13Chapter 10. Freud and the Forces of the Psyche: Psychoanalysis Meets Psychosis

In 1903, a high-ranking German judge named Daniel Paul Schreber – Doctor of Jurisprudence, former presiding judge of Saxony’s Supreme Court of Appeals – published a book in Dresden that many twentieth-century psychiatrists and psychologists would consider one of the most extraordinary documents in the history of mental illness. Its title: Memoirs of My Nervous Illness (Denkwürdigkeiten eines Nervenkranken).

Schreber was ill. He knew it. The walls of the psychiatric asylum had closed around him for years. Yet his memoirs reveal a terrifying, crystalline clarity—unheard of in someone submerged in psychotic delirium. How could this disintegrating mind describe its own torment with such precision? A mystery. Schreber heard voices. He was certain: God had chosen him. For what? A sacred mission. His body was to transform into a woman. And from him—from him!—a new humanity would be born. He watched his own flesh mutate before his eyes. He physically felt “divine rays” piercing through him, searing him from within. And always at his heels were They. The “fleeting-improvised men.” Beings who looked alive, breathing, real—but only for an instant. An illusion. Props erected by God Himself for His merciless trial.

Schreber’s book reached Sigmund Freud (1856–1939). Though Freud never met Schreber personally, in 1911—after carefully studying the memoirs—he published a work that became a turning point in psychoanalytic history: Psycho-Analytic Notes on an Autobiographical Account of a Case of Paranoia (Dementia Paranoides).

Thus, Freud—the founder of a discipline that had previously focused primarily on neuroses—first set foot into the realm of psychoses. And with this step, he opened an entire epoch in the understanding of schizophrenia.

Before examining Freud’s theories on schizophrenia, we must confront a fact that changes everything: Freud. Never. Treated. A schizophrenic. Not one. Berggasse 19, Vienna. The office where psychoanalysis was born. The couch where hundreds of neurotics lay. Free association. Dream interpretation. Transference analysis. All honed on them—the anxious, the obsessive, the hysterics. But a schizophrenic never lay on that couch. Not once. Freud admitted this openly. He stated—repeatedly—that psychoanalysis was unsuitable for psychosis. So the first question is: How did a man who never treated a psychotic patient become the author of one of psychiatry’s most debated theories of schizophrenia?

Why? The core of psychoanalytic treatment is transference—when a patient projects onto the analyst emotions and expectations formed in childhood relationships. Father. Mother. Siblings. First love. These old emotional templates are cast onto the analyst, who helps the patient recognize and understand them—and through this experience, reshape their psyche.

For Freud, transference was not merely a technical device. It was a fundamental precondition for the possibility of psychoanalytic treatment. Without transference, there is no treatment. There is no bridge between patient and analyst across which the therapeutic work unfolds.

And so, observing his neurotic patients, Freud concluded that transference does not form in schizophrenic patients. Or it forms in such a strange, distorted way that ordinary analytic work with it is impossible. The patient is too detached from the external world, too absorbed in his own internal processes, has lost too much of his capacity to form a stable bond with another person.

In his 1914 paper “On Narcissism: An Introduction,” which I regard as one of the most influential texts in the history of twentieth-century psychiatry, Freud gave this observation its theoretical shape.

Central to Freud’s idea is this: in human psychological development, there exists a stage he termed “primary narcissism.” The infant, unable yet to distinguish between self and the external world, channels all their psychic energy—libido—into their own “ego.” They are the center of the universe. Their needs constitute the entire world.

As the child develops, they begin to invest their libido in external objects—primarily their mother. This process is known as “object cathexis.” Now, the libido is partially attached to the “self” and partially to external objects. This represents the normal adult mode of existence.

And what is psychosis in this model? Regression. A return. At some point in his life, under unbearable pressure from an internal conflict, the patient makes a radical move: he casts the libido back. Energy detaches from external objects and rushes back into the “I.” The patient becomes narcissistic again. He withdraws into his own inner experiences. The external world instantly loses its reality for him. He lives in an inner world filled with fantasies, fears, grandeur, persecution.

Hence the symptoms clinicians observed in schizophrenia. Withdrawal into oneself (what Bleuler called “autism”). Emotional detachment. Hallucinations and delusions that reflect the patient’s inner world instead of external reality. Megalomania (delusions of grandeur)—as a manifestation of that same narcissistic return: if the “I” is once again the center of everything, then it becomes great.

And—most importantly—there can be no transference. If the patient’s libido remains locked within their own ego, the analyst ceases to be a significant figure for them, becoming instead one of those “fleeting, ephemeral people” Schreber wrote about. A hollow shell. A mere prop.

Freud drew a direct conclusion from this: schizophrenic patients are not amenable to psychoanalysis.

This is one side of the story. Freud—the reserved, austere Freud, willing to acknowledge the limits of his method.

But Freud had students. And not all of them were ready to accept such limits.

