THE CASE HISTORY

WIDLÖCHER, D., (1994). A case is not a fact. International Journal of Psycho-

Analysis 75:1233–1244.

Psychoanalysis Unit
Sub-Department of Clinical Psychology
University College London
Gower Street
LONDON WC1 6BT
Fax +44 20 7916 8502
Email: D.Tuckett@ucl.ac.uk

Arnold Wilson
In this discussion I will elaborate three general points: (1) psycho-
analytic writing on the case study, to its detriment, has heretofore over-
looked the stream of thought called pragmatism; (2) the case history is
the vehicle par excellence for approaching and solving problems inher-
ent in clinical work, and this is true for psychoanalysis as well as other
411
applied disciplines, such as law (see Bramley 1986); (3) this plenary
address by Michels is virtually a manifesto of pragmatism, though
it does not identify itself as such.
Psychoanalysts have productively tackled the implications of several
prevailing trends in current thought, such as postmodernism, the lin-
guistic turn in the social sciences, and the rise of cognitive neuro-
science. It is puzzling why the remarkable revival of pragmatism has
escaped our notice, since this movement has become something of
a cause célèbre. There is at least one proposal on the table suggesting
that contemporary pragmatism can be an integrative alternative to two
rather loud voices raised in the ongoing culture wars. The proposal,
brief ly stated, is that we combine the epistemological insights and
value awareness of certain threads of postmodernism with the method-
ological and conceptual achievements of the positivist paradigm
(Fishman 1999). The turn to pragmatism may also help untangle a
tension in certain psychoanalytic writings on the case study prior to
Michels’s paper. Those writings, by no accident, stem from these same
seemingly diametrical poles. On the one hand, Edelson’s bid (1988)
to f ind in the “fairly” written case study the possibility of classical
Popperian hypothesis testing never found great currency in the analytic
world of ideas, in part because it sought an epistemology that swept

Downloaded from apa.sagepub.com at PENNSYLVANIA STATE UNIV on March 16, 2015

 Commentaries

aside the clinical concerns native to the case study as a vehicle (the
pragmatist has as much interest in other forms of truth claim). On the
other hand, Spence’s ideas (1982) about the case study, as inevitably
yielding narratively constructed clinical data, likewise did not have the
impact they deserved because they, too, seemed to put analysts at a dis-
tance from their practical responsibilities, which are preemptive in a
pragmatic inquiry. The two poles have more in common, however, than
at f irst meets the eye. Both are inquiries into psychoanalytic “truth” and
recruit the case study to their way of thinking about things and posi-
tioning psychoanalysis with respect to science. Edelson and Spence
are both loyal to a particular tradition in the pursuit of psychoanalytic
truth and are, to their credit, grounded in the consistency of those tra-
ditions. What Michels helps us accomplish is to move beyond group-
ing according to truth claims, but because this is done in the absence
of a consistent philosophical posture his investigation runs the risk of
becoming a series of unconnected but canny observations.
Contemporary pragmatists are as concerned with right and wrong
(in the broadest sense) as they are with truth and falsity (see Bernstein
412
1992). To be sure, right and wrong were much clearer to our analytic
predecessors than they are to us. Extending pragmatism to psycho-
analysis allows us to envision a somewhat new (to analysts at least)
angle on the moral claims pervading psychoanalysis. Fashionable pur-
suits like “eclecticism” or “pluralism” in this sense have stark limita-
tions, because they contain no plausible comparative means or set of
standards to identify what is right and what is wrong in the current
psychoanalytic world. Pluralism, today’s saving grace, can easily
evolve into tomorrow’s nightmare, unless some guiding principles chart
an ever evolving integrative course.
The contemporary pragmatist would locate the potential for this
through the case study—Fishman (1999) makes this the central
argument of his book— and would look to account for prevailing ideas,
emphasizing our embeddedness in an interpretive community that
understands far more about language and reality, about authorial
intention and textuality, about the strengths and limitations of each and
every method we apply to our data, than did the founders of our
psychoanalytic schools. In other words, the work of Spence, Edelson,
and others need not be put aside but rather factored into a larger mix.
Pragmatism has a way of altering the landscape it addresses, so that
questions once hotly contested suddenly make no sense, and previously

