This paper is about case presentations, and specifically about the problems of representation and misrepresentation that bedevil them when an analyst attempts to transmit what has happened inside the clinic to an audience outside it. After reviewing the status of clinical case presentations in psychoanalysis and the role of language in the clinic, I home in on three questions about the role of truth in the analytic process to show that there are three corresponding traps that an analyst who is keen to talk about their analysands falls into. This critique of the form and content of clinical case presentations in psychoanalytic meetings and publications is pitched from within a Lacanian frame of reference, a return to Freud which also attends to the cultural-historical shaping of our practice in training and public professional forums, and it demarcates a properly psychoanalytic approach to the clinic from psychiatric, psychological and psychotherapeutic conceptions of treatment, and how it might be described to others.
This paper grapples with an ethical-political problem concerning the transmission of psychoanalysis. One of the key aspects of this problem, the aspect that the argument here hinges around, concerns what it is we are actually transmitting when we present a clinical case. What happens to the one-to-one, one-by-one encounter between analyst and analysand when the analyst condenses what has happened between the two of them over many hours into a written presentation that they then read to an audience of colleagues and trainees, a presentation in which the analysand is usually absent?
Most of the time when we listen to or read psychoanalytic clinical case presentations we focus on their content; we hear an account given of the analysand’s personal history, attend to the way that the analyst frames the story, and we track the function of particular words and phrases. We will then, perhaps, ask in the discussion after spoken presentations for more information and reflection on the interventions of the analyst, often to encourage them to expand the compass of the interventions, to include, perhaps, the ways in which elements of counter-transference and institutional imperatives may have worked their way into the analysand’s speech, and sometimes we will explore the ways in which the analysand’s speech is moulded and reported to us. The content of the case – what was said and what it was really about – is, of course, entangled with the form of the presentation, the representation. We know that there are always limits, which include questions of legally imposed and ethically self-imposed limits, to what could have been said and what can be reported, and now what must be reported.
I want to focus on the formal aspects of the clinical case presentation here, and show how these aspects also circumscribe the way in which we may then come to understand what psychoanalysis is as such. That is, what is at stake here is that a particular kind of practice of speaking, of an analysand speaking to an analyst under transference in the clinic, is transformed into another particular way of writing a case, presenting the case and then discussing the case with colleagues. My argument is that in the process one thing is transformed into another, mutates from one form of speech into another, and along the way something crucially psychoanalytic is lost, even turned into its reverse.
The status of clinical case presentations
I must admit that I have always been queasy about presenting clinical cases, and have sometimes felt a little nauseous at the way they function in therapeutic settings.
Clinical case presentations were a necessary part of my own training, and I find it difficult to imagine how that training could have worked without them. They have been a staple of psychoanalytic trainings from well before the formalisation of the transmission of our work when Freud gathered around him a circle of practitioners and then began to develop networks and institutions in different geographical locations in Europe and then globally. Just as the spread of a form of writing under ‘print capitalism’ came to provide the material basis of ‘imagined communities’ of the nation state (Anderson, 1991), so the written accounts of clinical cases became part of the imagined community of psychoanalysts as they formed their own first international and later internationals. The clinical case presentation became a requirement for training and then for professional development and updating of expertise. It crystallised into a format for describing and interrogating clinical concepts in practice so that what was being transmitted of psychoanalysis as it spread around the world was as much about the general nature of this form of description as about what was carried in it of the particular experience of analysands (Lewis, 2006).
This is what makes it possible for us to recognise that we are in a clinical meeting, and there are certain rules that structure how one of us will speak about our encounter with another, with an analysand in our work, and those rules structure what may and may not be said about it after the analyst has finished speaking. That one of us is, of course, invariably the analyst. We report and account and are brought to account in a particular way, formulating a narrative about their case that typically covers diagnosis of clinical structure, interpretations and effects of those interpretations. There is sometimes something routine, even banal about the form of that account, a reduction of hours upon hours of discourse and affective flow in the session, blockage and flow that is synthesised into a series of indicative events in the clinical narrative, turning points that may be conceptualised as trauma or insight.
