THE CASE HISTORY

Michels and his commentators has been heard in the past, but psycho-
analysis has never responded in a systematic way. Michels and the
discussants have done us a great service in alerting us once again to
the need for a more careful consideration of how we obtain and present
our data. Let us hope they will not simply be prophets crying in the
wilderness, and that the f ield will at long last pay attention to the issues
they raise.

111 North 49th Street

Philadelphia, PA 19139
Fax: 215–472–7718
E-mail: Spulver@bellatlantic.net

Stephen B. Bernstein
We have not yet developed a generally accepted and convincing
method of writing about our clinical work that would allow us to reveal
it to colleagues or show others the unique and powerful treatment that 381
is psychoanalysis. We have not often found an effective method of
translation from the familiar, private oral mode in which the analysis
takes place into the more public written mode while yet retaining the
“music” of the analytic interaction. Robert Michels addresses some of
these diff iculties in his comprehensive “history of the case history.” He
reviews and examines the historical, political, and dynamic forces that
have shaped and impeded the development of the analytic case report.
Michels’s central thesis concerns what he calls “intention” in case
histories. That is, he believes that case reports are written in a certain
context, for a particular purpose, and that this purpose is revealed in the
text either explicitly or implicitly. Michels would like writers to
become aware of these intentions and to share them more openly with
readers, because he believes that such candor will shed light on the ana-
lyst and on the analytic process.
In an effort to frame his thesis—that we can read to greater
advantage by observing the context or the analyst’s intention in writing
a case history—Michels contrasts two views of how clinical material
should be reported. He cites the recommendation of the Committee on
Certif ication that the report should be “a narrative of what happened
in the analysis, how you helped this happen, and how you under-
stand how this occurred,” and that this can be done with “short quotes,

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paraphrases, and vignettes” (Bernstein l995, p. 7). He contrasts this with

the reporting method recommended by the Committee on Scientif ic
Activities, a method that uses short verbatim specimens and was
developed “especially for the investigation of analyst-analysand inter-
actions, which require attention to minute details,” with specif ic anno-
tations in order to collect archival samples (Klumpner and Frank l991,
p. 545). Spence (1993), a member of that committee, envisioned “that
vigorously contested specimens might acquire a family of commen-
taries over time . . .” and that “a review of these reactions would help to
deepen our understanding of the original incident” (p. 45).
Both methods were initial attempts to depict elements of clinical
data, but for very different purposes—one for the representation of
clinical process for professional progression and certif ication, the other
for the collection of empirical data for research. Although their inten-
tions are different, the recommendations have certain similarities. Both
provide an explicit outline of elements that might be included in
a report, present a structured and predictable form of description,
and encourage an account of the analyst’s experience and ref lections.
382
Eventually the methods may inform each other, as clinicians feel more
comfortable revealing what has occurred and as researchers f ind ways
of gathering in the “music” of the analysis.
My own perspective arises from my work on the use of clinical
writing in analytic training and in certif ication. My interest has been to
help writers reveal the analytic process and the analyst’s participation
in it by providing a guide (Bernstein l995) and, more recently, a format
for clinical writing. Without such help, writers often inadvertently hide
the analysis and the analyst behind extensive historical accounts; non-
ref lective verbatim process notes; theory-driven descriptions; uninte-
grated compilations of interim reports written during analytic training;
or lifeless summaries often narrated in the passive voice. It is in my
search for the “hidden analyst” and the “hidden process” that my work
(Bernstein 1998) intersects with that of Michels. We are both interested
in what is hidden in written case reports. My intent is to give writers a
way to discover and uncover the process as they organize their material
to write about it. Michels implies that the act of writing, by its very
nature, involves contexts and intentions that are often hidden to the
writer as much as to the reader.
Michels mentions several ways to read and understand case reports.
One way is to look at the parallel between the story of the analysis and

