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THE STRUCTURE OF THE PSYCHOANALYTIC CASE HISTORY

Article · January 2006

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Andrew J. Lewis
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 THE PSYCHOANALYTIC CASE HISTORY1

Andrew J. Lewis

Her mask reveals a hidden sense

Quotation of Goethe’s Faust (Part 1, Scene 16) used by
Freud to describe Fraulein Elizabeth Von R.

The Australian Centre for Psychoanalysis (ACP) has presented the

clinical work of its members since its inception in 1986 under the name of
the Melbourne Centre for Psychoanalytic Research. In 1987 this seminar
became formalised into a fortnightly presentation known as the Clinical
Seminar and was delivered at Mont Park Hospital, Melbourne. In 1991 the
seminar moved to the Royal Park Psychiatric Hospital which in 1997 was
decommissioned. Thus the seminar left the terrain of public psychiatry
and was delivered at the Royal Society of Victoria where it continues
today.
The seminar has been intrinsic to the development of the ACP as a
psychoanalytic institution, serving as the meeting point of new version of
psychoanalytic theory and the clinical practice which can be derived from
it. Those presenting cases practice in a variety of settings, including
practitioners working analytically in child and adult psychiatry,
community health, drug rehabilitation services as well as in private
practice. The seminar consists of the presentation of a written case history
by the treating analyst, student or invited guest in a meeting lasting 90

1 Paper presented at a meeting devoted to the topic of the psychoanalytic case

presentation as it has developed within the Clinical Seminar of the Australian Centre for
Psychoanalysis. The meeting was held at the Royal Society of Victoria in October 2001
and was convened by the author at the request of members.
minutes. The presentations are followed by a collective discussion of the
case and the treatment. A slightly different format has been used when
members presented cases for discussion by an overseas guest. This was
largely the impetus for introducing the function of a designated discussant
in 1999. An analyst of the ACP who has completed their training takes the
role of discussant.
The seminar has been open to the participation of anyone with a
clinical background and an interest in psychoanalysis and it is often the
first point of contact with the ACP for those who develop such an interest.
The ACP has not adopted the practice of live interviews with patients,
known as ‘patient presentations’, preferring the discussion of analytic
treatments in so far as this can be sustained by the presenter and adopted
in the treatment by the analysand.2 Indeed this is one of the key questions
often discussed by members of the audience in the meetings.
While the format of this mode of case presentation is well
established, the practice does raise the question of the characteristic
features of a psychoanalytic presentation. In other words: what features of
a clinical presentation constitute a psychoanalytic case history? Are certain
modes of presentation incompatible with psychoanalytic discussion and
formulation or unable to represent psychoanalytic practice? Such
questions need an answer before one can assume that a forum, such as the
Clinical Seminar, functions not only as a means of presenting the
contemporary practice of psychoanalysis but also contributes to the
transmission of psychoanalysis per se.

The pre-history of the case history

2 Whilst different in their aims and modes of presentation, the patient presentation and
the case history presentation would not make these practices mutually exclusive in a
psychoanalytic institution. The Freudian School of Melbourne maintains a strong
tradition of patient presentations in several public adult psychiatry services and
participants have published accounts of this practice in the Papers of the Freudian School of
Melbourne.
 The presentation of cases as a written case history provides an
example of clinical practice, the collection of material which might
subsequently be used as an object of study and a useful exercise of
documenting and examining clinical work in the context of psychoanalytic
training.
The practice of writing up case histories has its origins in medicine
where the accumulation of cases in the medical literature provides
exemplars of the course of organic pathology and its amenability to
treatment. It is largely within this paradigm that the practice has been
adopted into psychiatry. Within medicine the presentation of cases is
intrinsic to training in the mode of observation of the signs and symptoms
of illness where the task is the detection of disorder or pathology.
One finds excellent discussions of this mode of seeing in Foucault
and Canguillem who draw attention to the fact that this mode of
presentation is based on a historically determined episteme which we are
still within. Emerging in the eighteenth century, the modern form of
medical knowledge was constituted on a transformation of language in
which the symptom, and the signs which announce it, are transparent
representations of the disease, no longer hiding the pathological essence of
an invisible disease. Hence the gaze isolates, differentiates and reduces the
complexity of symptoms in the case in order to bring what is unique into
the realm of the universal by means of classification into categories. The
medical case itself is only a vehicle for the “endless reproduction of the
pathological fact” and thus a case is only ever a member of series of cases
that display a common mode of suffering. Foucault thereby argues that
the medical clinic emerges in this period as a specific discursive structure
able to institute and control new fields of knowledge which in turn
constructs new subjects of that knowledge: the patient, the case history,
and the doctor.3
To place Freud in this context shows that psychoanalysis both
participates in this mode of knowledge but also exceeds it. As a
neurologist with a developing interest in ‘nervous disorders’, Freud’s
medical and scientific approach to the writing and publication of case
material was immediately challenged by his own discovery of
psychoanalysis. This applied to both the method through which he had
achieved his results and the nature of hysteria as a clinical entity. As Freud
launches into his discussion of Fräulein Elizabeth Von R. his acute
discomfort is apparent:

I have not always been a psychotherapist. Like other neuro-

pathologists, I was trained to apply local diagnoses and electro-
prognosis, and it still strikes me myself as strange that the case
histories I write should read like short stories and that, as one
might say, they lack the serious stamp of science. I must console
myself with the reflection that the nature of the subject is evidently
responsible for this, rather than any preference of my own. The fact
is that local diagnosis and electrical reactions lead nowhere in the
study of hysteria, whereas a detailed description of mental processes
such as we are accustomed to find in the works of imaginative
writers enables me, with the use of a few psychological formula, to
obtain at least some kind of insight into the course of that affection.
Case histories of this kind are intended to be judged like psychiatric
ones; they have however one advantage over the latter, namely an
intimate connection between the story of the patient’s sufferings
and the symptoms of his illness.4

3 Here I refer the reader to Michel Foucault, The Birth of the Clinic: an Archaeology of medical
perception (Vintage Books, New York, 1975) and Georges Canguilhem, The Normal and the
Pathological.(Zone Books, New York, 1991).
4 S. Freud. Studies on Hysteria, S.E., II, pp. 160-161.
Freud is thus somewhere between fact and fiction, no longer trying to
present clinical phenomena to be seen by the medical gaze, but telling a
story which is to be listened to. Indeed Freud is re-telling his version of a
story in a manner that exceeds a purely medical knowledge because the
re-telling implies his interpretation of the story and thus his subjectivity.
Despite this, the avowed aim of Freud and Breuer’s completed
Studies of Hysteria [1893-1895] was to use the presentation of case material
for the purpose of “illustrating” their developing theory expounded in On
the psychical mechanism of hysterical phenomena: Preliminary communication
[1893].5 In the completed book, the selection of cases from which the
theory had been in part derived now serves as the means of
demonstrating the new theory to others, that is, Freud’s intension is
demonstrative. Yet even within this simple strategy it is worth pausing for
a moment to consider the selection of the case of Fräulein Anna O. at the
head of these studies. Given the manner in which this particular case
unravels over the course of psychoanalytic history, it again suggests that
even this first published case of psychoanalysis shows that a case history
may contain a retroactive effect that unfolds over time and is something
quite unconscious to the writer.
Josef Breuer’s one and only case history of Anna O. predates the
others by around a decade and its status as a point of origin has become
that of a story to be told and retold. The retelling by Freud, and then his
biographer, Ernest Jones, finally adds the crucial missing components, the
spectacular erotic transference, the details of which are now well known,
in which the treatment was broken off and with it Breuer’s willingness to
participate any further in the birth of the troublesome child shortly to be
christened “Psychoanalysis”. This unspoken element of the case history
contained in its kernel something essential for psychoanalysis in the
experience of transference and the attempt of an analyst to give an account

5 S. Freud. On the psychical mechanism of hysterical phenomena: Preliminary communication.

S.E., II.
of it. The written case history transmits on several levels at once, the
scandal which could not be written at the time but was certainly told to
the young Freud by the elder and respected Viennese physician, Josef
Breuer. The retelling and thus repetition of this story in Freud’s writings,
and still today, is enough to indicate that it had left its mark.
What is important for an analyst is not a simple presentation of
clinical phenomena but an understanding that such phenomena emerge
clinically only under the conditions of a specific method, the Freudian
method. In his first published use of the term psychoanalysis Freud shows
that the new theory of pathology cannot be separated from the method
through which the symptoms of Hysteria could be unravelled. Freud
wrote in Heredity and the Aetiology of the Neuroses (1896):

