THE CASE HISTORY

Imre Szecsödy
It is both an honor and a challenge to respond to Robert Michels’s
comprehensive and interesting paper. “Psychoanalysis,” he begins, “is
based on theories and on clinical data, the events that transpire between
patients and analysts in the consultation room.” He then points to the
scarcity of extensive case reports, noting that “the clinical data in our
literature are more and more likely to consist of vignettes or snapshots,
rather than full-length accounts.” Michels emphasizes the importance of
comprehending “the psychoanalytic process as a whole, the story of the
unfolding of the patient-analyst relationship and its inf luence on every-
thing that transpires in the analysis.” He organizes his discussion around
f ive perspectives: (1) the nature and (2) the purpose of case reports,
(3) oral vs. written reports, (4) the relation between case reports and
analyses, and (5) how the case report offers a special vista on the analysis
itself, “revealing the analyst’s awareness and comfort vis-à-vis his or
her intentions” and conveying “more than the analyst knows,” as it
is “at least in part a countertransference theme or enactment.” It is easy
to follow his text, as he makes his point clearly. His conclusion is: “I f ind 397
it far more enlightening to have analysts tell as best they can why they
want to tell us anything at all, and then to weave an account of those
intentions into their account of an analysis. The most meticulous repro-
ductions of the most detailed data, dissociated from the context of why
it was selected, for what audience, and for what purpose, is like an
isolated electron microscope image separated from identif ication of the
tissue, the organ, the species, or the stain—a demonstration of method
isolated from scientif ic relevance.” This is what I wish to focus on, the
aspect of the purpose of case reports. I will emphasize the necessity of
opening windows on the analytic process.
Understanding, sharing of experience, introspection, and empathy
are prerequisites for psychoanalytic treatment, but objectifying
methods of some sort are indispensable correctives (Thomä and
Kächele 1975). Analysts have an emotional need to do their work in a
way that conforms with their personality, and each creates in the con-
sulting room a uniquely individual atmosphere. The analyst constructs a
patient’s psychic reality within the framework of the psychoanalytic
theory he or she prefers. Sydney Pulver (1987), in a fascinating dis-
cussion of clinical data presented by Martin Silverman, makes this very
point: “An analyst’s theoretical orientation has a marked impact on the
way he thinks about patients and the way he works with them” (p. 289).

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 Commentaries

To this I would add that all the discussants of Silverman’s presentation

seemed interested mainly in putting forward their own ideas. Hardly any
of them tried to understand why Silverman thought and worked as he
did. Pulver raises a “striking question: how can clinicians who think and
behave so differently get equally good analytic results?” (p. 289). Are
the differences more apparent than real? Are different analysts’ per-
sonal biases suff icient to signif icantly distort whatever is studied? Are
differences dramatized? Do specif ic factors work in psychoanalysis,
or is it the nonspecif ic factor common to all psychodynamic therapies
that counts? Is it that patients, “once they get used to the therapist’s work,
in fact do feel understood” and that “all analysts are working out the
same unconscious affects and fantasies in the transference, even when
they approach them on different levels”? (p. 298). In the same dis-
cussion, Evelyne Albrecht Schwaber (1987) points out that “the position
of the discussants cannot convince, because they argue for alternative
models without simultaneous inquiry into a way of explicating the
impact their model may have on the patient’s experience” (p. 275). We
could conclude that psychoanalysts have not one but several models of
398
the mind, and these inf luence the way we gather data about clinical
work and convey it to others in order to learn, to teach, to do research,
or to obtain certif ication, or for other purposes, rhetorical, political,
or social. As Schwaber (1996) emphasizes, “the analyst’s view of a
patient’s behavior is not a fact about the patient’s experience; as long
as this distinction is not made explicit, hypothesis and fact are blurred”
(p. 246). So does Steven Cooper (1996) warn that “facts all come with
a point of view.” They are f ictions, he notes, “with a transient credibility
and a passing utility” (p. 259); “our facts or formulations are a f iction,
inasmuch as our stance or interpretation is a conscious attempt to create
meaning” (p. 260).
In my view, the aim of psychoanalysis is to facilitate change,
growth, and emancipation for the troubled individual. The task is to
establish a specif ic relationship within a specif ic frame, in which
insight into consciously and unconsciously enacted experiences, expec-
tations, wishes, and fears becomes available to the patient. Central to
this work is the consistent application of the so-called mobile aspect
of the frame—the continuous, ref lective review of our work, together
with the patient, using the implicit rules and basic assumptions of
psychoanalysis, including unconscious motives, transference, counter-
transference, and the historical and narrative meaning of symptoms. The