1907–1908. Vienna. The tight circle of adherents gathered around Freud shuddered at a heretical question: might psychoanalysis after all be applicable to schizophrenia? Three dared to step over the line. Paul Federn. Karl Abraham. And—especially—Carl Gustav Jung. The very Jung who had worked at Burghölzli under Bleuler himself. Jung did not theorize behind an oak desk. He saw schizophrenics every day. He looked into their fractured eyes. He listened to their disintegrating speech. The hospital became his laboratory. He could see more clearly than Freud in prosperous Vienna.

Jung believed that schizophrenics possessed the capacity for transference, albeit in a highly distorted form. He also argued that psychoanalytic work with them was possible, provided it was suitably adapted. This stance became one of the many points of contention that led to Jung’s break with Freud in 1913.

By the 1920s, even despite the rupture, ideas about working with psychoses had taken root in the psychoanalytic movement. This was largely helped by the fact that psychoanalysts from all over the world came to study at the Burghölzli clinic, where Bleuler and Jung had for many years been applying a psychoanalytic approach to treating patients with schizophrenia. By the 1930s, psychoanalytic theory of schizophrenia already had its own history, its own schools, and its own techniques.

In the United States this tradition was continued by Frieda Fromm-Reichmann (1889–1957). A German Jew, a psychoanalyst. In 1935 she fled Nazi Europe and ended up at Chestnut Lodge in Maryland. What did she do there? What was considered impossible. Fromm-Reichmann took on the treatment of schizophrenics—those forever locked in the cage of their own delusions. She treated them with psychotherapy. How do you penetrate a mind that is destroying itself? Fromm-Reichmann sought an entry point with patience, empathy, a detailed understanding of psychodynamics. She was literally feeling for the pulse of another person’s disintegration. One of her patients was Joanne Greenberg. The girl clawed her way out of the abyss. Later, under the pseudonym Hannah Green, she would write the famous autobiographical novella “I Never Promised You a Rose Garden” (1964). Every page is a searing testament to the experience of schizophrenia and of a therapy that brought her back to life.

Other notable figures include Harry Stack Sullivan (1892–1949), an American psychiatrist who developed an interpersonal approach to psychotherapy for psychosis; Melanie Klein (1882–1960), who introduced the theory of object relations and the concept of the paranoid-schizoid position as a universal early developmental stage; and Herbert Rosenfeld (1909–1986), a student of Klein, who systematically treated psychotic patients in Britain.

This was a serious endeavor. Brilliant, conscientious clinicians—truly remarkable minds. Decades of dedication. Thousands of patients.

But what was the result in the end?

Here we need to be both respectful and rigorous.

Psychoanalytic thinking brought something monumental to psychiatry. It was the psychoanalysts who gave psychiatry a language to articulate the inner experiences of schizophrenic patients. Before Freud and his followers, schizophrenics were mere objects of observation—bizarre, incomprehensible, frightening. After Freud, they became people with internal logic, personal histories, and unconscious conflicts. Hallucinations were no longer dismissed as “meaningless phenomena”—they began to be read like texts containing vital information about the patient’s psyche. Delusions ceased to be pure absurdity—they became a defense mechanism, an attempt to impose meaning on the catastrophe of mental disintegration.

This revolution in understanding still underlies modern psychiatric practice today. When a contemporary psychiatrist listens to a patient with paranoid delusions and tries to discern why those specific delusional themes emerged in that particular individual, they are—consciously or not—operating within the paradigm Freud established.

On the other hand, the clinical efficacy of psychoanalysis in treating schizophrenia remains unproven.

Here’s the pivotal moment. Mid-20th century. For the first time, scientists dared to do what psychoanalysts had avoided for generations: conduct controlled comparative studies. They took psychoanalytically oriented psychotherapy and threw it into a ruthless showdown with other approaches—and even basic routine care. The results were devastating. Disillusionment set in. Patients who spent years on the analyst’s couch, undergoing psychoanalysis, showed—at best—the same outcomes as those who received standard care. The same recovery rates. No magic. But worse was yet to come. The worst-case scenario. Psychoanalytic intervention didn’t just fail to heal—it actively harmed. Intensive interpretation of unconscious conflicts acted like a detonator on an unstable patient. The verbal surgeon unwittingly reopened old wounds, exacerbating symptoms. What was meant to cure instead fueled the fire of mental illness.

One of the most famous studies of this kind—the Boston Psychotherapy of Schizophrenia Project (Gunderson et al., 1984)—compared intensive psychoanalytic psychotherapy with structured supportive therapy. The verdict? Structured support delivered better clinical outcomes than classical psychoanalysis. By the end of the 20th century, most international guidelines had declared classical psychoanalytic approaches to schizophrenia ineffective or minimally effective.