Downloaded from apa.sagepub.com at PENNSYLVANIA STATE UNIV on March 16, 2015

 THE CASE HISTORY

submerged questions swim into visibility and become worthy of

inquiry. Pragmatism is represented by quite diverse thinkers and posi-
tions, but they have certain threads in common. One I will emphasize
in this discussion is that pragmatism does not set as its priority the
search to uncover a truth hidden in things, lurking and waiting to be dis-
covered, obscured only by our inadequate methods. Pragmatism sub-
verts the appearance/reality distinction (Rorty 1998) by deemphasizing
“correspondence” as the ultimate arbiter of what is true. Nor does it
substitute the claim of “coherence” as an alternative, thereby elevating
narrativity to a position of preeminence. Rather, pragmatism is the
voice of utility; truth is not dispensed with, but neither is it seen in
the abstract as more compelling a goal of scholarship than is anato-
mizing what usefully gets a particular job done, and for whose benef it.
To def ine truth, one must f irst be clear about the nature of the job,
rather than force-feed methods into areas of inquiry more properly
designed to accomplish other, unrelated jobs. The pragmatist does not
defer to claims of certainty or uncertainty, though it has been argued
(Putnam 1998) that pragmatism is more compatible with a philosophy
413
of realism than with any antirealism.
Michels notes that the case study is Janus-faced, having the
potential both to enlighten and to deceive. In consequence, it cannot
be approached naively. In many guises, the concern with deception
has historically bullied science, and has often been at the heart of
a skeptical doubt that squeezes out consideration of the value of an
idea. The potential to deceive can be a factor, a pragmatist would
argue, but not one that should veto realizing an idea’s usefulness. We
can better learn from our mistakes if we concern ourselves with what
the case study does, to whom and for whom, as well as whether it is
true. In the tradition of Freud’s careful consideration of his results, as
in the Dora case, the case study can be most useful if it takes up what
goes wrong as well as what goes right an analysis.
Medicine suggests a pragmatics that psychoanalysis can identify
with, since it draws no hard-and-fast boundary lines between truth and
the exigencies of treatment. There are those who believe that psycho-
analysis should be scrutinized as a treatment, yet recognize that the
translation—from what actually takes place to its operational measure-
ment—is not yet (and may never be) clearly visible on the horizon. For
them, pragmatism may spark some new ways of thinking about matters
psychoanalytic. Pragmatism in psychoanalysis would insist that it no

