Since I was a staff psychiatrist at Chestnut Lodge from 1957 to 1967—and worked with some Lodge patients for many years after that—I especially appreciated the article in the May 2 issue, “Recalling Chestnut Lodge: Seeking the Person Behind the Psychosis.”
I want to emphasize that psychoanalytically informed therapy of psychotic patients always differed profoundly from classical psychoanalysis. Taken in isolation, a comment in the article about the patient’s silence not necessarily being a sign of “resistance” could mislead readers to believe that the treatment was a caricature of psychoanalysis. A description of what the psychiatrists did during their usual five sessions a week, highly individualized treatment would also include elements of what is now labeled cognitive-behavioral therapy, dialectical behavior therapy, and a host of rehabilitative activities. During different phases of the treatment, these elements could coexist with dynamic and psychoanalytic approaches.
During my time at Chestnut Lodge, there was also Stanton and Schwartz’s therapeutic community approach, Marian Chase’s pioneering movement and dance therapy, innovative art therapy, occupational therapy (which included patients running their own shop), various levels of group therapy, weekly all-hospital meetings in which patients raised questions of self-determination and suggested programs and activities, and a program in which families stayed for a week in the Frieda Fromm-Reichmann cottage. When modern psychopharmacology became available, the interactions of medication and intensive therapy were beginning to be studied.
Concerning McGlashan’s follow-up study showing that roughly two-thirds of the schizophrenia patients were functioning marginally or worse, it should be kept in mind that Chestnut Lodge offered treatment as the last resort. For most patients, all other treatment options had been exhausted and had failed. For such a patient population, a one-third positive outcome may even be remarkable.
John S. Kafka, M.D, M.S.