THE CASE HISTORY

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
Journal of Psycho-Analysis 15:117–126.

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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,
 Commentaries

pp. 403–404; Waelder 1962, p. 263; Mahony and Singh 1979, p. 442;
Leavy 1980, p. 75; Rubovits-Seitz 1992, 1998).
The proposal of more frequent case reports dealing with whole
analyses does not imply the elimination of clinical vignettes. The latter
serve an important function in case reports by illustrating relevant
themes in the therapeutic process; and vignettes are consonant with the
way an analysis actually proceeds—that is, by relatively discrete
dynamic episodes that coalesce only gradually, over months or years,
into larger conf igurations.
In his assertion that def initive interpretation of any fragment must
await completion of the whole analysis, Freud (1911, p. 93) hinted
at an additional advantage of studying and reporting the entire thera-
peutic process—namely, the availability of more extensive clinical
evidence. Freud’s use of the word definitive in this context implies
issues of completeness and accuracy, the latter being one of the most
neglected aspects of our science. Klumpner’s review (1989) of sixty
frequently cited papers in the psychoanalytic literature revealed, for
example, that none of these publications offered direct evidence for the
392
claims being made.
For psychoanalysis to make scientif ic claims, some model of justi-
fying interpretations is essential. As Sherwood (1969) observed, “The
essence of science is not so much the existence of a body of facts as the
existence of a method, a procedure by which ‘facts’ can be systemati-
cally ascertained and progressively revised” (p. 260). The accuracy of
interpretations depends on the power of evidence, which consists of
empirical data and logical arguments that support or disconf irm a con-
clusion. Being f irst-level inferences, the lowest level of theoretical
statements in psychoanalysis, interpretations are the only propositions
that can be tested by direct empirical evidence—that is, the data of
the case being studied. Higher-level clinical theories are tested in
other ways.
Interpretive justif ication during the actual treatment of patients is
limited, however; it consists mainly of attempting to determine the
most plausible among alternative constructions at a given time. To that
end the therapist checks how much of the data a construction can
account for; modif ies the construction so that it accounts for more of
the data; and rechecks the revised construction to determine whether
it now covers all (or at least most) of the data. The principal selection
criterion during this preliminary and partial phase of justif ication is
 THE CASE HISTORY

internal evidence—that is, determining which of the alternative

hypotheses accounts most consistently, coherently, and comprehensively
for the most data.
Coherence has been one of the most widely used justifying
methods in psychoanalysis, but its effectiveness has been questioned
for two reasons. First, the inherent circularity of the interpretive
process produces an illusion of coherence (Hirsch 1967); second, the
criterion of coherence has been applied unsystematically and almost
exclusively to macroscopic aspects of clinical data rather than system-
atically to small-scale elements. The latter, more detailed approach
is necessary for more def initive justif ication. Carried to extreme, a
“coherence bias” produces an interpretive tour de force—an over-
extended, weakly coherent hypothesis that strains to account for all
of the data, but in the end ignores details that do not f it (Spence 1982,
pp. 23–26).
Most contemporary psychoanalysts have adopted also Freud’s
emphasis on patients’ responses to interpretations, and consider this
criterion the principal method of justifying them (Michels 1994,
393
p. 1136). Wisdom (1967) pointed out, however, that “the response has
itself to be interpreted before we can consider whether it conf irms or
refutes the interpretation being tested. And this may look like some sort
of circular process, because it would hardly seem reasonable to test
an interpretation by another one whose truth is just as much open to
question” (p. 46). For this and other reasons, some investigators
(e.g., Schmidl 1955) have rejected the use of patients’ responses to
interpretations as a justifying criterion. Others argue against the cri-
terion of “benef icial effects” (from interpretations) on the grounds that
therapeutic improvement can result from inexact interpretations, or
from no interpretations at all.
For all of these reasons, the justif ication of interpretations during
the actual treatment of patients is relatively limited. More def initive
justif ication of clinical interpretations requires additional, postthera-
peutic investigation based on a record of the entire therapeutic process,
which the therapist or clinical investigator can study retrospectively in
as much detail as necessary. The latter process can employ multiple,
increasingly exacting justifying procedures, including microanalytic
methods of studying the data.
Accurate case reports of complete analyses cannot rely solely on
memory, but must utilize good clinical records. Michels notes in his
 Commentaries

essay that “tape recordings and verbatim transcripts are the current
state of the art in providing the highest quality data” (p. 16), but he
adds that there are other approaches. Shakow (1960) maintained, for
example, that signif icant progress in psychoanalysis “will come from
the ability to conceptualize data, rather than from elegant collection
of data” (p. 96). And Freud, contrary to widespread belief, did not
categorically interdict process notes; he recommended only that thera-
pists not attempt to take full notes such as a shorthand record. He saw
no objection to brief notes “in the case of dates, the text of dreams,
or particularly noteworthy events” (Freud 1912, p. 113; see also 1909,
p. 159).
Wolfson and Sampson (1976) have demonstrated that process notes
compare favorably with verbatim transcripts as representative samples
of the total clinical data, and Spence (1979, p. 494) believes that process
notes are actually better than verbatim recordings because the former
contain references to the therapist’s inner responses and interpretive
reasoning (see also Argelander 1984). I employ a two-step procedure
for making process notes. During therapy sessions I jot down very brief
394
notes that provide a record of the sequence, as well as the gist of the
patient’s associations. Immediately following each session, or as soon
as possible, I use these brief notes to dictate additional details of what
transpired during the session (see also Spence 1982, pp. 218–232).
Despite the diff iculties of making and maintaining clinical records,
their value therapeutically, scientif ically, and pedagogically seems
evident. Greenacre (1975, pp. 711–712) reported that going back and
reading her notes helped her recognize connections she had not seen
originally, and Fisher and Greenberg (1977) point out that for psycho-
analysis to be accessible to scientif ic scrutiny, “All that is necessary is
that there be clear and repeatable bookeeping about what is being
observed (p. 9). I would add that clinical records are necessary also for
the important but neglected process of justifying interpretations, which
increases the scientif ic, pedagogical, and therapeutic value of our
case reports.
Freud and other psychoanalysts have proposed over a dozen dif-
ferent methods of justifying interpretations, the more probative of
which draw on data of the whole analysis. These methods include,
in order of their relative probity, (1) pluralistic methodologies (combi-
nations of the following methods); (2) cross-validation of independent
data samples from the same analysis; (3) convergence of evidence from
 THE CASE HISTORY

different justifying methods; (4) organized interlocking microstructures

underlying interpretations; (5) “indirect” postdiction (postdicting classes
of antecedent events); (6) “indirect” prediction (predicting classes of
future events); (7) repetition of themes and patterns; (8) coherence
(internal consistency) and comprehensiveness; (9) the patient’s
responses to an interpretation; (10) quantitative methods; (11) external
evidence (e.g., old diaries, hospital records, home movies); (12) justif i-
cation by observation; (13) justif ication by implication; and (14) ruling
out the improbable. For detailed descriptions of these justifying meth-
ods, and clinical illustrations of their inclusion in a case report, see
Rubovits-Seitz (1998, pp. 211–282).

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 Commentaries

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