The Map of Psychosis: A Psychodynamic Investigation in Clinical Case Patterns and Therapeutic Interventions

Aim: For over a century, patients with psychotic disorders have been frequent participants in psychoanalytic psychotherapy. Although Freud’s theories created a reluctance in psychoanalysis to treat psychosis due to perceived challenges with transference, some clinical centers continued to document clinical cases adapting their psychoanalytic techniques over time. The value of case study methods for exploring psychotherapy processes and bridging the research-practice gap has been increasingly acknowledged, yet the contributions remain sparse and hard to access. This scoping review aimed to map the clinical knowledge regarding the treatment of psychosis by reviewing narrative case studies of psychoanalysis or psychodynamic psychotherapy with patients with psychotic disorders. Methods: A thorough search of journal articles was performed in PubMed, Web of Science, PsycInfo, and Pep Web to identify studies published from 1990 to 2024. The review followed the PRISMA-ScR guidelines (Khalil et al., 2021; Tricco et al., 2018) and The Joanna Briggs Institute Manual for Evidence Synthesis (Peters et al., 2015, 2020). The study protocol has been registered (https://osf.io/vafbd). Results: Seventy-six articles were included in this review, comprising a total of 85 case reports. The the most common diagnosis among psychotic disorders was “Schizophrenia,” (45.9%), followed by unspecified psychosis diagnosis (32.9%). From a narrative synthesis, eight overarching concepts emerged across studies: (1) Patients' emotional, cognitive, and behavioral responses toward the therapist, (2) Therapist's emotional, cognitive, and behavioral responses toward the patient, (3) The core trigger and conceptualization of psychosis through speculations on the core disturbances and etiopathogenetic factors underlying the disorder (4) Mechanisms of Change, during psychotherapy that led to functional improvement (5) Iatrogenic Factors hindering therapeutic alliance (6) Clinical Challenges during treatment (7) Clinical Remedies useful to face the challenges, and (8) how Therapeutic Working Alliance is formed, and maintained, by the dyad. Conclusions: The review is the first of its kind to map psychoanalytic literature providing otherwise inaccessible clinical-theoretical insights into the psychological dynamics and treatment of patients with psychotic disorders. Further analysis of this literature may improve insight into patients’ intrapsychic and interpersonal dynamics. This information could benefit both clinical practice and research, particularly in minimizing iatrogenic factors in therapy, fostering a trusting therapeutic alliance, and identifying effective strategies to enhance stability and long-term therapeutic progress.