Neuropsychoanalysis

An Interdisciplinary Journal for Psychoanalysis and the Neurosciences

ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/rnpa20

Clinical writing in neuropsychoanalysis

Daniela Flores Mosri, Jane Abrams, Virginia Barry, Iftah Biran, Rudi Coetzer,
Paul Moore, José Fernando Muñoz Zúñiga & Maggie Zellner

To cite this article: Daniela Flores Mosri, Jane Abrams, Virginia Barry, Iftah Biran,
Rudi Coetzer, Paul Moore, José Fernando Muñoz Zúñiga & Maggie Zellner (2022)
Clinical writing in neuropsychoanalysis, Neuropsychoanalysis, 24:2, 171-191, DOI:
10.1080/15294145.2022.2140068

To link to this article: https://doi.org/10.1080/15294145.2022.2140068

Published online: 21 Nov 2022.

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NEUROPSYCHOANALYSIS
2022, VOL. 24, NO. 2, 171–191
https://doi.org/10.1080/15294145.2022.2140068

SOCIETY PROCEEDINGS

Clinical writing in neuropsychoanalysis

Daniela Flores Mosri , Jane Abrams, Virginia Barry, Iftah Biran , Rudi Coetzer, Paul Moore,
José Fernando Muñoz Zúñiga and Maggie Zellner

ABSTRACT ARTICLE HISTORY

As the knowledge derived from the dialog between neuroscience and psychoanalysis has provided Received 8 October 2022
relevant insights in topics such as affects, instincts, consciousness, memory, dreams, and many Accepted 21 October 2022
others, the question of its clinical applications has gained increasing interest. Using
psychoanalytic techniques with neurological patients has gradually become a more common
practice. However, integrating neuropsychoanalytic perspectives into work with non-
neurological patients has represented a challenge that is being taken with caution. Case reports
have been crucial for the development of psychoanalytic ideas. Based on this principle, progress
in the clinical applications of neuropsychoanalytic knowledge can also benefit from case
presentations. Nevertheless, the neuropsychoanalytic perspective entails added challenges.
Hence, the editorial team of this journal gave a clinical writing workshop in February 2022. We
present here brief essays that cover some of what we consider the most important topics
involved in clinical writing in neuropsychoanalysis.

Introduction report, preparing case studies, and research based on

Neuropsychoanalysis is coming of age, and after over
twenty years of work, there is an increasing interest
in its clinical implications. Neuropsychoanalytic
approaches to neurological patients have been success-
fully reported both in books (e.g. Clinical Studies in
Neuro-psychoanalysis: Introduction to a Depth Neuropsy-
chology by Kaplan-Solms & Solms, 2000, and the recent
Clinical Studies in Neuropsychoanalysis Revisited by Salas
et al., 2021), and as case reports in various journals,
including Neuropsychoanalysis. There has also been a
slower and more cautious development of ideas
related to non-neurological patients. As this literature
develops, we are asking a key question: How is knowl-
edge in neuropsychoanalysis affecting clinical work
and psychoanalytic technique? Documenting our pro-
gress, experiences and questions is thus a crucial task
that helps us all to research and develop the topic as a
community. The editorial team of the journal Neuropsy-
choanalysis offered a clinical writing workshop in Febru-
ary 2022 as one of the first steps to discuss essential
aspects related to preparing a neuropsychoanalytic clini-
cal case report. This collection of short essays is based on
the talks we gave at the workshop and addresses topics
such as the basic criteria to write a neuropsychoanalytic
clinical report, ethical dilemmas, literary genres, the aims
of writing clinical case reports, clinical case reports of
neurological patients, the experience of writing a case
clinical case studies. We hope our essays will serve as a
guide to motivate potential authors to document their
neuropsychoanalytic clinical work.
Daniela Flores Mosri, Managing Editor
dannmos@yahoo.com
Criteria for a Neuropsychoanalytic Clinical
Report
Maggie Zellner
Introduction
The editorial team wants to encourage clinicians to write
about how models from neuropsychoanalysis and
neuroscience are enriching their clinical work. These
clinical reports are very much needed, as we flesh out
a developing literature on the benefits and challenges
of integrating neuroscience and psychoanalysis in our
day-to-day work with patients.
Clinical reports serve a variety of purposes. Writing
about work with individual patients is a vital tradition
in all schools of psychotherapy; students and seasoned
clinicians alike learn from descriptions of what transpires
between patient and analyst, why something works or
doesn’t work. As a form of collegial support, clinical
reports are an important resource for each of us in our
development as clinicians, as we read about how

