Correspondence: Richard D. Chessick, 9400 Drake Ave., Evanston, IL 60203-1106. e-mail: r-chessick@northwestern.edu

¹M.D., Ph.D., Professor of Psychiatry and Behavioral Sciences, Northwestern University Senior Attending Psychiatrist (Emeritus), Evanston Hospital Fellow, American Academy of Psychoanalysis and Dynamic Psychiatry, Training and Supervising Analyst (Emeritus), Center for Psychoanalytic Study in Chicago, Distinguished Life Fellow, American Psychiatric Association.

Abstract

A dramatic long-term psychoanalytic treatment of a psychotic character disorder is presented in detail. This patient began therapy with a long standing history of an eating disorder for which she had received many hospitalizations and forms of treatment without any success. She was in a deep despair and as a last resort agreed to a psychoanalytic therapy. During the many years of treatment the eating disorder completely resolved but was replaced by a series of very dangerous accidents that occurred each time she was betrayed and disappointed by a boy friend. This went on pari passu with a deepening understanding of her childhood and her psychodynamics but the middle of the therapy was very stormy and required tenacious efforts to maintain the treatment. The self-destructive behavior was traced to early and profound childhood disappointments and a sense that these were her fault because she was so unlovable and therefore deserved punishment. A dangerous stalemate developed in the treatment after a number of years. The analyst presented the case to colleagues several times and wrote it up in detail, which enabled him to understand his own countertransference and resolve it. This resulted in a dramatic change in the patient and a very favorable and happy ending to this very difficult treatment after 15 years. Although the author believes all patients in psychoanalysis should be approached with as neutral and objective a stance as possible, emphasizing free association and dream material in order to interpret the crucial childhood determinants of the patient's psychopathology, in cases such as psychotic character disorders the outcome clearly also depends on interpersonal factors. The case illustrates the deep partly conscious and partly unconscious interaction between a patient and her analyst over many years of treatment and the profound effect this has on the outcome. It underscores the importance of patients being allowed to heal in their own way and in their own time without intrusion or interference from the analyst. It also demonstrates the crucial importance of long-term psychoanalytic therapy as a life-saving procedure in cases where it is appropriate in spite of the great amount of time and expense involved.