Abstract
The history of psychiatry is about two hundred years old and that of psychoanalysis more than a hundred, with an important anniversary of the latter in 2011. Freud renewed and humanized psychiatry by enriching its static descriptive method with the new dynamic and interpretive discoveries of psychoanalysis. Freud's innovations, while developed in Europe, were integrated into psychiatry briefly by the Swiss School but mainly in the United States. After many years of fruitful collaboration psychiatry and psychoanalysis seemed to part company in the US in the last few decades. However, the tradition of combining psychiatric care with dynamic principles is still considered valid in the treatment of psychoses and severe personality disorders.

the psychoanalytic movement" (Brill 1944, p. 9) . In his numerous publications he made an essential contribution to psychiatry and psychotherapy in America. He founded the New York Psychoanalytic Society in 1911 and was co-founder of the present American Psychoanalytic Association in 1932, reconstituted in 1946 (Oberndorf, 1953) , the latter destined to play a crucial role in the world-wide spread of psychoanalysis after WWII.

Brill was born in the Polish town of Kańczuga (formerly Austro-Hungarian Galicia) which he left "at the age of 14 and came, alone and without resources, to the United States and New York City to seek his fortune. By the time he was 29 he graduated from the Columbia University College of Physicians and Surgeons and then trained in psychiatry and neurology" (Mosher & Richards, 2008) . Brill was unique in having had extensive experience as an institutional psychiatrist and who later, as practicing psychiatrist and psychotherapist, achieved many therapeutic successes.

Initially it was Adolf Meyer who had a transforming influence on the eager neophyte in psychiatry. Brill had borne witness to the bleakness and hopelessness of custodial psychiatry as reflected in the "notes of the pre-Meyerian period: 'John Doe, 26, single, laborer,… excitable, delusional, shouting and screaming.' A year or so later, the second note read: 'The patient is stupid, dull, and demented.' Some years later,… by another physician: 'Patient continues as above.' Then there was the final note: 'Patient died suddenly ' " (p. 17-18) . Adolf Meyer, Brill's first teacher of psychiatry in 1903, "taught [him] to describe the patient's attitude and manner, his anthropological make-up;

we examined all the phases of his orientation, memory, judgment, insight, etc. Last but not least, the psychiatric examination was always preceded by a thorough physical and neurological examination. The average case history ran from twelve to sixteen typewritten pages,… they were quite complete, … laying stress on the normal and abnormal psychic development; the treatment was purely symptomatic" (Brill, 1947, p. 4, 6 ). Meyer's approach, focusing on the biological, psychological and social factors of the case later called psychobiology, was an essential contribution. As early as [1905] [1906] Meyer had designed at Manhattan State Hospital a form for describing and classifying mental patients based on his psychobiological ideas which would become the seed of the future DSM-I (American Psychiatric Association, 1952) . Similarly, the prominent New York neurologist Dr. Frederick Peterson, who met Brill in the summer of 1907 in Paris at the famed Salpêtrière (where many had gone before, including Freud himself), "suggested…that I go to the psychiatric clinic headed by Bleuler and Jung" (Brill, 1944, p. 12) , which Brill did later that year. Prior to that, during his "New York State Hospital career, [Brill] had been an assiduous student of psychiatry … [and] almost became Kraepelin's translator"(p. 14). However, after his stint at the Burghölzli, he "devoted [himself] altogether to the study of psychoanalytic psychiatry,… as psychoanalysis is one of the most important contributions to the psychiatric armamentarium" (p. 14).

The atmosphere at the Burghölzli differed vastly from what Brill first encountered in an American psychiatric hospital and from the way psychiatry was practiced in most Austrian and German asylums of that period: a central concern here was psychological treatment. The doctors lived on the premises and mingled with the patients; Bleuler's own sister was a chronic patient there. Founded by Griesinger in 1870, its second director became Forel, who, like Freud after him, traveled to Nancy in 1887 to study hypnotic suggestion from Hippolyte Bernheim, made it a staple of treatment at the Burghölzli, and published a book on hypnotism in 1889, reviewed by Freud (1889) . Brill (1944) It was inspiring to be in a group of active and enthusiastic workers who were all toiling to master the Freudian principles and apply them to the study of patients.

Psychoanalysis seemed to pervade everything there. When one made a mistake in talking, he was immediately asked to explain it, and the frankness that was displayed on such occasions was truly amazing. Here was a group of experienced psychiatrists, Bleuler, Jung, Riklin, Abraham and Hans Meier, all working overtime in order to find something new. At the time of my visit, they all seemed convinced that the Freudian mechanisms existed in every patient. Bleuler was not yet convinced of Freud's sexual concepts (Brill, 1944, p. 30) .