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 THE CASE HISTORY

the analyst’s style in conducting the analysis. Another way is to see

the reader’s experience of the analyst as parallel to that of the patient.
But Michels’s central focus is on the analyst’s awareness of, and
comfort in, describing his or her “inevitable extraanalytic interest in
reporting and, for that matter in conducting the analysis”; how this is
integrated into the analysis; and how the analyst feels about disclosing
his or her motivation for writing the report. Michels neglects, however,
another def ining way of looking at case reports. Readers may draw a
parallel between the way they are helped in the reading experience and
how they might be helped in the analytic experience with the analyst,
since both the clinical work and the written account demonstrate
choice, tact, empathy, timing, and a sensitivity toward patient or reader.
The reader of a confusing, poorly presented case report may feel
annoyed and thwarted in attempting to follow the clinical work. The
affect mobilized and the effort needed to “f ind the analysis” in the
writing can interfere with the reader’s understanding of the process.
Michels describes our hesitancy, until recently, to acknowledge
the analyst’s intention to inf luence both the patient in the analysis and
383
the reader of the case report. He implies that we have a residual dis-
comfort with this awareness. He mentions a great many factors that
encourage the analyst to shape the material being written about. One of
these is the monumental impact of Freud’s original case reports, with
all their def iciencies. Another factor is that analysts have had little
preparation for clinical writing but instead have presented oral reports
in seminars and supervision. Candidates often have fears about expo-
sure, as well as a desire to look good. Michels says that when writing
begins for graduation or certif ication, there is a struggle to tell an engag-
ing and dramatic story in order to be thought well of, and that the result-
ing narrative may omit the natural uncertainty and ambiguity that can
be part of the analytic process and can illuminate it. I do not believe
that the act of writing must necessarily hide or falsify the experience.
A clearly written case report can retain the uncertainties, mysteries, and
surprises inherent in the analytic process, and these can be ref lected
on by the writer and discovered by the reader. But if the text sounds
confusing, a reader cannot be sure whether the confusion is the result
of the writing or of the process. At the same time, I doubt that Michels’s
supervisee who had diff iculty organizing her notes, and who confused
sequences and events in her oral presentation, would really have been
able to successfully “sterilize” her material in a written case report. If

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the text sounds like a polished and beautiful story, it usually doesn’t
sound like an analysis.
Michels sees the case report as a self-portrait, a window on the
analyst’s soul. He reads with an eye to observing the analyst’s stated or
latent intentions, which “may become even more important than the
story itself.” I agree that any piece of writing is necessarily a portrait
of the writer, at least indirectly, in that we see what the writer has
selected to focus on and how the writer represents this. But using the
reader’s assessment of the writer’s intention as the basis for evaluating
an analyst’s work to me seems perilous. To evaluate analytic work from
this perspective is especially problematic (and potentially unfair) when
the context is analytic training, progression, or certif ication. The levels
of motivation and defense in a case report are extremely layered
and complex. We cannot conf irm our conclusions the way we do in
a clinical situation, particularly because we may not be aware of our
countertransference to the written material. Thus, our conclusions
about a writer’s intentions will necessarily be indirect, speculative, and
unreliable, and using these conclusions to evaluate competence or
384
readiness for professional progression may increase the writer’s sus-
picion, fear, and sense of intimidation. Such concerns have prevented
many analysts from writing about their clinical work.
A more fruitful approach would be to study, and establish a
consensus, about what elements or conventions are necessary in order
to write about and evaluate our clinical work, perhaps including
issues about which the analyst may be unaware, such as those raised
by Michels. It might prove illuminating to examine the way the analyst
selects elements of analytic process in constructing a report and how
he or she interprets or translates these to the patient and the reader. These
are central and mature skills in the analyst as both practitioner and writer.
In both roles the analyst introduces, selects, ref lects on, and integrates
in-the-moment and longitudinal perspectives; facilitates the regulation
of affect through verbal interchange; and metes out and reviews the
process in comprehensible parcels. In all of this, the analyst structures,
guides, and gives meaning, whether to the analysis or to the text.
A consensus has not yet evolved regarding the elements necessary
in reporting clinical work, nor have we developed teachable conven-
tions and criteria about the writing and evaluation of clinical reports.
Only through a consistent approach to writing, reading, and evaluating
such reports can these texts and our methods of understanding them do

