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PULVER, S.E. (1987). How theory shapes technique: Perspectives on a clinical

study. Psychoanalytic Inquiry 7:141–299.
S CHACHTER , J., & LUBORSKY, L. (1998). Who is af raid of psychoanalytic
research? Analysts’ attitudes toward reading clinical versus empirical
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SCHWABER, E.A. (1987). Models of the mind and data-gathering in clinical
work. Psychoanalytic Inquiry 7: 261–275.
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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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 Commentaries

Michels’s review is exemplary and complements an earlier effort

by Widlöcher (1994), alongside which I found it interesting to read—
partly as an interesting comparison of French and American views of
the issues. Widlöcher, interestingly, as he occupied Charcot’s position
at the Salpêtriére, focuses less on the issue of how far clinical
reporting can “prove” anything and more on the issue of how clini-
cians can learn from experience. The difference in emphasis is rel-
evant to Widlöcher’s academic post. It has been argued that it was
upon Freud’s visit to Charcot at the Salpêtriére that he learned to value
and interpret clinical data in a way rather at odds with the approach
in the German-speaking, physiologically based medicine of the day
(Schwartz 1999, p. 38). As Freud (1893) reported, Charcot said, “La
theorie c’est bon, mais ça n’empeche pas d’exister. [Theory is good,
but it doesn’t prevent the existence of other things]” (p. 13). The
tension between the diff iculty of using “mere” clinical experience to
advance knowledge and the necessity of doing so seems to me to live
on and to be beautifully caught in Michels’s address, as it is in current
uncertainties about how psychoanalysts should establish conf idence
404
in their ideas. However, my main aim in this commentary is to take
up four of the main points Michels has raised and to consider them a
bit further.
Science. The f irst issue is the question of how we regard clinical
data. Michels demonstrates the severe diff iculty in drawing any secure
conclusions from the clinical material we have accumulated so far in
our discipline. He raises the question of what can constitute “scientif ic”
data and how the various “selections” typically involved in forms of
psychoanalytic clinical presentations can meet “scientif ic” criteria.
Avoiding scorn, Michels demonstrates in detail the limitations of
efforts to date and the failures to move forward over the past one
hundred years. I agree fully.
In any consideration of these matters I think we risk drifting
between the Scylla of naivete and the Charybdis of nihilism. At this
stage of the history and philosophy of science it is surely well estab-
lished that neither “truth” nor “facts” exist outside a dialogic consider-
ation of peers as to their validity. But this is not the same as saying that
every view is as valid as any other. Truth and fact are both established
via debate.
A f irst consideration for debate within such dialogue will be to
determine the observational stance from which claims to truth or fact

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 THE CASE HISTORY

emanate. Michels demonstrates how all observation f lows from an

intentional stance—that is from conscious and unconscious intentions.
Intentions provide the context for the inevitable temporal and spatial
selection we make whenever we try to say anything about anything.
Here he gets to the heart of the matter. Additionally, I would stress that
to say that all observation is biased is of little interest, except when
debating with the naive. Far more signif icant for determining validity is
an estimate of the direction in which any bias will tilt an argument. A
recent Internet debate stimulated by an editorial in the International
Journal of Psycho-Analysis by Spence (1999) revolved around the
effect of intentions in reporting clinical material. The debate took place
in terms of biases introduced by accounts produced for the purpose
of publishing psychoanalytic conclusions based on clinical data and
for that of achieving certif ication by the American Psychoanalytic
Association.1
Spoken and written reports. A second issue raised by Michels is the
distinction between spoken and written clinical reports. I am sure he is
right to stress the difference, and I think the problem so introduced into
405
any consideration of the validity of our clinical literature is signif icant.
However, given my own preoccupation with facilitating the develop-
ment of our discipline through the written word, I think it may be pos-
sible to dissect the problem a bit more exactly in order to establish
where the diff iculty actually lies. Understanding the diff iculty may
enable us to address it.
For me the issue Michels is raising is the need to specify the level
of the data being communicated and to give it more thorough and care-
ful consideration than has been usual. The spoken word and the written
word convey meaning in somewhat different ways. The former conveys
symbolic meaning within a directly inf luenced context of affective
and interactional channels of which we are largely unconscious (see