CONTACT Daniela Flores Mosri dannmos@yahoo.com

This article has been corrected with minor changes. These changes do not impact the academic content of the article.
© 2022 International Neuropsychoanalysis Society
172 D. FLORES MOSRI ET AL.
others approach specific treatment dilemmas. Clinical
reports are also good venues for testing out schools of
thought, yielding confirmations, innovations, and revi-
sions of what we have been trained to do.
Thus, clinical literature is vital in any psychotherapy
modality – and is particularly necessary for us as we are
trying to integrate neuroscience and psychoanalysis. In
the scholarly domain, it helps us assess the relevance of
neuropsychoanalysis to clinical work, answering questions
which have been posed to us since the beginning, like
“What good is neuropsychoanalysis?” and “What does
the brain have to do with clinical work?” Clinical reports
can also suggest new lines of research; as reports accrue
about using certain hypotheses, or working with certain
kinds of patients, it suggests the possibilities of wider
efficacy testing. Clinical reports are great arenas for devel-
oping new neuropsychoanalytic hypotheses about par-
ticular kinds of treatment dynamics, personality
structures, developmental effects, and more. Therefore,
now is the time to courageously put our ideas out into
the public forum, describing how our study of neuro-
science and neuropsychoanalysis has affected our work
as we build on more than 20 years of dialogue.
Criteria for neuropsychoanalytic clinical reports
on non-neurological cases
So what actually constitutes a neuropsychoanalytic clini-
cal report, as opposed to a regular case report? As we pre-
pared for the workshop, we discovered that we’ve never
actually spelled it out before! To begin with, a clinical
report is neuropsychoanalytic if it has both an explicitly
psychoanalytic perspective, and some substantive neuro-
science content. This is consistent with the essence of our
submission criteria for the journal – see our “Aims &
Scope” at https://www.tandfonline.com/action/journal
Information?show = aimsScope&journalCode = rnpa20.
Now, these criteria are relatively easy to meet if one is
writing about work with a patient who has survived
brain injury, has some kind of known brain disorder, or
who has had a neuropsych assessment or brain measures
of some kind. We have been pleased to publish numerous
case reports along these lines (see, for example, Biran,
2019; Edlow, 2014; Jackson, 2018; Muñoz Zúñiga, 2017;
Salas, 2012; Vales & Flores Mosri, 2022). However, we
now wish to encourage clinical writing about “everyday”
patients with no known brain injuries or brain measure-
ments (as a parallel stream to the continuing develop-
ment of our literature on working with neurological
patients). Of course, the criteria of brain measurements
(like MRI scans or EEG measurements) are not possible
to meet for the vast majority of our patients, for whom
we typically have no objective brain measurements.
Nevertheless, we are discovering over the years that neu-
ropsychoanalytic ideas are definitely enriching and chan-
ging our clinical work, so it is important to publish writing
about that.
Therefore, the criterion for a clinical report for a non-
neurological patient is that an explicit neuropsychoana-
lytic model or neuroscientifically-informed hypothesis
informs the treatment, or arises from it. In other words,
if you find that a particular neuropsychoanalytic or neu-
roscientific idea is impacting the way that you’re
working, that’s worth writing about! This could include
one or more of the following: testing out a particular
neuropsychoanalytic hypothesis; making a new connec-
tion between a neuroscience construct and a psychody-
namic process; sharing a neuropsychoanalytic case
formulation that may be helpful to others; describing a
series of interventions guided by a neuropsychoanalytic
hypothesis; reporting on instances of successfully (or
unhelpfully) using brain knowledge to engage,
educate, or otherwise dialogue with a patient; and more.
As we are in the early stages of developing this litera-
ture, the criteria will surely get elaborated and refined as
time goes on. But we can already say a few more specific
things about our general criteria. There needs to be
some kind of through-line or elaboration of a neuropsy-
choanalytic idea in the clinical work being reported. It is
not sufficient to submit a fully psychoanalytic case
report that only has a few lines about a neuropsychoana-
lytic idea or neuroscience finding at the beginning or
end of a paper, such as “the SEEKING system can be
equated with libido, therefore this patient likely has
low levels of endogenous dopamine” or “as our work
on the trauma progressed, the patient’s amygdala prob-
ably became less responsive to fear cues.” Rather, a
hypothesis related to a particular neuropsychoanalytic
idea should be developed throughout the report.
Conversely, for our journal it is not sufficient to
submit a strictly neuropsychological or neurological
report, which describes brain measures but lacks a psy-
chodynamic formulation entirely, or only gives brief
mention to a psychoanalytic concept. We sincerely
welcome case reports from neuropsychologists, neurol-
ogists, psychiatrists, and others working on the more
“neuro” side of the dialogue! We’re highlighting here
that these clinical reports also need to give a sense of
the inner world of the patient, the interpersonal
dynamics with the therapist, or other ways in which
the brain measures or neuroscientific formulations
form a synergy with a psychodynamic approach.
One further editorial note. In writing about non-
neurological patients, it’s inevitable that we must specu-
late about brain correlates. Because we are speculating,
it is critical to advance our formulations in a tentative