Association studies translated into therapeutic work. The concept of "emotionallyaccentuated ideas, or complexes" (p. 95), that arose from the associations experiments by Bleuler and Jung, Freud's ideas about compromise formation and "the mechanism of identification … patients impersonate all the parts of a drama" (p. 118), revealed by Freud's method of free association, all this "inaugurated a new epoch in the psychiatrythe method of interpretative psychiatry" (Brill, 1944, p. 32) , which he also called psychogenetic, i.e. psychogenic. Applying this method Brill became "captivated by the case histories because the patient no longer represented something entirely foreign to me, something insane, as I had hitherto regarded him when I merely described his strange behavior. Now even his most peculiar expressions as I traced them back to his former normal life struck familiar chords in me" (p. 33). Such attunement based on understanding and intuition also implied that this was an interpersonal communication, although 'interpersonal' had to wait for Harry Stack Sullivan to put it on the map.

Describing mutual dream analyses practiced by the doctors at the Burghölzli amongst themselves, Brill wrote: "If one gives free association to anyone who analyzes his dream he opens up, as it were, his whole psyche-that is, if he really withholds nothing that flashes through his mind. Most of us were perfectly frank… such mutual help in dream analysis turned out to be most successful if carried out by those who were in sympathy with each other… as a result of these experiences the Zurich school was the first to advocate what is now officially designated as training analysis" (p. 42). It is easy to see how such mutuality applies to the analysis of patients. In addition to Brill, a in dementia praecox just as they are found in hysteria" (Brill 1947, p. 15 Brill submitted his interpretation of a patient's verbal hallucination as a "condensation of his love affair" to Freud and Jung, Brill quipped about "having received the approbation of 'Allah and his Prophet,' as we were then in the habit of referring to Freud and Jung, as well as to the Vienna Psychoanalytic Society" (1944, p. 91) . However, over the years the most revealing and relevant to our topic were the many case histories of psychotic patients (with one or two exceptions) that Brill treated either as inpatients or outpatients, not only cited in the abovementioned books but in numerous clinical papers. In these case histories Brill revealed himself as a humanistic, compassionate, intuitive and empathic therapist-in short, a man of great tact and clinical wisdom.

It was surprisingly unknown to Brill himself (1944, pp. 49-50) , that Freud was not only trained as neuroscientist and neurologist but also had a psychiatric training, had examined psychotic patients and wrote up their case histories before he became a practicing psychotherapist and psychoanalyst. Prior to journeying to Charcot, Freud did a five month stint as an assistant on the psychiatric service of psychiatrist, neuroanatomist and sometime psychologist Theodor Meynert (1833-1898) (Hirschmüller, 1991) . After discovering the method for decoding the manifest "meaninglessness" of hysteria (1895, p. 93) Freud went on to apply it to explaining the meaning of madness (Freud, 1894 (Freud, , 1896 , the content and intent of psychotic hallucinations, delusions, and paranoid projections. Such decoding was at the same time a method of treating them: "I had the opportunity of undertaking the psycho-analysis for therapeutic purposes" (Freud, 1896, Bleuler showed in this paper that the same wish mechanisms are also discernible in organic and toxic psychoses (p. 98). This is still true today, but it is also true now as then that the meaning of psychotic behavior is not the same as the cause of the psychosis: in fact, Bleuler and Jung maintained that in schizophrenia, the paradigmatic psychosis, is both a psychogenic and a physiogenic, i.e., biological disorder, i.e., that some toxin is involved, as acknowledged by Freud himself: "As far as I know even today Bleuler maintains the view that the various forms of dementia praecox have an organic causation … which takes no account of the libido theory" (Freud, 1914, p. 29) . Viewing libido, shorthand for sexuality, as a fusion of physiology and psychology, Freud had no need for other organic theories. More importantly, the "libido theory of the neuroses … missed by the Swiss investigators" (p.

29) was the keystone of his theory of schizophrenia. Therefore, the other Swiss investigator, " [Jung] Maeder (1910) and the first clinical study connecting homosexuality and paranoia was published by Ferenczi ( 1950 Ferenczi ( [1911 ).