1
The following statement was recently posted to the members list of the American
Psychoanalytic Association on the Internet: “In fact, what Spence (1999) is suggest-
ing is that the case reports are the result of “conscious and preconscious narrative
smoothing” (emphasis added). To be blunt, I think he’s saying that the case material
on which the reports are based serves as a sort of raw material, or modeling clay, from
which are sculpted fictional (Spence’s word) accounts of cases—accounts that follow
the course of an idealized analysis— a course that applicants evidently think the com-
mittee wants to see. If this is really so, then what the certification process is really
evaluating is an applicant’s ability to perceive what an idealized case would sound
like and then to create a report reflecting that understanding—in other words, to “play
the game” (Mosher 1998).

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 Commentaries

Canestri 1994; Tuckett 1983). If true, this proposition must apply

both to the patient’s communications to the analyst and to the analyst’s
remarks to the patient. When the analyst presents an account of part of
a session, these different levels of communication are conveyed to the
audience unconsciously. I suggest that the combination of presentation
and discussion can, if the specif ic positions of presenter and audience
are properly accounted for, produce a particular quality of validation
(Tuckett 1993, 1994).
All of this raises the fundamental question of what the data really
are in clinical psychoanalysis. Here I think we cannot avoid the propo-
sition that the observing instrument is the analyst’s subjectivity and that
the context for this subjectivity is the specif ic setting of the f ifty-
minute session. This view has led me to argue (Tuckett 1994) that
“within the focus provided by the background orientation to any ana-
lyst’s observing and listening, . . . if psychoanalysis is being under-
taken, the occurrences noted by the analyst in the session, provided
they are apprehended within the framework of free-f loating attention
and free association, are what is to be regarded as the psychoanalytic
406
data” (pp. 1160–1161; emphasis added). I still take that view and in this
sense I believe now “that if there is a reasonably detailed clinical
account intended to describe what has actually gone on in the session,
then that account is usefully considered as providing the clinical facts.
The account will include information about what the analyst has
noticed and also, through hints that other analysts will quite probably
notice, can even provide signif icant information about what was
noticed unconsciously but not immediately apprehended, or even
what was completely ignored . . .” (p. 1161).
In the last paragraph I have used the term free-floating attention to
mean not the “clearing of the mind” of thoughts or memories, but rather
the capacity to allow all sorts of thoughts, daydreams, and associations
to enter the analyst’s consciousness. They are registered there while
he or she is at the same time listening to and observing the patient (see
Sandler 1976, p. 44).
I reiterate this stance about the subjectivity of data because I think
we could become terribly confused were we to think we could solve
the problem of clinical data by some kind of pseudo-objectivity. The
core issue here is addressed neither by the laying down of rules exhaus-
tively prescribing analytic activity, thereby discounting the analyst’s
subjectivity, nor by audio or video recordings of sessions (or, in