Downloaded from apa.sagepub.com at PENNSYLVANIA STATE UNIV on March 16, 2015

 Commentaries

longer really matters whether a theoretical contribution is couched in

empirical, experimental, descriptive, or narrative terms; all are
acceptable in the psychoanalytic house of science. In this sense, prag-
matism welcomes a hard-and-fast split between Reichenbach’s venera-
ble warhorse, the contexts of discovery and justif ication (1938). Thus,
pragmatism leads to the recognition that becoming more “scientif ic” is
not necessarily a sign of progress, or even a good idea. It can also be
a sign of progress, however, if it solves previously vexing problems.
Michels teases out what it is about our trove of knowledge that is
distinctively psychoanalytic, and how our institutional life digests and
uses this knowledge to govern itself and perpetuate the profession.
“Accounts of theories and clinical cases,” he says, “should form the
core of our scientif ic literature and the heart of our professional
discourse. However, the proportions are strikingly unbalanced.” Note
the lack of concern, in this essentially pragmatic statement, with
abstract struggles over truth claims. He describes how Freud introduced
the “dialogue that continues today between psychoanalysis as science
and psychoanalysis as art; between cause and meaning, objective and
414
subjective, explanation and understanding.” Note too that this roster of
voices does not include all the speakers wanting to be heard, for the
pragmatist’s voice is missing.
A pragmatist might add to Michels’s concern with the nature of
a case history the point that case reports, rather than busying them-
selves ref inding what is already known, should have a tropism toward
originality. Approaching old problems in new ways trumps approach-
ing new problems in old ways. Finding one’s own voice is an all-
important product of a progressive democratic spirit that is pervasive,
and such values should be more routinely represented in psychoanalytic
institutes. Each case history should be an exercise of the imagination,
not a rehash of someone else’s imagination. The pragmatist is more
concerned with difference than with similarity, and so one must focus
on how to sympathize with individuals, or aspects of an individual,
remarkably different from ourselves or those around us we know well.
None of this is mere f lag-waving; these principles are bound up with the
history of pragmatism (see West 1989).
Each case report should clearly articulate the problems being
addressed and the solutions being tried. If this is done openly and hon-
estly, many solutions will reveal themselves as bids to solve the wrong
problems. The candidate who writes a case report in order to solve the

Downloaded from apa.sagepub.com at PENNSYLVANIA STATE UNIV on March 16, 2015

 THE CASE HISTORY

problem of graduation has more in common with the graduate writing

to solve the problem of certif ication than with the analyst—at any stage
of professional development—writing in order to solve the problem of
how a patient can be better understood. Solutions should be outcomes
of the problems that require them. Michels’s paper repeatedly exposes
how institutional psychoanalysis can specialize in missed opportuni-
ties, made manifest by its doggedly solving the wrong problems, an
inevitable occurrence when psychoanalysis—as an institution—forces
the real problems underground. Michels describes this phenomenon
all too painfully. The pragmatist not only approaches problems imagi-
natively, diagnosing derailments in the pursuit of their solution, but
also intervenes in order to see the problem through to its solution. Thus,
how the understanding gleaned from a case study translates into action
is a proper focus of investigation. Michels asks why we have paid so
little attention to this, and attributes at least part of the responsibility to
organizational mischief in our institutes. He makes it clear, though, that
this is a symptom of a more general problem and that addressing it at
the local level treats the effect but not the cause.
415
What else prevents the case study from realizing its usefulness?
One reason not mentioned by Michels is the often thoughtless and
insensitive reception case studies are given in a variety of venues
(certif ication, case conferences, etc.). Psychoanalysis has not formally
worked out a means of distinguishing the constructive criticism of inad-
equate clinical work from the destructive criticism case presentations
tend to attract. Presenters inevitably feel vulnerable, and our psycho-
analytic culture will do well to learn how to receive case histories gra-
ciously, so as to encourage their use. Stanley Coen writes in this issue
of the usefulness of treating case reports as if the characters were f ig-
ures in a literary f iction; this, he argues, leads to a method that avoids
punishing authors for what their case reports are not. Since case reports
can be construed in a virtually inf inite variety of ways, responding
punitively or scornfully should be recognized as a rather cheap and
disturbingly showy victory. An analogy might help; think of an oncol-
ogist presenting f indings at tumor rounds. These case histories are
straightforwardly yoked to treatment planning around perplexing and
life-threatening clinical problems, and the hope is that students, col-
leagues, and patient will all benef it from the discussion. Participants
will brainstorm about etiology and the range of possible treatments. No
one is interested in going home and starting a whisper campaign that

