Freud introduced the negative therapeutic reaction as a clinical concept. But, as always, he also refl ected on it on a metapsychological level. At the end of his 32nd lecture, in which he considers the relation between “Anxiety and Instinctual Life” (1933), he reveals how he came to develop his second drive theory: It was the negative therapeutic reaction that gave him pause. Hence, Freud’s conception of the negative therapeutic reaction is the clinical root of his second drive theory and his introduction of the death drive. It follows that in order to fully appreciate and explore its meaning and value in contemporary psychoanalysis, it seems sensible to consider this particular connection from the perspective of a contemporary drive theory (Schmidt-Hellerau, 2002, 2005, 2006). It is my contention that we can still gain new territory from making use of a revised drive theory for which I will provide a brief introductory sketch before tackling the question of anxiety and the negative therapeutic reaction.