The Freud Museum

Events Archive

23 September 1995 - 24 September 1995

The Presentation of Case Material in Clinical Discourse

Conference Report

The focus of this conference was on the different contexts and forms in which psychoanalysis is conveyed, and the various implications of this. Without doubt the most common rhetorical form is the 'case history' or 'clinical vignette'.

The conference began with a paper by Ron Britton on 'publication anxiety'. He considered some of the unconscious factors which contribute to anxiety surrounding the presentation of new ideas within psychoanalysis and other fields. For instance a new author may feel he is destroying a previous authority-figure and taking illicit possession of the 'scientific object' which can lead to inhibitions and alterations in his own text. In a meticulous piece of detective work Britton uncovered the traces of these effects in papers by Karl Abraham, Muriel Gardiner, and others. However, there is one distorting agent which it is impossible to avoid in psychoanalytic writing - the requirement of confidentiality - which Susan Budd considered in her paper "Tell me no secrets and I'll tell you no lies". In a wide-ranging paper which dealt also with the difference between clinical and theoretical understanding, Susan Budd conveyed the delicate balance the analyst must strike between the desire for accuracy and the fundamental requirement of confidentiality in all types of communication of clinical material.

In an erudite historical paper, John Forrester scotched the myth that the psychotherapeutic approach to case histories is entirely unique. By using historical examples from medicine and law he put forward the case that the way psychoanalysts think about their clinical material has not only a complex history but manifold connections and analogies with other disciplines. This indeterminacy was highlighted in a different way by Richard Klein in the following paper. His close reading of Freud's essay "Constructions in Analysis" from a Lacanian perspective led him to the conclusion that case material can be strictly speaking 'undecidable'. We cannot point to a single truth because everything in the mind exists in many different registers at once, as in Freud's famous analogy of the various layers of the city of Rome.

Don Spence's intriguing presentation "On developing perfect pitch for the past" ended the first day of the conference. It continued his recent work on The Rhetorical Voice of Psychoanalysis and described in detail some of the subtle influences which can distort the data of analysis and subsequent written accounts. Following on from his work with computer analysis of analytic sessions he looked forward to the possibility of a standard vocabulary for clinical writing which is both 'unambiguous' and 'poetic'. It is worth pointing out that such a standard vocabulary was attempted at the Hampstead Clinic through the use of the Hampstead Index, a way to categorize and present clinical material so that it was accessible to more than one therapist. Don Spence's paper, along with those of Ron Britton, Susan Budd, Laurence Spurling and Julia Borossa have been published in a museum book.

On the Sunday, Julia Borossa presented some fascinating insights into the history of clinical writing. The writing up of material is affected not only by the relation to the patient but by the institutional setting in which it occurs and the cultural climate of the times. Once again, the subtle pressures which affect the form of a discourse were exposed to view. Laurence Spurling's examples of the ill-judged use of jargon in student's clinical presentations on counselling courses showed how the allegiance to a form of writing can undermine proper understanding. He also showed in a simple and lucid way the features he considered essential for a good case presentation.

Finally, the conference was brought to an end by the expansive paper delivered by Robert Langs. Speaking without notes he expounded on some of his latest ideas, ranging as far afield as evolutionary biology and the structure of the brain, to the problems of 'framing' in the therapeutic encounter. He insisted that many of the 'free associations' of patients are actually re-actions to disturbances which have occurred in the analytic setting. Once the trigger is found the analyst is able to interpret the patient's communications with some confidence, but without this point of reference the analyst is floundering in a sea of 'undecidability'. At some points Dr Langs even touched on the topic of 'Supervision without process notes', which was the main title of his paper! Langs' paper inspired a lively and stimulating plenary discussion.

The conference was expertly chaired by David Tuckett, who not only sat though the whole event and kept everything to time, but made telling interventions throughout the day and a half. The high level of discussion and the relaxed atmosphere of the conference was remarked upon by many who attended.

The book The Presentation of Case Material in Clinical Discourse is now available from the Freud Museum bookshop and Karnac Books.

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