A clinical case can be reduced further so that it has the status of a component of theoretical argument, even as a vignette produced by way of evidence that what has been said is grounded in reality. Many clinical case presentations are structured in this way; the opening conceptual elaboration opens onto the main stretch of the presentation before a refrain of the argument at the end, and this sequence then provides a template for many theoretical papers in psychoanalytic meetings so that there is an expectation that a dense review of conceptual issues will at some point give way to a case example. Then the analysand appears in the presentation in what often turns out to be in the guise of anecdote, and one can sometimes notice the relief of the audience as they settle back, safe in the channels of a kind of narrative they have already learnt to feel comfortable with from their own training. Thinking can then give way to voyeuristic enjoyment, and the danger of this kind of presentation is that the questions then revolve only around the case which has by now taken shape as a scenario structured within the frame of sophisticated gossip (Forrester, 1991).
These cruel caricatures of professional meetings are not, unfortunately, always wide of the mark, and they sketch worst case scenarios onto which are latched some of the most destructive and vicious critiques of psychoanalytic theory and practice (Grünbaum, 1988). Claims that psychoanalysis is redundant because it is ‘unscientific’, that case studies cannot therefore provide sufficient ‘evidence’ for the theory are of this kind (Midgley, 2006). It is then understandable that psychoanalysts should defend this defining element of their training and professional activity (Willemsen et al., 2017), and stake out a claim for theoretical pluralism in that field (Willemsen et al., 2015). But anti-psychoanalytic critiques do hook onto something, a real problem. It is necessary that we respond to the critiques with internal critique of our own, internal critique that is able to step back and ground critical reflection in an analysis of the conditions of possibility for others to speak to us and for us to relay that speech within specific closed settings to others. That analysis of the conditions of possibility for psychoanalytic discourse and the institutional forms that house it also requires some critical distance from our own received images of psychoanalysis as such.
Some versions of psychoanalysis have taken shape since Freud’s time in such a way that the problematic aspects of clinical case presentations that I will identify in this paper are so thoroughly embedded in their practice that we will need also to tackle some deep taken-for-granted assumptions about them along the way. So, I should spell out where I am coming from in order to engage in this critique, and you will see my own standpoint elaborated at points in the paper.
First, there are versions of psychoanalysis that have adapted themselves variously to psychiatric, psychological or psychotherapeutic frames of reference. This is part of the problem, and I will return to these issues later. Suffice to say for the moment that I see psychoanalysis as fundamentally different and opposed to psychiatry, psychology and psychotherapy (Parker, 2011).
Second, the versions of psychoanalysis that tend, in different ways, to detach their understanding of the human subject from language are particularly susceptible to the problems I will describe. Language provides the conceptual grounding of Freudian theory and is the ground of psychoanalytic practice (Forrester, 1980). I will be approaching this problem through my own training tradition and the conceptual lens of Lacan’s (2006) return to Freud in which the unconscious is viewed as structured like a language and which is underpinned by the argument that no meta-language can be spoken. That is, our descriptions of and interventions into a phenomenon are always necessarily part of that phenomenon, not separate from it.
Third, Lacanian psychoanalysis is not as such itself immune to these problems, and there is an understandable replication of the problems as Lacanians adapt, deliberately and tactically or unwittingly, unconsciously, to forms of discourse in dominant institutions. My critique here is part of a broader argument that our theory and practice needs to be culturally-historically situated, and needs to connect with other critical traditions of work that aim to dismantle the ‘psy complex’, that contradictory network of apparatuses in schools, prisons and clinics through which contemporary subjectivity is specified and governed (Rose, 1985).
Language in the clinic
Much rests on how we conceptualise our work in the clinic. The clinic is a strange precious space in which one subject, the analysand, speaks to another, the analyst, about themselves and, more importantly, speaks in a way that they have never spoken before. When the analysand follows what Freud (1904) called the ‘fundamental rule’ of free association they encounter the impossibility of saying everything. The hesitations, ellipses and gaps in their speech are sometimes noticed by the analyst, but we know well from our own analyses that the breaks and obstacles to saying everything are mostly noticed by the analysand themselves, as are the most significant connections and contradictions between the things they say. It is the analysand who is analysing, and there is a crucial difference between what registers and changes for them in the course of analysis and what might register and sometimes change for the analyst.
Even for the analysand, the counter-intuitive non-linear temporal logic of the clinic means that it is not always entirely clear to them exactly what they are talking about, what it is that their symptom in the clinic speaks of, and, even less so, when exactly things shift and what that shift means. It is not clear when the analysis is over, and the span of analysis for them does not necessarily correspond to the time they begin and end their time with the analyst. Time in the constitution of the trauma is retroactive, as it is in the narratives that are spun out and disentangled in the clinic, and as it is in the cure. The analytic work carries on between the sessions and after the termination of analysis, much of that invisible to the analyst.