Freud's libido was never scientifically verified as a biological energy while the hypothetical flows of libido, let alone homosexual libido , were fiction and metaphor, while Schreber's multifarious hallucinations and delusions were reduced to a "simple formula" (1911, p. 41), thus freely mixing energetics with exegetics. However, on Freud's own showing, the question why Schreber yearned when he did for a passive homosexual gratification from his psychiatrist Paul Flechsig (1847-1929) could "not be answered in the absence of more precise knowledge of the story of his life" (p. 46), so that "anyone who was more daring than I am in making interpretations, or who was in touch with Schreber's family and consequently better acquainted with the society in which he moved and the small events of his life, would find it an easy matter to trace back innumerable details of his delusions to their sources and discover their meaning" (p. 57). As an explanation, Freud's theory of Schreber's illness, a shibboleth for generations of psychoanalysts, could not stand; furthermore, Freud did not consider aggression, at least not for another decade or more (Lothane, 1992 ; for a complete bibliography see Lothane, 2010a) . Bleuler (1912) Freud himself said nothing about utilizing his formulas in the psychotherapy of Schreber and claimed that Schreber healed himself: "The delusional formations, which we take to be the pathological product, is in reality an attempt at recovery, a process of reconstruction" (1911, p. 71) , which Brill (1944) consequently the mechanism of cure which we carry through with other peoplethe revival of the pathogenic conflict and the overcoming of the resistance due to repression-cannot be operated with them. They remain as they are… We cannot alter this in any way (p. 447).