So what works? The foundation of treatment is antipsychotic medication combined with psychosocial interventions—cognitive behavioral therapy for psychosis (CBTp), family therapy, social skills training, assertive community treatment. Psychoanalytically oriented individual therapy may serve as a useful add-on for select patients after stabilization, but never as first-line treatment—and certainly not as a substitute for medication.

The most dramatic example of psychoanalytic thinking taken too far is the concept of the “schizophrenogenic mother.

The term was introduced in 1948 by Frieda Fromm-Reichmann in her article “Notes on the Development of Treatment of Schizophrenics by Psychoanalytic Psychotherapy.” She described this type of mother as cold, detached, domineering, simultaneously overprotective yet emotionally absent. According to her hypothesis, it was precisely this type of motherhood that contributed to the development of schizophrenia in a child.

The idea spread. Other authors picked it up. By the 1950s, it became widely accepted in American psychiatry—and in parts of European psychiatry—to blame the mothers of schizophrenic patients, asserting that their illness was the result of their upbringing. These mothers would come to their son’s or daughter’s psychiatric appointments and hear from the doctor that they themselves were to blame for their child’s illness.

It was cruel. It was false. And it was harmful—both to the mothers themselves, tormented by guilt, and to patient care, which became steeped in an ideology of blaming the family instead of seeking help.

The 1960s–1970s saw genetics and neuroscience draw their sword. The concept of the “schizophrenogenic mother” crumbled under the weight of new data. The chilling riddle was solved: the nature of schizophrenia lies in genes, not in cold maternal words. The numbers are merciless: up to 80% heritability. Twin studies revealed this—eighty percent! This means that millions of women bore the heavy cross of guilt for a crime they never committed for years. Maternal communication style? Yes, it exists. But it influences the course of the illness merely as a spark that triggers an exacerbation, not as the root or primary cause. It is not an etiological factor. Then came 1990. American psychiatrist John Neill delivered the final verdict. His article resounded like a judgment: “Whatever became of the schizophrenogenic mother?” The conclusion was ruthless and clear. The idea was flawed. It shattered lives and caused unbearable suffering. It was abandoned—finally, mercilessly, and forever.

This episode isn’t just a page of history. It’s a crack in psychiatry’s foundation. Look: the concept of the “schizophrenogenic mother.” Not politics. Not a hunger for fame. Just a theory. A good one. A smart one. Applied without sufficient empirical controls. And its consequences — trauma. For patients. For their families. This is how psychiatry gets it wrong from within its own scientific paradigm. Not under political pressure, as in Soviet punitive psychiatry. Not out of a thirst for glory, like the lobotomists. But because the theory proved more convincing than the facts. And that is the most dangerous thing of all.

But—and this is also crucial—psychiatry itself uncovered this and moved on. Through research. Through the accumulation of data. Through public scrutiny.

A Hellinger practitioner looks the client straight in the eye and delivers the verdict: your depression is retribution for your great-grandmother’s unabsolved sin. The blow lands. Pain lances through the body. But what lies beneath? At its core, the facilitator is doing precisely what 1950s American psychoanalytic psychiatry did with its concept of the “schizophrenogenic mother.” Coincidence? Hardly. It’s systemic. They pin the blame for illness on specific family members. They fabricate cause-and-effect relationships unverified by empirical evidence. They inflict additional trauma upon the patient.

The difference lies in the mechanism of correction. Psychiatry in the 20th century acknowledged this mistake and moved on from it. Hellenger’s methodology in the 2020s does not—and cannot—do this, as it lacks institutional mechanisms for self-criticism. There are no independently reviewed journals, ethical committees, systematic reviews. There is no obligation to report failures.

So what, ultimately, has psychoanalysis contributed to our understanding of schizophrenia? I think it can be summed up this way.

Psychoanalysis never solved the problem of treating schizophrenia. That problem has been solved — in part — by antipsychotics since 1952. It remains unsolved in full even today.

But psychoanalysis gave psychiatry a language. A language to speak about the inner life of a patient, their fears, fantasies, and meaning-making world. Without this language, psychiatry would be a descriptive science of symptoms. Thanks to it, psychiatry became—or strives to become—a discipline capable of understanding the human being in all their complexity.

And one more thing. Psychoanalysis has demonstrated that listening to the patient is not merely a medical formality but a therapeutic tool. It may not suffice as the sole method for treating schizophrenia, but there is no good psychiatry without it.

So, as I close this chapter, I want to say something unexpected. I’m a skeptic when it comes to psychoanalysis as a treatment for schizophrenia. But I’m a believer in psychoanalysis as an anthropology of the human psyche. Freud. However contentious many of his specific theories may be, he taught medicine one essential thing. A person has depth. The unconscious exists. Childhood history leaves traces. Symbols carry meaning.

Without this, psychiatry would be mechanical. With it, it becomes medicine for the whole person.

Now we leave Freud and his disciples and turn to another major theorist who contributed as much to the understanding of schizophrenia as Freud did—but took a completely different path: Carl Gustav Jung.