The psychoanalytic knowledge on psychosis in a nutshell: a scoping review of single case studies

Introduction. For over a century, patients with psychotic disorders have frequently participated in psychoanalytic psychotherapy. Although psychoanalysts have not evaluated its efficacy through high quality experimental studies (Solmi et al., 2023), they have documented numerous narrative clinical cases that have significantly influenced psychoanalytic theory, research, and practice (Meganck et al., 2017, 2022). The value of case study methods in exploring psychotherapy processes and bridging the research-practice gap has been increasingly recognized (Iwakabe & Gazzola, 2009; Stefana et al., 2023). This scoping review aimed to map journal articles featuring clinical cases or vignettes of psychoanalysis or psychoanalytic psychotherapy with patients affected by psychotic disorders. Methods. A scoping review was conducted following PRISMA-ScR guidelines. PubMed, Pep Web, Web of Science, and EBSCO/PsycINFO were searched for studies published from January 1, 1990, to April 15, 2024. The review focused on psychoanalysis, psychodynamic, or psychoanalytic psychotherapy provided to individuals with psychotic disorders in any clinical setting. Pre-registered study protocol is available here: osf.io/b8esa Results. Ninety-two case studies were included. The primary theoretical framework used was "ego psychology." Six overarching concepts emerged: (1) “Patient’s perception of the therapist,” encompassing the most frequently observed attitudes and transference patterns towards clinicians; (2) “Therapists’ emotional responses,” including common reactions experienced by clinicians such as frustration, helplessness, hope, and fascination; (3) “Conceptualization of psychosis,” involving speculations on the nature and progression of the illness in terms of its underlying pathogenetic factors leading to symptoms; (4) “Mechanisms of change and iatrogenic factors,” including interventions and variables that either improved or worsened the prognosis and recovery process; (5) “Clinical challenges and remedies,” highlighting the most common challenges and what explicitly or implicitly helped or hindered the patient's recovery process; (6) “Therapeutic alliance,” referring to the role of the collaborative relationship throughout therapy, how it is built and maintained, and its effects on the therapeutic process. The review also highlighted necessary modifications to therapeutic techniques and emphasized the critical importance of the therapeutic alliance. Conclusion. The findings reveal a rich psychoanalytic literature that provides helpful insights into the core disturbances, psychological dynamics, and treatment of psychosis. This knowledge is valuable for both research and clinical practice, especially considering the partially unmet need for diverse treatment approaches that account for the patient's subjective experience, the challenges they face, and their recovery pathways.