As regards the second class of major neuroses, hysteria and

obsessional neurosis, the solution of the aetiological problem is of
surprising simplicity and uniformity. I owe my results to a new
method of psycho-analysis. Josef Breuer’s exploratory procedure; it
is a little intricate but it is irreplaceable, so fertile has it shown
itself to be in throwing light upon obscure paths of unconscious
ideation. By means of that procedure… hysterical symptoms are
traced back to their origin, which is always found in some event of
the subject’s sexual life appropriate for the production of a
distressing emotion. Travelling backwards into the patient’s past,
step by step, and always guided by the organic train of symptoms
and memories and thoughts aroused, I finally reached the starting
point of the pathological process; and I was obliged to see that at
bottom the same thing was present in all the cases submitted to
analysis - the action of an agent which must be accepted as the
specific cause of hysteria.6

In 1896 Freud names this specific cause as the actual experience of “sexual
abuse” occurring before the onset of puberty, in other words, the so-called

6 S. Freud. Heredity and the Aetiology of the Neuroses. S.E., II, pp. 151-152.
seduction theory. The Freudian method implies a new epistemology
which differs from that of medical science. The emergence of clinical
phenomena in psychoanalysis are contingent upon the procedure which
implies also the subjectivity of the practitioner, the subjectivity of the
analyst, the discovery of which prevented Breuer from continuing in the
psychoanalytic discovery. Thus, what is presented, made present, is not
actually a ‘case’ but the process which transpires between analyst and
analysand. As such, in the presentation of any case, both the analyst and
the analysand are on show. This may account for why the ACP’s Clinical
Seminar has also been the point where a certain amount of anxiety has
been focused.

The interplay of history and structure

We have a significant challenge in discussing the clinical practice of
psychoanalysis in so far as the unconscious, which is at its basis, cannot be
simply presented for observation. The unconscious can only be
determined structurally and this determination is made retrospectively,
using the Freudian notion of Nachträglichkeit, deferred action. As soon as
clinical work is reduced to a descriptive presentation a case is flattened
out and one loses the relationship between the temporal unfolding of the
case within the transference relationship.
This point was not lost on Lacan whose theories of the temporality
of transference can be used to develop it. It is with this in mind that Lacan
comments on Freud’s presentation of Dora in Intervention on Transference
that,

It is striking that heretofore no one has stressed that the case of

Dora is laid out by Freud in the form of a series of dialectical
reversals. This is not a mere contrivance for presenting material
whose emergence is left up to the patient, as Freud clearly states
here. What is involved is a scansion of structures in which truth is
transmuted for the subject, structures that affect not only her
 comprehension of things, but her very position as a subject, her
”objects” being a function of that position. This means that the
conception of the case history is identical to the progress of the
subject, that is, to the reality of the treatment.7

This is one of the few direct statements by Lacan concerning the

case history. It implies that the psychoanalytic presentation of a case
attempts to transmit the truth of the subject, but only as it emerges in the
dialectical unfolding of the treatment. Presenting the case in this manner
promotes the temporal unfolding of the case over the structural analysis of
its elements. However, each of these moments in the dialectic is selected as
key moments in which the structural elements of the case came to the fore.
This implies that the presenter is selecting or interpreting a dialectic on the
basis of a retrospective view of the structural features of the case.
It is clear that Lacan’s idea is that a case history is not the history of
the patient but the history of their psychoanalytic treatment. While the
structure of a case presentation is held in place by the theory of the
treatment, the presentation of theory is not the aim. What is presented
must remain as close as possible to the speech of the analysand, in the
order in which it unfolds and in the equivocal nature of its utterance. In
this sense a case history is the presentation of a history divulged in the
psychoanalytic treatment and also determined by the fact that it is
divulged in this context. The two are inseparable and thus any recourse to
the veracity of that story become problematic. One can never discern the
actual history outside of that method.
To use Lacan’s distinction, the material used in the history is the
saying [dire] of the analysand and the analyst, that is, a psychoanalytic
case history stresses speech as an act. To present what is said [dit], that is
the series of statements which are assumed to be asserting in the saying, or
worse, the facts supposed to be derived from these statements, is only a