The analyst functions as catalyst for these things to be said in the clinic, with interventions, punctuation and cuts of session that mark what may be of significance, but which usually touch a real in the speech which is often as surprising and unexpected to the analyst as it is to the analysand. There is a process of clarification and reduction that goes on in the analysis, but we should not confuse what the analyst is doing as they clarify and reduce the speech within the terms of the analytic discourse they have absorbed in their training and in their supervision and professional meetings with what the analysand is doing as they struggle to make sense and then question what sense they are making of what they do and who they are.
There is a peculiar dialectic at work in the clinic between construction and deconstruction in which, paradoxically, it is the analyst who is impelled to continually reconstruct what is going on so that they may better facilitate the unravelling of everyday functional norms concerning behaviour, interaction, sense of self and emotional response that usually, outside the clinic, guide the analysand in their attempt to adapt to reality. The analyst constructs and reconstructs what they think is happening in order that they may direct the treatment, and so that the analysand can analyse as they speak. That is the only way that analysis will happen, as the analysand engages in a process of deconstruction of who they have been told they are, of what kind of subject has been shaped by the signifiers that represent them to other signifiers in familial and cultural symbolic systems.
It is in this respect that some psychoanalysts, particularly some Lacanian psychoanalysts are attentive to lessons from cognate fields of work in postcolonial and feminist theory concerning representation, misrepresentation and appropriation of experience and ‘voice’. We analysts are cautious about offering interpretations that threaten to describe and prescribe a meaning, as if the ‘latent’ content is to be excavated by us from beneath the ‘manifest’ content of speech. We intervene in such a way as to enable interpretations to be made by the analysand, knowing that to spell out the meaning to them would be, in effect, for those interpretations to operate as a form of suggestion and to thus colonise the analysand’s speech. And analysts are aware at some level, if not immediately of the wording of current theoretical debates, of the tension between the tactical and strategic use of signifiers by the analysand, on the one hand, and the impossibility of dismantling a system of language by, as Black feminists have put it, using the master’s tools to dismantle the master’s house (Nayak, 2014). The shift in analysis from one position in relation to language to another is not achieved by simple translation from one series of signifiers into another, even less by the analyst positioning themselves as master and providing new signifiers to their analysands. On the contrary, the analyst disrupts relations of colonial mastery which pretend to know what their subjects are thinking and feeling, and we Lacanians can conceptualise that disruption as a form of productive ‘non-relation’ (Lacan, 1975/1988).
It is the peculiar enigmatic non-relation between analysand and analyst that makes it difficult to precisely characterise what occurs in a psychoanalytic session, let alone in the longer span of analysis. Beyond a description of the arrangement of the chairs in the room, the shift of analysand to the couch and the length and number of the sessions – a formal architecture of the space in which the speech takes place – there is no direct way to describe what happens. The content of that weird speech is, strictly speaking, unrepresentable, so we resort to a series of available narrative devices that do symbolic violence to what was said when we try to account for our practice to another audience outside the clinic. It is given form by us as we analysts speak about our practice.
To be clear, as clear as possible in this context, I am not claiming that what happens in the clinic is noumenal, that it is about things as they really are that can never be put into words, or numinous, having some spiritual quality that cannot be expressed in speech, or intuitive, concerning some kind of emotional sense and interaction that exists beneath language to which we then appeal. Whether we like it or not and whether the analysand likes it or not, what happens in the clinic is structured, structured like a language. What there is of the unconscious in the clinic is structured, as is what is said of it. The point is that there are forms of gap, irremediable contradictions between what is said of the unconscious, between conscious and unconscious, and between analysand and analyst. These forms of gap are not to be healed, and some unity restored, the least so unity of understanding over what took place. The analyst is therefore faced with an impossible task, an impossibility that psychoanalysis enables us to account for. And account for it we must instead of pretending in our clinical case presentations that we can, even temporarily, suspend it, suture it and make it possible.
Representation and misrepresentation
Speech in the clinic facilitates dramatic shifts in the human subject’s relation to language, shifts which may be marked as an accretion of moments of insight or as a point at which there is mutation in the nature of the subject’s idealisation or demonization of significant others. Whether we conceptualise such insight or mutation in terms of the role of the ego and its relation to the unconscious or of the role of the Other and the objet petit a, one thing is sure, that there are profound transformations, transformations which are rational and irrational and which reconfigure the relationship between rationality and irrationality.
