhancingcommunication are used, including individual sessions with a designated key worker, grouptherapy, art therapy, music therapy, occupational therapy, family therapy, CBT, social work,community nurses, outreach workers and day centres.

I am therefore not talking about the use of one treatment in preference to other availabletreatments, but how, as a general psychiatrist, I � nd applied analysis enormously helpful in myeveryday work.

We still remain very limited in our knowledge of the aetiology of schizophrenia. We relypurely on the descriptive level for diagnosis. We know of some organic disorders that canproduce a similar clinical picture to schizophrenia, such as amphetamine psychosis, temporallobe epilepsy, porphyria and Huntingdon’s chorea. However, we don’t yet know how manydifferent causes, whether genetically determined or otherwise, will emerge to account for thesyndrome we call schizophrenia. In such a situation, the ordinary general psychiatrist, who hasresponsibility for his patients on a lifelong basis, like an extended family, remains questioningof any excessive therapeutic claims, whether organically or psychologically based. Controlledresearch conducted in laboratory conditions may not necessarily impress the psychiatristhaving to manage his/her patients in the real world.

In my paper I am talking about the contribution of analysis to help in making sense of and

Richard Lucas 13

managing challenging situations arising in everyday clinical practice, when compliance withmedication is not the primary issue.

The vignettes that I was asked to provide have, of necessity, been presented in a condensedformat in relation to the length and purpose of the paper. They were meant to illustrate aspectsto an analytic framework that I have developed and found helpful over many years in relationto the demanding work of everyday general psychiatry. It is up to others working in the � eldwhether they � nd the concepts, linked to the clinical illustrations, of use to them in their work.

I strongly disagree with Michels’s suggestion that psychoanalysis has ‘no more specialrelevance to schizophrenia than it does to multiple sclerosis or cancer or homelessness’. Thelatter conditions do not require continual risk assessment. Their communications do not requirequestioning as to whether they are straightforward communications from a non-psychotic partof the personality or denial and rationalisation from the psychotic part, which may beharbouring dangerous intents.

The brief vignettes on the man who threw bleach in a young woman’s face and the womanwho jumped out of a window refer to this area. Space prevented my describing the events inmore detail. In relation to the interpretation to the patient who jumped out of the window, itproduced a dramatic response, and a shift in emphasis, after months of things remaining static.It brought her murderousness into the open. I believe that the frightened non-psychotic part feltsupported, and was grateful, for my intervention, as certainly was the case for her involved andcaring mother.

Michels refers to psychoanalysis as providing a framework for conversations about humanexperiences, but only one amongst many others. He seems to underplay the difference betweenpsychoanalysis and other psychological disciplines, with its recognition of an unconsciousinternal world and its in� uence on the individual’s life. In relation to schizophrenia, from ananalytic point of view, one needs to go further in one’s thinking. One needs to tune into thepsychotic wavelength and familiarise oneself, analytically speaking, with the different mode offunctioning of the psychotic part.

Many people may intuitively be very sensitive in their work, without carrying any underlyingframework of reference. General psychiatry teaches one how to take a history, perform amental-state examination and elicit � rst-rank symptoms. It does not teach the junior doctorhow to relate to, or make any sense of, bewildering countertransference experiences or start todevelop an interest in processing them.

By focusing solely on the research outcome of controlled trials, one is in danger of movingaway from clinical issues and throwing the baby out with the bathwater. I will end byreaf� rming my view that in schizophrenia, where psychoanalysis has come to be regarded bymany as an irrelevance and a discredited mode of treatment, I have found that appliedpsychoanalysis has a unique contribution to make, of great relevance, within everyday clinicalpractice.

When I informally expressed such views on the contribution analysis has to make in thisarea to the then President of the Royal College of Psychiatrists, John Cox, he responded that Iwas pushing at an already open door. The problem remains of how many analytically mindedpsychiatrists, logistically speaking, there are of us around to push at that door.

TranslationsLucas: Eine Antwort auf den Kommentar von Robert Michels. In diesem Abschnitt antwortet der Autorauf den Kommentar von Dr. Michels. Im Gegensatz zu der Situation in den Vereinigten Staaten, gibt eswesentlich weniger Psychoanalytiker in Grossbritannien und wirklich sehr wenige, die in der allgemeinenPsychiatrie arbeiten, um diese Praxis zu beein� ussen. Es wird argumentiert, dass die Psychoanalyse sich von

14 PSYCHOANALYTIC CONTROVERSIES

anderen psychologischenAnsatzen durch ihre Anerkennung der inneren Welt und ihres unbewussten Ein� ussauf das tagliche Leben des Individuums unterscheidet. Michels schlagt vor, sich auf outcome Studien zukonzentrieren,um die Wirksamkeit der Psychoanalysebei Schizophrenie zu beurteilen. Darin liegt die Gefahr,das Baby mit dem Bad auszuschutten insofern als die Psychoanalyse in dem Verstehen, in der Vorstellung vonklinischem Material und bei der Risikoeinschatzung in der taglichen allgemeinenPsychiatrie hilft.

La Relacion entre Psicoanalisis y Esquizofrenia. Una Respuesta al Comentario de Robert Michels. En estaseccion, el autor responde al comentario del Dr. Michels. En contraste con la situacion en los Estados Unidos,hay muchos menos psicoanalistasen el Reino Unido, y en realidad poquísimos en la psiquiatría general, comopara in� uenciar su practica. Se alega que el psicoanalisis di� ere de todos los demas enfoques sicologicos, porsu reconocimiento del mundo interior y su in� uencia inconsciente en la vida cotidiana del individuo. Michelsnos invita a concentrarnos en los estudios basados en resultados (outcome studies) para juzgar la efectividaddel psicoanalisis en la esquizofrenia. Aquí podríamos acabar prescindiendo de elementos utiles, pues elpsicoanalisis nos ayuda a entender y presentar el material clínico, y nus ayuda en la evaluacion de riesgos en elacontecer cotidiano de la psiquiatría general.

Reponse au commentaire de Robert Michels. Par opposition a la situation aux Etats-Unis, il y a beaucoupmoins de psychanalystes au Royaume-Uni et tres peu en effet qui travaillent en psychiatrie generale pourin� uencer sa pratique. L’auteur indique que la psychanalyse est differente de toutes les autres approchespsychologiques par sa reconnaissance du monde interne et son in� uence inconsciente sur la vie quotidiennedes individus. Michels invite a se concentrer sur des etudes de resultats pour juger l’ef� cacite de lapsychanalyse dans la schizophrenie. Il y a un danger de jeter le bebe avec l’eau du bain en ce que lapsychanalyse aide dans la comprehension du materiel clinique presente et dans l’evaluation du risque dansla psychiatriegenerale quotidienne.

Rapporti tra psicoanalisi e schizofrenia—Risposta al commento di Robert Michels. Contrariamente allasituazione negli Stati Uniti, nel Regno Unito vi sono assai meno psicoanalisti, e in realta sono pochissimiquelli che operano nel campo della psichiatria generale tanto da in� uirne sulla pratica. Si e sostenuto che lapsicoanalisi differisca da ogni altro approccio psicologico poiche riconosce l’esistenza di un mondo interiore eil suo in� usso inconscio sulla vita quotidiana dell’individuo. Michel invita a concentrarsi sugli studi divalutazione dell’esito nel giudicare l’ef� cacia della psicoanalisi nei confronti della schizofrenia.C’e il rischiodi buttare il bambino assieme all’acqua sporca, in quanto la psicoanalisi aiuta a capire presentando materialiclinici, e aiuta a valutare i rischi della comune psichiatria generale.

Richard Lucas 15