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 THE CASE HISTORY

the future, recordings of measurable brain events). I am not opposed

to recordings. It may well be interesting to use them to see what is
noted and what is not and to explore what the analyst has to say about
that. But the essence of psychoanalysis is that the analyst, as a receptive
human being making sense within a communicative f ield, uncon-
sciously (as well as consciously) picks up the data within a framework
of meanings. A subjective report rather than an “objective” transcript
is therefore indispensable as the basic data.
If something along these lines is accepted, we can lay down some
guidelines to take account of intentionality directly and to permit more
evidentially based written argument within our f ield than has hitherto
been possible. The analyst’s account must include as background what
he or she considers necessary to explicate the subjective occurrences
to be reported. The account must also include information about how
the analyst felt and how at the moment he or she understood both the
patient’s words and his or her own responses. The account must include
what the analyst thought he or she was saying to the patient when
making an intervention, some idea of how the patient responded, and
407
what the analyst made of it. In writing up such an account, the goal is
to convey some of what is often present in spoken accounts, and we
must rely on the author’s integrity to give us the facts as he or she expe-
rienced them.2 There might be a case for journal editors and other pub-
lishers to insist that something of this kind is the minimum starting
point for authors, though in keeping with my dialogic view of how to
establish truth with conf idence, I would always allow an explicit argu-
ment for doing something different.
Obtrusive effects. In his thorough review Michels considers the
obtrusive effects on their potential truth claims of analysts’ intentions
in reporting and the possible influence of these intentions on the data. I
agree this is an issue, about which it is legitimate to speculate regarding
the validity (for a given purpose) of the clinical data presented. Indeed,
I believe it merits further thought than Michels has given it. To start
with, I think we should separate frank (and dishonest) distortion from
unintentional systematic bias. The former, a problem in all disciplines,
2
This admittedly is an Achilles heel, but bear in mind that even so-called hard sci-
ences have had some instances of fraud and that these have not been widespread
(indeed, they could not have been, as the very concept of fraud requires the assump-
tion that most people are honest). As protection we have our collective sense of con-
viction and the expectation, as in other fields, that worthwhile and useful ideas will
prove useful and be reported by others.

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 Commentaries

is not easy to address, except by insisting on many more than one well-
described account before feeling at all conf ident about any proposi-
tion. Beyond that, I think the fear that taking notes after a session
will distort it—or indeed that any record of it will—in fact indicates
something more fundamentally wrong in our discipline.
As I have argued, the fact of bias is of little signif icance per se.
What matters is the systematic direction of any distorting effect and its
consequence for a specif ic truth claim. The role of obtrusive effects is,
I suggest, overstated when discussed in the abstract (i.e., outside the
context of a specif ic proposition we are seeking to validate). In my
view, it is because as a discipline we have such low standards of record-
ing and reporting that we suspect their effects. Recall how often col-
leagues who present detailed data in public are called “brave”—for
simply revealing what they do several hours a day, every day, in
exchange for fees. If an analyst’s practice ethic included a strong nor-
mative requirement for regular and systematic recording (through notes
taken after each session), I wonder if the obtrusive effect of recording
would be so great (see Tuckett et al. 1985, pp. 30–31). Recording and
408
reporting, when infrequent, may well maximize obtrusive effects.
A second check on the validity of any truth claim can come from
“seeing what happens next.” We have often been remiss in our disci-
pline (and as editors, authors, and commentators) in allowing col-
leagues to build theories based on snapshots of clinical material
without our routinely demanding to know what happened in the end.
I well remember the total amazement I once occasioned a senior col-
league when I passed on the information that the referees reviewing a
paper this colleague had submitted did not think that the material pre-
sented supported the paper’s argument and so wanted to know more
about what happened later in similar situations. A charitable interpre-
tation of this colleague’s inability to respond is that the process notes
had perhaps been lost. Less charitably, it could be argued that the point
the author was making could not be illustrated by additional material.
The comparative method (comparing like situations over time) and
imaginative and thoughtful investigation of objections in a creatively
skeptical mode are fundamental to the task of establishing a discipline
with real conf idence in itself.
To address the problem of obtrusiveness and to deal with it properly
does not seem to me to be particularly problematic. But it does seem to
require us all to address core aspects of our clinical and scholarly prac-