One way of grasping these transformations, something that will be common to most forms of psychoanalysis, is to attend to their manifestations in the transference. The way the analysand speaks to another, the analyst in the clinic, also speaks of a host of other relationships that have come to determine who they think they are. Lacanian psychoanalysts will attend to the play of signifiers in this transference relationship – repetitions of words and phrases which include or obscure them as witnesses to what is happening in the analysand’s speech – and it is the fact that this analysand is speaking to them, to this analyst, that makes analysis possible and impossible. It is an impossible profession but it makes certain kinds of speech possible.
We Lacanians conceptualise the impossible contradictory interplay of rationality and irrationality in the transference during which the unconscious opens and closes through the motif of truth. The analysand does their level best not to speak the truth in analysis, but sometimes they fail. Through slips of the tongue and jokes and dreams they hear something of the truth, and there are moments when they own that truth and it appears in their own speech. But this ‘truth’, the truth of the subject, is as impossible to capture as it is to predict. This truth of which we speak as we step back to characterise it is not the empirical factual truth of positivist science, not a fixed thing to be enumerated and accumulated. My bet is that it is not even the kind of thing that can be transmitted. This truth, the truth that concerns us, does not directly appear unmediated in the speech of the analyst, either in the clinic or in a clinical case presentation. We should not pretend that it can. Let us approach truth in the clinic through three vectors to emphasise this point.
The Wall of Language
The first vector concerns the role of language in a psychoanalytic conception of the human subject and the role of speech in the psychoanalytic process itself.
Representation and misrepresentation are at the heart of psychoanalytic theory, with the clinic operating as the key place in psychoanalytic practice where truth can be spoken, spoken but quickly covered over again. The clinical process in the midst of which truth glimmers and disappears makes it difficult enough for the analysand to speak of what occurred, and extremely difficult for the analyst to detect. It would be a rash analyst who claimed that the veils of consciousness were parted in the clinic so that the subject of the unconscious as such could speak, and the most that can be hoped for is that there is a momentary rearrangement of the boundaries between rational conscious thought and unconscious primary processes. Freud’s invention of the unconscious specified a realm of ‘thing presentations’ which he contrasted with the conscious assemblage of thing and ‘word presentations’ (Freud, 1915). He then named a series of defence mechanisms by which the connection between the two kinds of representation could be maintained, including rationalisation and intellectualisation.
Lacan pointed out that the linguistic medium we use to communicate with others is structured as a dense symbolic network of signifiers in which rationalisation and intellectualisation are but two of the names of the game, that our attempts to reach across to others are blocked by what he called ‘the wall of language’. The problem is compounded when each of the partners in clinical language games imagine that they are breaking through or circumventing this wall and instead get trapped in a wall of mirrors that confirm their own peculiar image of what communication with another should look like. When we enter language, Lacan argued with a neat French pun, it is as if we enter the realm of the ‘inter-said’ – a neologism to describe something between speakers which in French is ‘inter-dit’ – but we actually get trapped in medium in which certain things, including communication as such, are prohibited (in French ‘interdit’).
This means that whatever is said in the clinic is necessarily refracted through at least two different dimensions – through the symbolic register in which language is structured and the imaginary register in which we assume it is not – neither of which permit the unconscious to reveal itself as such to consciousness. This is why Lacan argues that the truth can only be ‘half said’. It appears in the gaps and has a form conditioned by those gaps rather than being fully present to itself; it is not fully present to the analysand, still less so to the analyst. The first trap set for the analyst by the wall of language and the conscious restructuring of the image of the wall by those who are intent on wishing it away, then, is the idea that it would be possible to restructure the interaction between themselves and their analysand and to re-present it in symbolic form for another audience. That is what a clinical case presentation is; it is a symbolic exercise which reconfigures what has happened in the clinic and which closes over the very gaps through which the analysand has spoken the truth, misrepresenting what they have said as being ‘about’ something rather than being the process itself of speaking.
Statements of Fact
The second vector through which we can approach the question of truth concerns the relationship between truth and statements of fact that seem to express it in certain forms of discourse.