This departure from Freud's account of the treatment of the paranoid woman in 1896 was rebutted by the successful therapy of a paranoid woman by Poul Bjerre (1911) and Spielrein's (1911) inpatient case. But the contested interpretations do not detract from the 1911 essay's methodological yield: the developmental dynamics of psychosis, of personality and character, all lacking in Kraepelin's descriptive and diagnostic formulations of psychosis, and thus a prolegomenon to Freud's theory of narcissism and ego psychology. This lasting contribution to psychiatry was magisterially set forth by Arlow and Brenner (1964) . They omitted discussing any homosexual issues in Schreber but instead focused on his world destruction fantasies as an expression of a psychotic detachment from reality and the restitution of this vital contact in the form of delusion and hallucinations, as stated by Freud (1911, p. 71, above) , and also underscored the role of aggression (chapter 10, pp. 144-178). (Stengel, 1957 (Stengel, , p. 1174 ).
Relevant to this discussion is
This had also been stated by Sullivan (1933, p. 301 Theodor Lidz (1966) , a Yale psychiatrist and psychoanalyst, captured Meyer's influence on psychotherapy: "His influence is still very much alive: not only in his students but virtually in all American psychiatrists. It enters in the way we talk to our patients and conceptualize their problems; in the way we think about personality development and the nature of psychiatric disorders; and, indeed, why we are interested in the person and his life experiences rather than, as so many of our continental colleagues, primarily in a disease process" (1966, p. 321) . Based on the fact that the family is a social system, investigator Lidz (1967) found that "the family environment in which schizophrenics grow up [has] pertinence to the etiology of schizophrenia… the disturbed family milieu is a major factor… One of the ways of achieving objectivity in psychiatry is to get rid of content. …I do not consider schizophrenia to be a disease but rather a severe aberration of development.…Familiarity with roles and institutions is also an essential part of interpersonal communication and interaction" (pp. 133, 134,135 (1915, 6th edition 1933) , the first to include psychoanalysis. White further elaborated a synthesis of psychiatry and psychoanalysis in two books (1916, 1917) . Freud (1916 Freud ( -1919 Paul Federn (1952) made an important contribution to the psychoanalytic treatment of schizophrenia; he had discussed the dramatic direct analysis of John Rosen (Federn, 1947) . As noted by Arieti (1959) The young woman "with a borderline personality disorder" in the case reported by Glen Gabbard and Mardi Horowitz became enraged at a store clerk who refused to accept her credit card, shouted, and felt humiliated as "she made a spectacle of herself." She "would not have shouted except that the clerk was rude and curt with her" (p.517). She then got furious at her therapist for asking whether the clerk was followed store policy or that he refused her card. The patient felt humiliated. The therapist interpreted the event in the store as the same thing that was happening with her and him. Detailed process notes would undoubtedly show more than an abbreviated vignette. Perhaps creating emotional storms was a long-standing character habit, the store clerk evoking a reaction similar to others in her past. The clerk was described as rude and curt, and if the woman was correct, then she was right to expect sympathy for how she suffered and therefore became enraged at the therapist's well intentioned question. The episode could be seen as a double enactment, in and out of therapy, in response to an interpersonal drama, i.e., trauma. From the perspective of enactment, the clerk and the therapist were actual, real, encounters, acting as dramatic day residues for the emotional storm in both situations.
Relevant to this discussion is
The reality of the encounter in the here-and-now is acknowledged first, prior to any rush to diagnose or interpret transference. A preferred sequence would be: first commiseration, followed by clarification, and finally confrontation, building up to interpretation, a conjoint activity of patient and therapist. An essential component in dramas in real life and on stage, confrontation thus emerges as a basic therapeutic technique. The issue here is one of a therapeutic philosophy, strategy and tactic which I named dramatology (Lothane, 2009 (Lothane, , 2010b (Lothane, , 2010c (Lothane, , 2011 , the application of the dramatic concept to life, disorder and therapy. This approach is valid in the treatment of both character disorders and psychotic disorders.
Confrontation is not in Gabbard and Horowitz as a technique but is mentioned in
an article in which Otto Kernberg is a co-author (Levy, et al. 2006 ) cited in their references. More explicitly, Gabbard (2009) , comparing Kohut and Kernberg, favored Kernberg, the originator of transference focused psychotherapy (Kernberg, 1975 (Kernberg, , 1984 (Kernberg, , 2002 ): Kernberg, among others "Helps patient see his or her own contribution to problems in the relationships, Confronts and interprets resistance as defensive maneuvers, Examines both positive and negative aspects of the patient's experience, Focuses on envy and how it prevents patient from acknowledging and receiving help" (p. 199); "he would see the goal of psychoanalysis as much broader than Kohut's (p. 200). Some therapists still view confrontation as harsh or punitive, but no technique, however empathic and supportive, can prevent emotional storms from happening. Firstly, there will be many unconscious reasons for enactments by both patient and therapist. Second, the most meticulously crafted transference may contain his/her unresolved countertransference.
Confrontation is not in Gabbard and Horowitz as a technique but is mentioned in
Finally, it is the patient who needs to confront his/her own maladaptive patterns of behavior, and for this he needs the psychotherapist's confrontation to gain such awareness.
Confrontation is not in Gabbard and Horowitz as a technique but is mentioned in
In recent years the term 'transference enactment' has been preempting the previously dominant acting out which Freud discovered in the Dora case and enshrined in his papers on technique. Marcus (2003) , experienced in working with near-psychotic, i.e., borderline, patients has offered important insights on action, acting out, and enactment.
Confrontation is not in Gabbard and Horowitz as a technique but is mentioned in
The Oxford English Dictionary defines 'enact': "5.To represent (a dramatic work, a 'scene') on or as on the stage; to personate (a character) dramatically, play (a part); also the final product, the delusion, an event it its own right, contains a kernel of truth, a hidden reference to the "reality event, with its sequences and contexts that is meaningful and therefore a reality evoker of affect and of symbol" (p. 112). In near psychosis, the day residue "can be an event in reality that seems dramatic or minor…but never minor to the patient" (p. 117). Marcus is of two minds about confrontation: he prefers "the term active questioning to the more standard term confrontation, because confrontation often implies, especially to the beginner, an aggressive stance or attitude" (p. 144), but when discussing reality testing "in the behavioral enactment of the borderline" he avers that We need to eschew both ideological extremes: psychophobia among neuroscientists and biophobia among psychodynamic psychiatrists, and strive for an integration of biology and psychology as demonstrated in the works cited. Neuroscience seeks to explain the biological causes of psychosis as a constitutional bodily condition while drug therapy helps control target behaviors, e.g., violent aggression. Psychoanalytic psychology seeks to understand the person, the person's conduct and the content of the various hallucinations and delusions as well as their intent -in short, the person as acting, adaptively or maladaptively, in an evolving life's drama, in search of love, truth, and justice. We need both to be effective healers of the suffering person. Let Schreber's case serve as an example. Prior to his second psychiatric admission in 1893 and during an interview with Prof. Flechsig, the latter "developed a remarkable eloquence […and] spoke of the advances made in psychiatry since my first illness, of newly discovered sleeping drugs, etc., and gave me hope of delivering me of the whole illness through one prolific sleep" (Schreber, 1955, p. 65) , which had struck the patient as one of Flechsig's "white lies … hardly ever appropriate in my case…a human being of high intellect, of uncommon keenness of understanding and acute powers of observation" (p. 62). Psychotherapy, which Schreber sorely needed, was not part of Schreber's warning is timely in view of the continuing crisis of psychiatry: its being retooled as a branch of neurology and a growing reliance on drug treatments with dwindling support and reimbursement for psychotherapy. In the zeal to reduce the person's thoughts to things, e.g., the brain and its parts, let us be reminded of Buber's (1958) message: "The primary words are not isolated words, but combined words. The one primary word is the combination I-Thou. The other primary word is the combination I-It. … Hence the I of the man is twofold. For the I of the primary word I-Thou is different from that of the primary word I-It" (p. 3). In the course of our life's dramas we have various relations to things, i.e., objects, but interact in relationships with persons, in interpersonal relationships (not, perish the word, in object relations!), as defined by the immortal Sullivan.

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