manner. First of all, we are still very early on in neurop-
sychoanalysis, with much to learn and integrate, so
any definitive statements about what’s happening for
a particular patient in neuropsychoanalytic terms
would be premature and incomplete. In addition, in
our community in general and in our journal in particu-
lar, we are cautious about overly strong and premature
applications of neuroscience to psychoanalysis, similar
to Freud’s concerns (1910) about “wild analysis” in the
development of psychoanalysis. Finally, and most impor-
tantly, with non-neurological patients we are by
definition always only presuming about any neural cor-
relates of clinical processes, and therefore must continue
to be tentative about our hypotheses. It is not a well-
supported declaration to say, “When I said X, my
patient’s amygdala and orbitofrontal cortex did thus-
and-so,” for example. However, if you have a hypothesis
about the amygdala and OFC that guides a set of inter-
ventions over time, we’d love to hear about it; the neuro-
science is a critical support to the clinical hypothesis, but
it always remains a tentative one in the absence of
objective measures. In this regard, I personally view neu-
ropsychoanalytic conceptualizations as in the same cat-
egory as any other kind of extra-analytic knowledge or
theory (i.e. information from outside of the immediate
experience with the patient that informs our work),
such as historical understandings, personal associations,
and so on.
One last note about our criteria: we do not expect all
submissions to be explorations of existing neuropsy-
choanalytic hypotheses. While we welcome explorations,
elaborations, or critiques of current hypotheses, such as
Solms’ theory of repression (Smith & Solms, 2018), or
Yovell’s (2000) formulation of working with traumatic
memory, there is a vast realm to explore in the intersec-
tion of neuroscience and psychoanalysis, and clinical
reports are a great place to tentatively raise some new
ideas that can be elaborated in the future.
Similarities and differences in submission
processes
As I’ve been describing, a neuropsychoanalytic clinical
report must meet the same criteria for original articles
(the other main type of article in our journal), in that it
must have both an explicit psychodynamic aspect and
an explicit “neuro” aspect. In terms of the submission
process, a clinical report is also similar in that it is sub-
jected to blind peer review: the manuscript is sent to
at least two reviewers with relevant backgrounds, who
read the paper, assess its suitability for publication in
our journal, and give feedback on the paper’s strengths
and weaknesses. The editor managing the peer review
NEUROPSYCHOANALYSIS 173
then takes into account the reviewers’ responses,
making the final determination about whether to
accept the paper for publication, and which revisions
are necessary if publication is indicated.
On the other hand, a clinical report differs from an
original article in terms of the expectations for the litera-
ture review. We do not expect a clinical report to have
the substantive literature review that an empirical or a
theoretical paper should have, in which the author(s)
situate their study or review in the context of a signifi-
cant number of previously published papers and books
addressing the topic. Instead, a clinical report can have
a more modest literature review in the introduction,
briefly covering some of the relevant papers to the
case. As you will be illustrating how a certain model,
idea, or finding influenced your work, interested