The earliest cues that something could be achieved by speaking to another, as if one person was putting experience into words with another person as witness to that account, came not from a psychoanalyst but from a pre-psychoanalytic patient Anna O who dubbed the practice the ‘talking cure’ and who also noticed that the relief was temporary, was akin to what she called ‘chimney-sweeping’ (Freud and Breuer, 1895). Thus began a tradition of psychoanalytic practice as something ‘interminable’, which is a fundamental conceptual description of the process as unending, incomplete. The metaphor of chimney-sweeping does already indicate that evidence of its success cannot be found in the production and display of clean flow, neither clean drives nor completely clarified thoughts. The successful outcome of an analysis is not a visible product of any kind, nothing that has been dredged up from the dirty depths of the subject or that has taken shape as a truth from which error has been drained. The analysis may indeed have therapeutic effects, but analysands often report that they are no clearer about what happened to bring about those effects than they are about the actual causes of the problems that brought them to see an analyst in the first place (Cardinal, 2013).
Psychoanalysts since Freud have had to struggle with the filtering of truth through discursive procedures that are antithetical to the process they describe, and we have to insist both that the ‘memories’ that are produced in analysis are not necessarily of real events that actually took place – our concern is rather with the staging and transformation of memories of events by way of unconscious fantasy – and that the truth of the subject describes the relation the subject configures to those events rather than empirical truth about the events as such. The discursive procedures that turn relational processes into static fixed things do themselves have formal properties that Lacan (1991/2007) described in one of his later seminars on the ‘four discourses’. Thus it is that the ‘discourse of the analyst’ is designed to provoke a questioning rebellious relation to knowledge that he called the ‘discourse of the hysteric’, and the ‘discourse of the master’ attempts to hold things in place with the aid of the ‘discourse of the university’. The latter two discourses which reify creative ongoing activity, turning processes into things, make it seem as if statements about the human subject are statements of fact.
Psychoanalysis is processual, and the truth of its practice cannot be reduced to factual statements about the nature of analysands or even about the nature of one particular analysand. Instead, and explicitly against such a reduction and reification of subjectivity, psychoanalysis enables the subject to speak, not as a ‘subject of the statement’ but as ‘subject of the enunciation’ (Lacan, 1964/1973). Enunciation refers to the process rather than fixed status of speaking, but the attempt to turn what has been facilitated in discourse – by the discourse of the analyst and discourse of the hysteric – into a discourse that relays that process to a third party, to an external audience, is another trap structured by discourses of mastery and all-embracing university descriptions of the world. This trap turns description as ongoing partial fragmentary process into something that is amenable to being described. That is what a clinical case presentation is; it is a reconfiguring of the enunciative process that occurs inside the clinic into a series of statements so that the subject of psychoanalysis – and truth spoken by the subject of the enunciation – is betrayed and replaced with an image of the subject as subject of the statement.
Fact and Fiction
There is an internal contradiction in the texture of psychoanalytic knowledge, and we attend to this internal contradiction in the third vector through which we approach truth.
Psychoanalysis is a form of knowledge that comes close to a scientific worldview, but which, Freud (1933) insisted, is the closest that his invention comes to any worldview. As such, psychoanalysis often presents itself as being scientific in some way – either as a natural or human science – and so as elaborating a distinctive field of knowledge about the human subject. Freud himself was ambiguous about the nature of this knowledge, and Lacan was sceptical about it, arguing that it operated in such a way as to reconfigure the kind of subject that was historically produced by the arrival of scientific systems of thought. This Lacan (1966/2006) summed up in the assertion that rather than being scientific as such, psychoanalysis works upon the subject of science. And so, here is the contradiction; on the one hand there is now an apparatus of quasi-scientific knowledge – including psychoanalysis as a system of thought – in which the human subject is alienated, reduced to the status of ‘subject of the statement’, subject to the statements made about them by different scientific disciplines; and, on the other hand, there is now a practice – and it is psychoanalytic practice which is at stake here – which facilitates the separation of that subject from the knowledge that pretends to know them and enables the subject to almost, but not quite, speak for itself as subject of the enunciation. Psychoanalysis is conditioned by and unravels scientific knowledge.
It is clear that this knowledge plays a productive role, and often does so by masquerading as factual description, nowhere more so than in the case of human subjectivity and relationships where we are forced to play roles in familial and broader symbolic systems and become committed to those roles and to the depth of character that is supposed to attach to their underside, inside us. The division between conscious and unconscious realms of signification, between this public and that other hidden side of the language we use to speak about ourselves, and division at the level of the unconscious – division which gives us the status of divided subject and subject of science – leads Lacan to notice something peculiar about truth when it is spoken, must be spoken in a language that is structured in such a way as to obscure that truth. Instead of resorting to the fantasy of ‘fact’ when speaking about truth, Lacan (1986/1992) argues that every truth has the structure of fiction. Scientific and other ostensibly factual kinds of discourse are fictional, parades of metaphors, and so the trick when speaking the truth is how to enunciate it in such a way as to work with it, with it as something that is always structured by the apparently definitive and alluring registers of the symbolic and imaginary and by tempting stories about the real outside discourse.