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 THE CASE HISTORY

tice that might be in serious need of change. We may also need to con-
sider psychoanalytically why it has taken us so long to face these rather
obvious requirements.
Confidentiality and disguise. To complete his review Michels raises
the twin issues of the problem for clinical reporting presented by its
obtrusive effect on patients and their treatment, and the problems posed
where efforts to get around this lead to distortions of the data. To his
discussion I would add only two points.
The problem of protecting conf identiality needs to be seen within
the f ramework of conf licts that exist more widely (Tuckett 1976,
p. 193). Built into the role of many professionals is a series of inherently
irresolvable conf licts that can be negotiated only on a moment-by-
moment basis. I have in mind the conf lict of any clinician between
the interests of one patient at one moment and that patient and all others
at a later time. This conf lict is present throughout medicine, as indeed
wherever (as in education) an innovation requires a present population
to be guinea pigs for the next. I would therefore stress that what have
constantly to be balanced are the advantages and disadvantages to any
409
patient from being reported, as opposed to the advantages and disad-
vantages for patients later. The issue is too often discussed in funda-
mentalist terms. In my view, the negative effects of a profession that
cannot learn from clinical experience by sharing it in full and frank
detail has become alarmingly obvious. The risk that an individual
patient may be harmed by disclosure is there, but it must be considered
in this wider ethical framework. The trend in many countries (certainly
in the U.K.) is toward far stricter rules of clinical governance for a
variety of professions—and for good reason, given the public’s right to
adequate standards and all that we know about single-handed practice
in a variety of professions.3 This trend makes creative solutions to the
problems of conf identiality an urgent task.
In closing, I suggest that Michels’s address and the vital issues
he raises amount to a timely call to our profession to attend to
problems that unsolved threaten its claim to legitimacy. We should
move the practice of psychoanalysis out of an individual organiza-

3
Bollas and Sundelson (1995) have argued persuasively against the psycho-
analytic profession passively surrendering to the trend toward disclosure. They
believe it will threaten the fundamental rule. While I think this argument merits seri-
ous consideration, it seems to me wholly untenable if we do not put our house in
order.

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 Commentaries

tional context into a collective one—that is to say, toward working

with individuals but regularly and routinely making notes to ourselves
and discussing cases with colleagues. We should also move from our
current cross-sectional reporting method to a longitudinal one. That
is to say, we need to work with individuals but we might organize
that work in groups (along the lines of the Hampstead Index project).
Such groups might routinely meet to formulate views of each case
and to examine their utility, in detail and over time. Such efforts
would offer an opportunity for clinical reporting and research, though
perhaps at the price of some individual narcissism. Cases and
f indings could be reported by study groups rather than by individuals,
with details of conf identiality both considered and facilitated by this
approach.
REFERENCES
BOLLAS, C., & SUNDELSON, D. (1995). The New Informants: The Betrayal of
Confidentiality in Psychoanalysis and Psychotherapy. Northvale, NJ:
Aronson.
410 CANESTRI, J. (1994). Transformations. International Journal of Psycho-
Analysis 75:1079–1092.
FREUD, S. (1893). Charcot. Standard Edition 3:11–23.
MOSHER, P.W. (1998). Message posted to the Members List, American
Psychoanalytic Association, September 9.
S ANDLER , J. (1976). Countertransference and role-responsiveness.
International Review of Psycho-Analysis 3:43–48.
SCHWARTZ, J. (1999). Cassandra’s Daughter: A History of Psychoanalysis in
Europe and America. London, Allen Lane: Penguin Press.
S PENCE , D., (1998). Rain forest or mud f ield? International Journal of
Psycho-Analysis 79:643–647.
TUCKETT, D.A. (1983). Words and the psychoanalytical interaction.
International Review of Psycho-Analysis 10:407–414.
———— (1993). Some thoughts on the presentation and discussion of the
clinical material of psychoanalysis. International Journal of Psycho-
analysis 74:1175–1190.
———— (1994). Developing a grounded hypothesis to understand a clini-
cal process: The role of conceptualisation in validation. International
Journal of Psycho-Analysis 75:1159–1180.
———— B OULTON , M., O LSON , C., & W ILLIAMS , A.J. (1985). Meetings
between Experts: An Approach to Sharing Ideas in Medical
Consultations. London: Routledge.
———— ED. (1976). An Introduction to Medical Sociology. London:
Tavistock.

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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

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