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 THE CASE HISTORY

justice to the clinical interaction. A different problem arises when case

reports are used to fulf ill requirements for higher levels of professional
and political activity in psychoanalytic organizations. Because there
is no consensus on standards for writing case reports, they have become
lightning rods for various scientif ic and political disagreements and
dissatisfactions regarding participation in analytic organizations, local
autonomy, national organizational oversight, and faculty or training
analyst appointments. To some it appears that power and position are
attained as a result of a “test” for which they feel unprepared. I would
like to describe a format for case reports that can help writers reveal
the analytic interaction, including the analyst’s participation and under-
standing, as well as the patient’s experience.
The format. The format has a three-part structure that is repeated
throughout the presentation of the clinical material. In the f irst part, the
experiencing section, the reader is involved in the analysis through
experience-near (microprocess) descriptions of well-chosen segments
of the analytic work or interaction that cover a relatively circumscribed
period and that illustrate one or more central themes. These descrip-
385
tions can be enlivened by including short quotes or paraphrases within
narrative sentences. Each microprocess description can often be set
forth in three or four paragraphs.
In the second part, the reflecting section, the writer steps back from
immersion in the analytic microprocess and ref lects (for a paragraph or
so) on the longitudinal meaning (the macroprocess) of the preceding
descriptions. In this section the writer may in part be formulating
about the process between patient and analyst. This adds the analyst’s
internal experience to the usual formulation of the patient’s psycho-
dynamics. Thus, the writer shows how the analytic interaction may
ref lect the past, now increasingly experienced with the analyst, and how
the analyst understands and works with this. A ref lecting section might
begin with a statement such as “I understood the preceding to mean . . . ,”
or “Over the last two months I sensed a change in . . . ,” or “I saw this
sequence as a result of. . . .” The separation of the experiencing section
from the ref lecting section parallels the important separation of the
“experiencing ego” and “the observing ego,” as discussed by Kanzer
and Blum (1967) in their elaboration of Sterba’s work (1934).
In the third part the reader is transported to the next set of experi-
encing and ref lecting sections by a transitional narrative section that
serves as a bridge to a time later on in the analysis. Here changes in the

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process or in the patient’s life situation that have occurred in the

interim can be summarized and their possible relation to the ongoing
process discussed. The repeated experiencing, ref lecting, and transi-
tional narrative sections are a basic format for the presentation of
clinical process in an analytic case report. The writer oscillates between
showing the reader what patient and analyst have experienced,
describing the analyst’s understanding of this material, and carrying
the description on to the next area of focus.
Use of the format. I will illustrate the proposed format with clinical
material drawn from the beginning phase of the analysis of a middle-
aged man.
Experiencing section. Mr. A had impressed me early in our work.
This middle-aged businessman had come to treatment with a sense of
emptiness, saying to me quite f irmly, “I want to feel before I die.”
Now, during an early morning hour in the spring, he said, “You
planted grass seed in the lawn, I see. It needs dampness to germinate.”
Yesterday in a restaurant he had ordered sparkling water, and a sweet
elderly waitress had said, “Sparkling water just like you.” He liked
386
this: “It was nothing sexual, but I was noticed and when you are
sixty-two and bald it’s nice to be noticed.” He spoke of closing his
eyes “to rest in a comfortable limousine to the airport.” His sense of
comfort and refuge with me in the hour told me he did not need me
to speak yet.
Then he spoke of his wife, and of a bookkeeper who didn’t listen
to him, and of how he had felt insulted and hurt. I asked myself why he
had changed from enjoyment in feeling “sparkling” to this sense of
insult, and I said, “It’s diff icult not feeling listened to.” He said, “It
hurts me and I push it down, but I can’t keep it down when I get here,
it just comes out.” I said, “It’s nice to be recognized as ‘sparkling’ and
to feel you have found a place here to rest and put down some roots
like the grass, but just below the surface there are wishes and doubts
germinating. And there are the questions about yourself and your sense
of insult and hurt.” He ended the hour by saying, “Yeah, I think some
of my feelings are like a little ant crawling out of a crack in the
ground.” As he left, he looked back and said, with both humor and
a knowing smile, “Are you going to water the lawn today? Want
me to do it?” Here was his question of whether his feelings would be
nurtured in the analysis or whether he would have to do this on his
own, as he had always done.