We need to be careful, however, not to confuse this kind of truth structured as fiction with the myriad of fictional forms that still, in different ways, masquerade as factual description or with strategic means to convey something factual. There is a slippage between these different ways of handling truth using various fictional rhetorical devices. Such is the case with forms of ‘narrative’ which function to suture over divisions in the subject and to replace the fragmentary divided nature of the subject with a convenient comforting story-line which seems to bring an array of facts into linear causal relation to each other (Laplanche, 2003). We do not aim in psychoanalysis bring an analysand’s life to order, to narrative order, but rather to decompose the contradictory narratives into their signifying elements. The trap set for an analyst who has successfully accomplished this decomposition is that when they try to convey what has happened to someone else they do it precisely by stringing the signifiers back onto a narrative, their own narrative of what becomes the ‘case’. That is what a clinical case presentation is; it is a narrative which presents fiction as if it were structured as truth, covering over and effectively reversing the process by which fiction may have staged the truth of the subject in the clinic.
These problems with the clinical case presentation format in psychoanalysis are not accidental or incidental glitches, but are structured into that format, a necessary and irremediable part of it. More than that, the format is itself embedded in a series of practices that comprise different component disciplines of the psy complex. Clinical case presentations reinforce and warrant those practices each time an analyst presents an account which describes diagnosis and treatment with someone who is not present, and so unable to speak back, whether that diagnosis or treatment is viewed as categorical and certain or elaborated more discursively through a more sophisticated narrative. The format connects with and colludes with disciplines which psychoanalysis would otherwise disagree with, and those other disciplines return the favour with their own unhelpful elaborations on how a case might be presented to others (Nissen and Wynn, 2012; Wolpert and Fonagy, 2009).
Psychoanalysis had to break from psychiatry, for example, shifting diagnosis from observable signs of disorder to a concern with what the practitioner heard and with what was being said, which are two different aspects of the question of speech between analysand and analyst. What psychoanalysis retained from psychiatry were detailed record-keeping, medical case notes, and public presentations of patients for training purposes. We know from medical anthropology that case notes get ‘worked up’ as different practitioners review, interpret and add to the file, and many psychoanalysts are wary of taking on good coin a diagnosis of clinical structure that is offered to them along with a new patient. Psychiatric practice still continues, however, in the parading of the patient, something that would seem at first glance to mitigate some of the problems I have raised about witnessing the patient’s speech first hand (Gallagher, 2009). In fact, this performance of case presentation does little more than offer the patient the stage in a peculiar limited role for a limited period of time during which elements of their speech may be observed by the audience and the reality of the illness that has been diagnosed thereby confirmed to them. Far from solving the problems I described, psychiatric forms of psychoanalysis exacerbate them and reframe them in medical terms so that the analyst is indeed reinstated as the master. The clinical case presentation is itself quite compatible with a psychiatric conception of the human subject.
In the case of psychology, there have been attempts to bypass the problem through the mechanism of randomised controlled trials in which the professional is distanced from the phenomenon they describe by virtue of their supposedly neutral position as ‘scientist practitioner’ and through the accumulation of descriptions of behaviour in a sample. The particularity of each patient is thus lost. The reaction to this positivist model of research and clinical practice has, perhaps, as a result of this history, been stronger, with clinical psychologists involved in critique of diagnosis preferring a form of ‘case formulation’ which organises a description of the problem in the frame of a narrative that the patient may also participate in constructing (Johnstone and Dallos, 2006).
This ostensibly democratic negotiated approach to case formulation, however, enrols the patient as an ally of the psychologist, and entails a division of the subject between the irrational part of the subject which has the problem and the rational part which is able to reflect and formulate a description of it. For all the talk about counter-transference in some versions of psychoanalysis, the appeal to subjective involvement of the analyst in the process they describe usually amounts to no more than instrumental use of that subjectivity to access underlying emotional dynamics in the encounter with the analysand (Stefana, 2017). Not only is this tantamount to a form of telepathy – counter-transference is assumed to connect with phenomena underneath or outside language – but it also reinforces the overarching assumption that the analyst who describes the case after it is over does so from a more objective position. The clinical case presentation thus becomes compatible with a psychological conception of the analyst and then also of the analysand.