7J. Lacan. Presentation on Transference. Ecrits, (Trans. Bruce Fink) Norton Press, New York,
2006. p. 178.
means of obscuring this saying.8 This same point is highly applicable to
the process of psychoanalytic supervision which becomes untenable if the
supervisee only presents their version of what is said rather than the
analysand’s saying.
One of the common ways in which a presentation to the Clinical
Seminar fails to be psychoanalytic is when it becomes impossible to
separate out the analysand’s discourse and its unfolding from other
discourses which tend to impinge and distort the analysand’s speech.
These are typically institutional or familial discourses. For example,
assuming a patient referred by a G.P for the treatment of their
“depression” is actually attending for that purpose, or that a child referred
by his or her parents is to be treated for the problems which afflict the
parents. An important structural feature of the case is always centred
around the demand for treatment which can be quite different from why
someone is sent to treatment by others. Some cases presented to the
Clinical Seminar show that, despite an amount of treatment from analyst,
and this may be in some cases, years of work, some patients never get to
the point of making a demand for psychoanalysis.
Another frequent failure of the case presentation is the imposition
of analytic theory directly into the analysand’s discourse. This may well
represent a manner in which the presenter tries to manage their own
anxiety by trying to resolve the meaning of the case before it is even
presented. In this sense, so-called ‘theory’ is just another dissimulating
discourse which masks the analysand’s words, the transference and the
unconscious at play.

Diagnosis, formulation and discussion

In the presentation of clinical cases in the ACP it has become habitual to
leave over extensive discussion and formulation of a case to the case

8In L’ètourdit, Lacan proposes this formulation of the analytic discourse: ‘Qu’on dise reste
oublié derrière ce qui se dit dans ce qui s’entend’.cf. Scilicet, 4. Seuil, Paris, 1974. p. 5.
discussant and the general audience discussion which follows the
presentation of the clinical material. Some presenters choose to raise a
series of questions or make some preliminary remarks on the diagnosis or
distinctive aspects of the case at the end of their presentations. However,
the primary focus of the presenter is to make available the case material in
as close a fashion to the original as possible, to attempt to capture the key
moments in the history of the treatment which would include the
modification brought about through the analysand’s entry into the
transference. From this perspective it is then possible for the presenter to
show how the case has or has not responded to the analyst’s interventions,
what strategy they have employed and some of the tactical manoeuvres
which they have employed.9 The speech of the analysand and its
construction of a history, however discontinuous this may be, are the
primary elements of the case history.
The use of diagnoses and the terms through which cases are
formulated shows the differences between psychoanalytic schools, as it
does the distinction between psychoanalysis and psychiatry or clinical
psychology. In the first place, the use of diagnostic categories is not
universal in psychoanalysis and this stems from the differing views
regarding the continuity of clinical phenomena. Freud organised his
clinical work around discrete pathological entities and re-worked clinical
entities into a number of classifications such as transference neuroses or
narcissistic neuroses, diagnostic terms which only make sense within the
analytic framework. He invented new categories such as obsessional
neurosis and reserved the term psychosis for a discrete and definable
series of mental states. His work was also responsible for the introduction
of the analysis of character formations now taken up, via the elaborations
of Wilhelm Reich, as the dimension of ‘personality’. Freud’s views on

9See here Lacan’s notions of the politics, strategy and tactics of analytic treatment as
discussed in: The direction of the treatment and the principles of its power. Ecrits, (Trans.
Bruce Fink) Norton Press, New York, 2006.
psychopathology have influenced contemporary psychiatry in a manner
which is often unacknowledged nowadays.
On the other hand, Melanie Klein and those who have developed
her theory have introduced the notion of a universal psychotic core based
in psychotic anxieties derived from the paranoid-schizoid position, an
organisation to which, in principle, any individual might regress in the
course of analysis. This corresponds with Klein’s emphasis on the early
Oedipal and then the pre-Oedipal periods which are seen as somehow
prior to the Oedipal organisation. Thus the distinctive interplay in
neurosis between the castration complex and its fate in the Oedipal
complex is subsumed into the organisation of fantasy and modes of
anxiety in terms of the depressive and paranoid-schizoid positions which
are seen as more fundamental in the psyche. Within the Kleinian
paradigm a specifically psychoanalytic diagnosis gives way to a continuity
between pathological organisations.
Jacques Lacan took the Freudian view together with the influence
of early Twentieth Century French and German psychiatric classifications
to re-establish the centrality of diagnosis in psychoanalytic clinical work.
For Lacan the classificatory works of Kraepelin and Clérambault are of
particular importance for their careful analyses of clinical presentations
and their differentiation of these entities. Theoretically, Lacan’s work
elaborates a relationship between a clinical structure and the mechanism
of defence through which it is generated. The absolute distinction between
the clinical structures of psychosis, neurosis and perversion, the
mechanisms which generate them, foreclosure, disavowal and repression
respectively, is a consequence of a fundamentally structuralist view of
psychopathology to be distinguished from the phenomenological methods
dominant in Psychiatry.10 The specific aims and techniques appropriate to