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 THE CASE HISTORY

frame also makes it possibile for the analyst “to become attuned to the
patient’s affective state, to provide f irm enough boundaries to contain
healthy protest, and to be tuned into countertransference so that neither
aimlessness nor controllingness prevails” (Holmes 1998, p. 237). Within
the frame both the analysand’s and the analyst’s “implicit relational
knowing” (Stern et al. 1998) can be recognized and altered. The overall
aims of analysis are to set in motion the unfolding of a developmental
process and to construct a new way of experiencing oneself with
another. According to Holmes and Stern, this is not so very different
from classical psychoanalysis. What is new is the context in which
analysis is practiced, the introduction of ideas from developmental
and psychotherapy outcome research, and the possibility of integrating
analytic techniques with techniques from other therapeutic modalities.
To study the psychoanalytic process it is necessary to follow change
processes over time, and to gain repeated information about how these
changes develop during treatment. These processes include change in
the way the analysand perceives self and other (mentalizing function or
ref lective functioning; see Fonagy 1995), change in the dynamic of
399
interaction, and change in the quality of the relationship. Research
has just began to focus on the process of change in psychoanalysis (see,
e.g., Bachrach 1995; Bucci 1985; Dahl 1997; Teller and Dahl 1995;
Emde 1991; Fonagy 1995; Gill and Hoffman 1982; Horowitz 1993;
Kächele and Thomä 1995; Kantrowitz 1995; Kernberg 1995; Luborsky
and Luborsky 1995; Thomä and Kächele 1975; Wallerstein 1986;
Weiss et al. 1986). Unfortunately, systematic empirical research at
times encounters resistance within the psychoanalytic community.
For instance, at the fall meeting of the American Psychoanalytic
Association in 1974 it was strongly recommended that a more scholarly
atmosphere be fostered in the institutes and societies, an atmosphere in
which members, faculty, and candidates can work together in under-
standing, challenging, and extending psychoanalytic method and theory.
Great stress was laid on creating a climate in which self-study and active
learning are the responsibility of the student. Closer collaboration with
universities was advocated, and research education (perhaps even par-
ticipation in a research project) was proposed as an integral part of
training beginning early in the curriculum. Despite these recommenda-
tions, there were in 1998 only four institutes at which research was
included in the training curriculum (Schachter and Luborsky 1998).
Although a great number of psychoanalytic treatments have been

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recorded in the past thirty years, there is still rather strong resistance
among analysts to taping their sessions. It is argued that analyst and
analysand, when they are taped, are no longer engaged in psycho-
analysis, or that studying a transcript conveys nothing of what really
occurs between and within the participants. Gill et al. (1970) quote
Glover to the effect that the tape recording of analytic sessions would
destroy the most essential spontaneous aspects of the analyst’s response.
“He did not, however,” they note, “write from personal experience with
tape recorders, and our experience leads us to doubt that he was right”
(p. 95). Gill et al. (1968) sought to determine whether the recorded
therapy possesses the essential ingredients of an analysis and to study
the inf luence of recording on the two participants. “Our experience,”
they concluded, “leads us to believe that the diff iculties of a recorded
research analysis have been overblown and are not of a different order
than the problems of an ordinary analysis. As with so many other things,
once we become convinced that the endeavor is worthwhile and bring
ourselves to face and deal with specif ic problems, they are not nearly
the bugaboos that they had seemed to be when they were in the realm of
400
the unseeable and the unspeakable” (p. 243). Another obstacle to
studying the psychoanalytic process is the idea that the presence of a
“third” will compromise conf identiality. I agree with Gill that “conf i-
dentiality is meaningful only in terms of what it means to the two par-
ticipants. The working alliance is ultimately based upon trust, and trust
is ultimately based—assuming the patient is not one who is incapable
of trust—upon the analyst’s demonstration to the patient in the course
of their work together that he is in fact trustworthy. Trust is neither guar-
anteed by the formal criterion of conf identiality, nor destroyed by its
absence, any more than an analytic situation is guaranteed by the formal
criteria of f requency of interviews, recumbent posture, etc., nor
destroyed by their absence” (p. 238).
As the report of the House of Delegates committee on the crisis of
psychoanalysis emphasized (IPA Newsletter 6:2, 1997), “we are in a
crucial time in the history of psychoanalysis (called a turning point by
some and crisis by many) and that unless we make some wise decisions,
psychoanalysis will be dead—at least as a therapeutic approach—
though it may survive in other f ields such as literature and art.” As we
know, society—which puts abundant emphasis on economic growth and
productivity, on instant relief of suf fering—is downsizing its
investment in the humanities and in research that does not promise

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 THE CASE HISTORY

immediate solutions to problems. This decreased level of support will

certainly affect for the worse those looking for psychoanalytic treat-
ment or training. I do not doubt that psychoanalysis is eff icacious, the
treatment of choice for an important group of patients, but it is diff icult
to prove this. As Arnold Cooper (1995) notes, “Our capacity to select
cases for analysis is poor, half of them never experience an analytic
process; they show improvement but it cannot be demonstrated that
this is the result of specif ic components, there are examples that show
that the reverse is true. We would like to assure all parties that, based
on clear evidence, we can predict the therapeutic outcome with reason-
able certainty” (p. 385). The most important f inding of three studies
(Bachrach 1995; Kantrowitz 1995; Wallerstein 1995) is that neither
experienced clinicians nor sophisticated psychological testing can
predict outcome based on the study of the patient alone.
We have to deal with the relative lack of well-documented research
proving the value and eff iciency of psychoanalytic treatment. We have
to be able to “sell” our knowledge, our experience, and the results of
our studies to third-party payers, our nonanalytic colleagues, and the
401
general public, and this requires that we present our work in a manner
that renders it comprehensible and useful. We have to be able to show
that analysis is in the long run a worthwhile investment in time and
money. We need to deepen our dialogue with other disciplines (neuro-
science, the social sciences, and the humanities), as well as to reach out
to the community. We need to study how psychoanalysis works, and to
determine what kinds of interventions produce what kinds of change
under what kinds of circumstances. We have to foster in our institutes
and societies that more scholarly atmosphere urged upon us in 1974.
This is how I understand Michels’s emphasis that “we should disap-
prove of analysts who have no analytic interests other than the analysis
of their analysands. They are practitioners, but not professionals, since
they fail to contribute to their colleagues or to future patients.”

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Karlavägen 27
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Fax:+46–8–662–1161
E-mail: Imre.szecsody@mip.ki.se

David Tuckett
Robert Michels’s skillful and incisive discussion of the history
of the psychoanalytic case history exposes, in the manner in which
we are accustomed to expect f rom him, the still chaotic state of our
intentions when seeking to draw conclusions f rom what we tell each
other we do.

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