Psychotherapy, meanwhile, complements this focus on rationality in the presentation with an attempt to directly access and represent experience. This more direct experiential level of engagement with the patient or client is approached either through reports of intuitive rapport between the two partners in dialogue during which the client has explicitly contracted to have their story relayed to others, or through attempts to include the audience in first-person dialogue with the client. In the former case – contracted agreement between client and therapist – there is clearly already a third party in the room through the course of the therapy, and the effect is to encourage imaginary identification between the partners under the gaze of this Other, the symbolic medium through which the client will be represented by the therapist. In the latter case – inclusion of the audience in techniques such as a ‘reflecting team’ (Andersen, 1987) – the audience participates in a living case presentation which is also part of the therapy itself, and which relies upon the agreement of the client, and pressure upon the client to confirm the interpretations that are generated by the professionals they have the privilege of witnessing speak about them. Neither option solves the underlying problem, and does little more than defer decisions about how to represent this process after the event, deferring it while producing a psychotherapeutic conception of the psychoanalytic process.
These are but three disciplinary standpoints on clinical case presentations within the psy complex. They together comprise a field of debate in which some of the problems I have raised are worried over, and usually framed in terms of the ethics of representation and the rights to confidentiality of those seeking help. There are many other versions of those different responses in the fields of forensic practice, nursing and social work which repeatedly raise and fail to solve such moral and ethical dilemmas, and these failures indicate not only that psychoanalytic clinical case presentations are implicated in the broader problematic of the psy complex but also that apparent solutions to deep underlying contradictions actually serve to draw psychoanalysis closer to the psy complex, to the very apparatus that it should be taking a critical distance from.
So, what is to be done? There is no easy escape route, but there are some alternative practices that may help us to shift frame and construct more authentically psychoanalytic ways of reporting and reflecting on what we do. When Lacan (1966/2006) argues that no meta-language can be spoken, this is a precise formulation which draws attention to a key difference between the flow of speech and crafted inscription. It does not, however, mean that any and every form of writing allows for the production of a meta-language. In fact, the forms of writing which most directly claim to represent either social reality or a real outside symbolic and imaginary registers of language are most liable to fail in doing so. In contrast to clear, apparently transparent speech or writing, it is allusive, convoluted and elliptical writing and speech that is configured like that kind of writing that is most able to construct a meta-narrative. If we are to begin with an ironic approach to language and to the clinic, 2001), we must do this in order to simultaneously facilitate the combination of alienation and separation in language that connects subjectivity and objectivity in such a way as to permit truth to be spoken or written in a mediated theoretically productive way, true to the unconscious as a form of ‘textual knowledge’ (Miller, 2001). I suggest three possible options.
The first is that we take seriously the structure of fiction. One of the differences between a clinical case study and a fictional representation of subjectivity in a novel or film is that while both of them are literary, fictional, the clinical case is literally crafted as a particular kind of fiction for a considerable period of time before it is presented to another audience outside the clinic. This makes it all the more liable to be moulded, through the subtle interplay between hints and expectations, interventions and interpretations that guide the discourse along the tracks of a particular psychoanalytic tradition. This also makes it all the more difficult to critically reflect on the case from a different psychoanalytic tradition when it is presented, let alone an anti-psychoanalytic one. Fictional representations of subjectivity are also saturated with elements of the psychoanalytic culture in which they are formulated, but they are potentially more open to multiple competing semiotic evocations of what psychoanalysis is. More use could be made of such deliberately fictionalised accounts (Orbach, 1999).
The second is that we shift focus from the analyst’s account to the analysand’s. Autobiographical accounts of psychoanalysis by analysands are as prone to idealisation of the process as those offered by analysts, and sometimes are more prone to derogation of the process, sometimes for good reasons (Gunn, 2002). Accounts of the trajectory of analysands through different kinds of analysis, with an evaluation of the practice of different analysts, are liable to be written off as some kind of acting out by the analytic community, but these accounts are nonetheless useful. There is, of course, a tradition within Lacanian psychoanalysis of the ‘pass’ in which an analysand gives an account of their analysis to others who then transmit this to a third group for evaluation. This does not provide a perfect model for how testimony could be given, and it has tended to be embedded in institutional procedures which work against an honest account of failures as well as successes. Nevertheless, it gives a different standpoint from which to speak of analysis (Laurent, 1999).