10A comprehensive discussion of the phenomenological method of Psychiatry can be

found in Andrew Sims, Symptoms of the mind: an introduction to descriptive psychopathology:
Third edition, (Saunders (W.B.) Co Ltd, London, 2002). Further elaboration on the use of
the treatment of each of the Lacanian diagnostic decisions becomes as
indispensable as it is orienting. The importance of the differential
diagnosis between psychosis and neurosis in case presentation is
discussed by Jacques-Alain Miller:

By using this very simple grid [of neurosis, psychosis and

perversion], you understand why Lacan stresses that psychosis, if
you understand it as the dominance of the imaginary relationship,
is not dialectical because the dialectical concerns the symbolic axis.
Psychosis has a specific inertia when compared with the dialectical
potential of neurosis. Don’t think that when we say “dialectical”
we are merely talking philosophy; you can truly see what dialectical
means in case presentations. In psychosis we find no true speech,
that is, no creative speech which implies a dialectic. That is why
foreclosure may be distinguished from repression: foreclosure is a
non-dialectical mode of negation. “I don’t want it; well perhaps I
want it if it is given to me; but if it is given to me, why is it being
given to me - perhaps I have to refuse it.” There we see dialectical
negation: you take into account what the other may think and what
you think. In case presentations, you can detect non-dialectical
elements where there is no give and take. The very fixity you will
find in psychosis is a clinical criterion: the non-dialectical fixity of
particular elements.11

A clinical seminar, set up in the manner of the ACP seminar is an

ideal testing ground of the validity and pragmatic value of these different
approaches to psychoanalytic diagnostics. Case material, so long as it is
properly obtained using the psychoanalytic method and presented in a

phenomenology in psychiatry can be obatined from Karl Jasper’s seminal papers. General
Psychopathology, Volumes 1 & 2, The John Hopkins University Press, Baltimore, 1997.
11Jacques-Alain Miller, ‘An introduction to Lacan’s Clinical perspectives’, In, Reading Seminar
I and II, eds. Richard Feldstein, Maire Jaanus, and Bruce Fink. State University of New
York Press, Albany, 1996.
manner which respects that process, provides the empirical content upon
which psychoanalytic theoretical differences can be debated and hopefully
resolved.
In principle, the Lacanian case history ought not to be so different
from any other psychoanalytic case presentation, especially in terms of its
format. However, one would expect that its discussion would be clearly
distinct. While the presentation privileges the diachronic over the
synchronic, the discussion of cases typically attempts to reverse this. The
discussion attempts to draw together the key structural features of the
case and thereby to engage with the clinical question which the
presentation evokes, either explicitly or implicitly. This might be a
question regarding the differential diagnosis in the case, it may be a
question about the possibilities of the entry into the transference, it may be
a question of differentiation within one of the major diagnostic categories
or the extent to which the analysand presents a symptom to be analysed.
Designating a specific discussant to initiate and orient the clinical
discussion has been a useful addition to the format. The discussant is there
not only to comment on the case, but in a sense not unlike Freud’s
relationship to Breuer’s presentation of Anna O, to listen to what may not
be said in the presentation, to what might remain unconscious for the
presenter and to use all of this to try to think through a logic of the
treatment in a coherent and concise manner. The discussant thereby
represents the possibility of a new dialectic unfolding with regards to the
case, one which takes the subjective position of the presenter into account.
In this sense the successful discussion might be seen as functioning for the
presenter like a successful interpretation for the analysand; that is it
presents an opportunity to think of where one did not think to think.

Address for Correspondence:

Andrew Lewis
School of Behaviour and Social Sciences
University of Ballarat
 Mt Helen, 3350
Victoria, Australia

Email: a.lewis@ballarat.edu.au

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