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 THE CASE HISTORY

In the next hour he described an angry interaction with his wife. He

ended the description by a wave of his hand and the command “Next
subject.” When I asked him about this, he said, “I feel like a prize-
f ighter dancing around the ring. It’s diff icult to stay engaged and not
cover up and withdraw.” I thought of his immobilized invalid father,
from whom he had unsuccessfully sought approval, but who was the
unmourned critical presence he often struggled with and was now
dancing to avoid. I spoke about his cutting off feelings of hurt and
insult by saying “Next subject.” To this he responded, “I can feel the
anger with my wife and in business, but I can’t feel the love.” As he
spoke, he sighed and rubbed his eyes. He said, “I haven’t said or felt
much today. It’s like a wasted hour.” I asked if there was something he
felt with me today that made him feel more distanced and so judging of
himself, especially since he had experienced some intense feelings.
He said, “No, I just felt so tight and controlled.”
Perhaps it was my asking about his experience of me in the hour,
or my aff irmation of his feelings, or my acknowledgment of his self-
judgment, but his next association was “I had a wet dream last night. It
387
was a surprise and I don’t remember a dream, but I felt good knowing
everything was working.” He had spoken earlier in the hour of feeling
wasted, and I wondered to myself if he had felt the wet dream too had
been wasteful. I was aware here of his recent associations to decreased
control of his feelings and thought this might relate to the nocturnal
emission. I mentioned his having spoken about his wasted marriage,
and the wasted hour, and said I wondered if he might feel that the wet
dream too was wasteful. “Sometimes,” he responded, “I feel my whole
life is wasteful.” The hour ended on this seemingly defensive diluting
of his feelings. I noted to myself my desire to reassure both of us that
the hour had not been wasteful, and this led me to wonder about the
impact of his feelings on me. I think we were both responding to his
underlying mourning for the years of wasted opportunity. However, I
felt that at this time he needed me to hear and share in the intensity of
his feelings and to share in tolerating them, and reassurance from me
might have prevented this.
Ref lecting section. I understood the process in these hours as related
to the patient’s greater comfort, despite his newly mobilized feelings
in the beginning of analysis. He seemed preoccupied with yearnings for
a sense of rootedness and acceptance from me and with fears that the
deepening of his experience would loosen his control over his sexual

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and aggressive fantasies. I felt that his reassurance to me that the