Downloaded from apa.sagepub.com at PENNSYLVANIA STATE UNIV on March 16, 2015

 Commentaries

the presenter is inept and is the source of the problem. Whether the
presenter is inept or not it is hardly the point of the exercise, and
this case study method enjoys currency on oncology units at teaching
hospitals.
Michels explores how psychoanalysis has been looking in the
wrong places to wring out the value of case studies, which tell more
about the analyst than about the patient. Indeed, in our times there
can be no compelling examination of transference without a simulta-
neous examination of countertransference. But we can go further.
A friend once remarked that he f inds himself suspicious of much
applied analysis because he thinks the only valid subject for psycho-
analytic inquiry is someone who can talk back. Similarly, studying the
analyst might be seen as providing him or her an opportunity to
“talk back” rather than be “exposed.” This suggests that the distinction
Michels draws between oral and written case histories is useful not
because of what is told about the analyst as narrator, but because it
clarif ies how under different conditions an appreciative dialogue can
be promoted, with all the benef its that ensue. Dialogue—not mono-
416
logue—is the operative phrase here.
In conclusion, I have touched on a line of thinking that endorses
Michels’s proposals for placing the case study at center stage, its
rightful position in psychoanalysis. There is a sea change afoot, and
we clearly are more invested today in f irst grasping the signif icance of,
and only then distinguishing and moving between, theory-driven data
and data-driven theory. I have suggested a way to achieve a consistency
of thought that can weave together what might appear to be unrelated
observations about the case history. In this way, analysts can rally
behind expanding the scope of the case history, yielding data every bit
as distinctive as, and equivalent to, how some physicists understand
quantum particles, others “strings,” in order to grapple with the universe
they seek to understand. Psychoanalytic ideologies today are in general
certainly not obsolete, but they are regulated by trade rules set by con-
temporary procedures of discourse. Friedman (1997) exults in a new
intellectual vibrancy in psychoanalysis—in its journals and at its
meetings—and Michels’s paper is an important contribution to a trend
that is becoming inexorable. Psychoanalysis is in transit, examining
itself while in metamorphosis, drawing new lines in the sand that them-
selves, inevitably, will soon shift.

Downloaded from apa.sagepub.com at PENNSYLVANIA STATE UNIV on March 16, 2015

 THE CASE HISTORY

REFERENCES

BERNSTEIN, R. (1992). The resurgence of pragmatism. Social Research

59:813–840.
BROMLEY, D. (1986). The Case-Study Method in Psychology and Related
Disciplines. New York: Wiley.
EDELSON, M. (1988). Psychoanalysis: A Theory in Crisis. Chicago: University
of Chicago Press.
FISHMAN, D. (1999). The Case for a Pragmatic Psychology. New York: New
York University Press.
FRIEDMAN, L. (1997). Ferrum, ignis, and medicina: Return to the crucible.
Journal of the American Psychoanalytic Association 45:21–35.
PUTNAM, H. (1998). Pragmatism and realism. In The Revival of Pragmatism,
ed. M. Dickstein. Durham: Duke University Press, pp. 37–53.
REICHENBACH, H. (1938). Experience and Prediction. Chicago: University
of Chicago Press.
RORTY, R. (1998).Truth and Progress. Cambridge: Cambridge University Press.
SPENCE, D. (1982). Narrative Truth and Historical Truth. New York: Norton.
WEST, C. (1989). The American Evasion of Philosophy: A Genealogy of
Pragmatism. Madison: University of Wisconsin Press.
417
300 Mercer Street, #20C
New York, NY 10003
Fax: 973–746–7986
E-mail: Drarnoldwilson@cs.com

Response by Robert Michels

It is a double privilege to be invited f irst to present a plenary
address and then to respond to f ive distinguished and thoughtful dis-
cussants. They each agree that the topic is important, and in general
they agree with my thoughts about it, though with several important
elaborations, explanations, and amendments. My response will be
highly selective and will focus on their additions and some possible
points of difference among us.
Imre Szecsödy and David Tuckett write from the greatest geo-
graphic distance and emphasize the broadest context of my remarks.
Szecsödy speaks of the purpose of case reports as “opening windows
on the analytic process” and quotes with approval the IPA committee
that warned that “unless we make some wise decisions, psycho-
analysis will be dead—at least as a therapeutic approach.” He shares

Downloaded from apa.sagepub.com at PENNSYLVANIA STATE UNIV on March 16, 2015