reported by REACTION STANLEY L. OLINICR. M.D.That the topic of negative therapeutic reaction was a well-chosen one was made evident by what newspapers like to call "a capacity audience attendance." T h e proliferating nouns indicate that this topic, more than half a century in age, continues to be of great interest and essential to the discriminating understanding of a large group of clinical and theoretical problems. That it is not a thoroughly resolved problem was demonstrated by the explicit disagreements among the panelists; but it was clear that it is resolvable, and that there is a large area of ready agreement about the syndrome's phenomenology and metapsychology. hlilton H. Horowitz opened with a thorough and comprehensive review, placing the concept of the negative therapeutic reaction in perspective. Regrettably, his presentation can be given here only in condensed version.Freud referred to the worsening of symptoms during psychoanalytic treatment in his technical papers of 1913-1917. He first referred to "negative reactions" in the case history of the IVolf hlan. There he commented on the patient's habit of producing transitory "negative reactions" when something had been conclusively cleared up; aggravation of the symptoms contradicted the effects of the analytic work. He reflected that children often respond to prohibitions in this way, repeating the act once more after the interdiction, as though to gain the point both of stopping of their own accord and of disobeying the prohibition. By 1918, Freud viewed exacerbation of symptoms, following their analysis, as instances of negativistic defiance related to the anal-sadistic phase of libidinal development.His views underwent a considerable alteration by the time he wroteThe Ego and the Id. T h e negative therapeutic reaction occurred in "certain people" who, when one spoke hopefully to them, o r expressed satisfaction with the course of the treatment, or interpreted accurately, showed a n exacerbation of their condition. He saw this as due fundamentally to a powerful "moral factor" o r sense of guilt, with a consequent refusal to give up the Held at

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The author outlines his clinical observations during the "middle game" of psychoanalysis, leading to recognition that structural change is taking place. "Middle game," "structure," process, and content are defined and critically discussed. Illustrative clinical vignettes are offered. The presentation emphasizes the importance of an active and resolving transference "struggle"; in addition, more traditionally noted criteria are briefly touched on, e.g., development of observing ego and treatment alliance, changes in dream function and communication, and the reviewing of the neurosis and transference during the termination phase as instances of mourning and working through. The concept of optimal psychobiological function in the service of a homeostatic principle is discussed.

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