waitress’s statement was “nothing sexual” defended against a narcis-
sistic wish for me to appreciate him as “sparkling,” as well as his fear
of revealing his sexual yearnings. His need for me in the transference
made him feel like a vulnerable ant. He seemed to worry that if I did
not nurture his germinating loving feelings he would become angry
and withdrawn, and that this would lead to further wasted opportunities.
The greater closeness and safety the patient was experiencing with me
seemed rewarding and comfortable to him, like the ride in the limousine
and the sleepiness he often mentioned feeling as he sat in the waiting
room. But he feared that his loss of control over his fantasies might lead
to dangerous action and the rupture of our important relationship. He
wanted to avoid his shame and my repugnance vis-à-vis his inner life.
I wondered and did not yet know how the wet dream was related to
the increased pressure of the deepening analytic process.
It was clear that the patient wanted to be acknowledged, and feared
the rejection and abandonment of not “being heard.” We were then
beginning to analyze his withdrawal and the cutting of f of feelings
388
by his “Next subject” response. I also foresaw his need to engage his
unconscious feelings and fantasies of disapproval by his father as an
unmourned and judging presence. I wondered if my bringing up the
theme of wastefulness in his associations and in relation to the wet
dream was necessary or might have evoked some shame at this early
stage of the analysis. Had I to do it over again, I would mention the
theme of wastefulness but leave any connection with the dream up to him.
Transitional narrative statement. Over the next several months
Mr. A continued to feel comfortable in the deepening process, exhibiting
a comfort and ease that I too experienced. I saw this in his associations
to greater ease in his professional work and a markedly greater close-
ness to his three sons. He had not seemed to appreciate their achieve-
ments before, but now there seemed to be a dawning realization of their
successes and greater expression of care and closeness toward them. In
addition, he spoke of having more discussions with his wife. After one
analytic hour he found himself crying in his car on the trip home. On
his arrival he sat and cried with his wife and described his sadness to
her. He began to have fantasies about his deceased parents walking
toward him on a beach, and although there were not yet any associated
feelings, we both sensed that the fantasies would evolve and develop
in some way.

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 THE CASE HISTORY

Discussion of experiencing section. In this sample of an experi-

encing section, the writer has invited the reader to gradually become
immersed in the analysis. We see the progression of the theme of comfort
and germination defended against by isolation of affect and withdrawal.
This is described over a relatively short period, and the reader is drawn
into the process by short quotes in the ongoing narrative. We see how the
analyst has discovered various themes, in part as a result of his inner
experience, and we sense how the analyst decides when and how to
intervene and when to stay silent. The writer is personal and direct with
the reader and uses the active voice to tell us how he hears and what
he chooses to say to the patient. The writer tells us of his experience of
the patient, he is moved by the patient’s statement that he wants to feel
before he dies, we hear his understanding of the metaphor in the
patient’s associations, and we observe the humor and acceptance of
the patient’s questions about watering the lawn. The writer shows us the
patient’s awareness of his increasing feelings and his withdrawal from
them, and he shows how he analyzes the “Next subject” withdrawal from
feelings. Then, after tracing the allusions to loss of control, the writer
389
mentions the wet dream, its relation to the theme of wasting, and
its place in the deepening analysis. Finally, the patient’s response to
a preliminary interpretation is mentioned. The writer ends the section
with the allusion to a countertransference response in his desire to
reassure the patient and himself that the hour has not been wasted.
Discussion of reflecting section. In this ref lecting section the writer
uses a conversational and collegial tone as he steps back from describ-
ing the process to tell the reader how he understands the interaction
between patient and analyst. When the writer chooses to formulate, he
is formulating about the interaction, not just about the patient. He
acknowledges he is a participant in the process, rather than merely an
observer of the patient’s dynamics. We are told how he heard the mate-
rial, how his associations or ideas led to a specif ic understanding, and
how and why he chose to intervene or remain silent. He mentions the
effect of his countertransference and other experience on his under-
standing and technical choices. He questions his interpretation about
the theme of wastefulness and says that on ref lection he might have
done otherwise. Thus, the analyst as writer may choose to reanalyze
some of the work in order to show a change of perspective or theoreti-
cal stance, or a more subtle understanding. In addition, the analyst may
reveal his or her thinking about the nature of the transference. The