The third is to break from the individualising frame of the analytic session and produce collectively elaborated accounts. Whether given by the analyst or the analysand, the single-person account is still liable to be trapped in the mirror-like interactions – enamoured or hateful – that structure the transference. The clinical case presentation is one way of opening this imaginary dimension of analysis into a properly symbolic representation in which the operation of a third term becomes fully operative. This shift from imaginary to symbolic can be more effectively managed, however, if there is a comparative and contested practice among analysands which then becomes the basis for public presentation in a psychoanalytic meeting (Ireland and Widlöcher, 2004). However, this would also enable a break from single-thread narratives which structure a case presentation to multiple interweaving narratives, even of the making visible of the real as an impossible to suture the ground and effect of language. Multiple standpoints do not guarantee that there is no covering over of contradiction, but they do make it possible (Bates, 2006). There are no guarantees of any complete solution, and we should rather look to incompleteness as a touchstone if we are to get anywhere.
The problems I have described go way beyond complaints about confidentiality and the moral injunction codified in many legal systems that accounts of harm or self-harm in the clinic should be reported to the authorities (Bollas and Sundelson, 1996), complaints that can often entail no more than agonised liberal hand-wringing which leaves the apparatus of misrepresentation of another’s speech in place. The argument that, despite all these problems, the clinical case presentation is so useful, that there is so much to be learned from hearing an account of a case, is bankrupt; it resorts to an instrumental ethics that is antithetical to psychoanalysis. I have argued that critical reflection on these problems cannot be developed from within the psy complex. Precisely the reverse, the psy complex is part of the problem and apparent solutions that the different disciplines in the psy complex offer actually exacerbate the problems. The conditions of possibility for psychoanalysis to be spoken about are also the conditions which make it impossible to be spoken about without being recuperated, absorbed and neutralised by traditions of work hostile to psychoanalysis itself, impossible without attempts to break from the standard format in professional meetings.
Critical reflection on psychoanalytic clinical case presentations can come from within psychoanalysis itself. In fact, these arguments are not new. Versions of this argument against clinical case presentations have already been elaborated from within Lacanian traditions of psychoanalysis outside the English-speaking world that attend to the way that diagnosis of clinical structures, for example, tend to embed our practice in the psy complex, in what is termed the ‘pernepsy’; that is, the perversion, neurosis, psychosis triad much-beloved of most psychoanalysts, including most Lacanians (Allouch, 2014). This runs alongside a series of internal critiques of the complicity of psychoanalysis in the psy complex and Lacan’s resistance to that complicity (Allouch, 2010) and of the role of clinical case studies in transmitting a distorted image of psychoanalytic practice (Le Gaufey, 2016; Rangel, 2010). Such internal critiques have appeared in psychoanalytic journals in France, Mexico and Uruguay. The point is that the clinical training and case presentation line of work which threads together the experience of psychoanalysts in formation also encourages them to utilise the kind of narrative they use to sum up the progress of a case in their own practice while they are listening and intervening with their analysands. This is a narrative that is also explicitly or implicitly demanded in supervision of the case, though often more tentatively.
Supervision and personal analysis in psychoanalytic training leaves open the possibility that a case might ‘fail’, however we might conceptualise what success or failure is. Diagnosis in supervision is always provisional, tracking the session by session shifts in transference, and particularly in the Lacanian tradition in which transference is open and mutable rather than locked into place by interpretation (Leader, 2010). Supervision in training and beyond includes discussion of the preliminary sessions in which there may indeed be analytic work but in which the analyst and analysand have not yet committed to the analysis as such, and it includes the many cases of analysands who, for a variety of reasons that we may try to grasp as a ‘negative therapeutic reaction’, leave analysis. Who knows what progress has been made and when it will be registered, if it is registered at all? Personal analysis is almost equally as uncertain in its prospects, with psychoanalytic trainings refusing to guarantee completion, graduation to the status of analyst, precisely because the analysis may lead the analysand to conclude that this is not what they want. Against these indeterminate trajectories in psychoanalysis, the clinical case presentation tends to select out for professional or public presentation either those analysands who have made progress, in which there has been success, or failures in which the analyst is able to register their own success in recognising what went wrong (Casement, 1985).
The meandering messy nature of psychoanalytic treatment is thus systematically misrepresented. We know this, and our refusal to acknowledge it simply gives more ammunition to our enemies. In sum, the clinical case presentation is anti-psychoanalytic. We need to think again and speak differently about what we do.
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