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analyst may describe changes seen as occurring in the analysis, and

how they are viewed as promoted by the analyst’s participation.
Discussion of transitional narrative section. The writer has carried
forward and linked the experiencing and ref lecting sections to the next
section of the analytic microprocess. We learn about the patient’s
greater comfort in the analysis, more direct awareness of his feelings in
the transference, and his concern about his decreased sense of control.
There are changes in his relationships and feelings toward his wife and
children, and direct expressions of sadness. The writer presents an
overview of what he believes is evidence for a deepening of the ana-
lytic process, even as we sense that we are about to read about a con-
tinuation of the process at some later time in the analysis.
Concluding comments. Analytic training may eventually occur
within a “writing environment.” In such an environment the interpre-
tive translation from oral to written would be gradually introduced by
increasing tasks throughout training: in seminars, workshops, and writ-
ing tutorials, and as part of supervision. These tasks might begin while
the analyst is still in analysis. A format such as I have described is a
390
starting point and can be elaborated, changed, or discarded as the ana-
lyst’s comfort and creativity in the writing task evolves. Such a format
might provide a predictable structure for the analytic reader, a retro-
spective guide for the analytic writer, and a way for the analyst to
examine and clarify the issues of intention noted by Michels.

REFERENCES
BERNSTEIN, S.B. (1995). Guidelines: Comments on treatment report writing
and describing analytic process. In The American Psychoanalytic
Association Committee on Certification of the Board on Professional
Standards: Standards, Procedures and Guidelines. New York: American
Psychoanalytic Association (internal publication), pp. 7–12. Also in
Journal of Clinical Psychoanalysis 1:469–478, 1992.
——— (1998). Writing about the psychoanalytic process. Presented at the
Annual Meeting of the American Psychoanalytic Association, December
16–20, 1998, New York.
K ANZER , M., & B LUM , H.P. (1967). Classical psychoanalysis since 1939.
In Psychoanalytic Techniques: A Handbook for the Practicing
Psychoanalyst, ed. B.B. Wolman. New York: Basic Books, pp. 93–144.
KLUMPNER, G.H., & FRANK, A. (1991). On methods of reporting clinical ma-
terial. Journal of the American Psychoanalytic Association 39:537–551.
S PENCE , D.P. (1993). Traditional case studies and prescriptions for

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improving them. In Psychodynamic Treatment Research, ed. N.E.

Miller, L. Luborsky, J.P. Barber, & J.P. Docherty. New York: Basic
Books, pp. 37–52.
STERBA , R.F. (1934).The fate of the ego in psychoanalytic therapy. International
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146 Wallis Road

Chestnut Hill, MA 02467
Fax: 617–327–8385
E-mail: Sbb@massmed.org

Philip Rubovits-Seitz
This discussion presents arguments for two proposed improve-
ments in psychoanalytic case reports—namely, more frequent reports
of the whole analysis, and greater emphasis on the presentation of clini-
cal evidence. These two suggested improvements are related, because
an important source of clinical evidence—the justif ication of interpre-
tations—draws on the data of the whole analysis.
391
Early in his essay, Michels notes that our clinical literature consists
largely of vignettes rather than full-length accounts of the therapeutic
process, and he asks why this is so. In one of his writings, Freud
(1918) asserted that reporting a complete history is both “technically
impractical” and “socially impermissible,” and would in any event be
“unconvincing” (p. 8). Elsewhere, however (Freud 1905), he concluded
that an “intelligent, consistent and unbroken case history” is possible
only at the end of a treatment; that completed cases offer the advantage
of hindsight; and that def initive interpretation of any fragment must
await completion of the whole analysis (p. 18)—in short, “the whole
analysis is needed to explain it” (Freud 1911, p. 93; see also Schafer
1986, p. 156; Goldberg 1997, p. 437). Thus, the preparation of a case
report is best postponed until the analysis is over.
In his report of the Wolf Man, Freud (1918) referred to still another
advantage of waiting until the end of an analysis before writing a report
of the case. He indicated that all of the information that made it pos-
sible to understand the patient’s neurosis “was derived from the last
period of the work, during which resistance temporarily disappeared
and the patient gave an impression of lucidity which is usually attain-
able only in hypnosis” (p.11; for similar views on the clarif ication
of pathodynamics during later stages of analysis, see French 1958,

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