readers want to explore the resources that have inspired
you. In addition, references to any previous reports in
the clinical literature will indicate that you are aware of
the relative novelty of your case (if there are few or no
prior case reports) or how it harmonizes or contrasts
with earlier relevant reports.
For more information, please visit our Instructions for
Authors [https://www.tandfonline.com/action/author
Submission?show=instructions&journalCode=rnpa20],
and email us at support@npsa-association.org if you
have questions or encounter any difficulties.
Conclusion
This essay is focused on clinical writing about non-
neurological patients, and thus has emphasized the inte-
gration of neuroscience findings or neuropsychoanalytic
hypotheses into “everyday” clinical work. However, it’s
important to emphasize that neuropsychoanalysis is a
bridge going in both directions, as each domain can
enrich the other. Our journal, and the ethos of the Neu-
ropsychoanalysis Association as a whole, does not privi-
lege one or the other as the primary source of truth. We
welcome submissions of experimental, clinical, or theor-
etical papers that take both mind and brain into account.
To summarize, we strongly encourage clinicians of all
backgrounds to share how your neuropsychoanalytic
perspectives are enriching your work, so that we can
learn from each other. Writing up a neuropsychoanalytic
clinical case about working with a non-neurological
patient necessitates speculation, so that is inevitable
and welcome. But one’s formulations should be tenta-
tively expressed, well-grounded, and elaborated
beyond just one or two statements about purportedly
relevant brain processes. Given the need for a robust lit-
erature base as we make progress in neuropsychoanaly-
sis, each contribution is valuable. Writing about our
174 D. FLORES MOSRI ET AL.
clinical work is a vulnerable process, and also a truly gen-
erous one. We hope you will consider making a
contribution!
mzellner@npsa-association.org
Publishing case reports: Ethical and clinical
dilemmas
Jane Abrams
This paper will provide a brief summary of the history of
writing, presenting and publishing case reports of psy-
choanalytic patients, and will discuss current ethical and
clinical concerns resulting from broad access to our
written work via the internet. The paper will highlight
the complexities of what may seem like a straightforward
solution – informed consent – and offer suggestions for
protecting patient confidentiality and adhering to
journal policies while still using clinical writing as a vital
means of disseminating new knowledge.
Since the beginning of psychoanalysis, the single most
important method for the generation and dissemination
of knowledge in the field has been the single case
study. In his preface to his case of Dora, Freud (1905)
described the dilemmas he pondered when deciding to
write about his patient and referred to the question of
whether and how to present his case histories as “ … a
hard problem for me to solve” (p. 8). He speculated that
his hysterical patients, given the psychosexual origins of
their suffering, would never have spoken openly if they
had known that he was going to write about them and
they would never have given him permission to do so.
Freud (1905) nonetheless concluded that the phys-
ician’s duty is first and foremost to science. He further
stated that it would be cowardly not to publish scientific
findings via case studies that might prevent suffering for
other patients, as long the physician did no harm to an
individual patient. He concluded, based on the following
considerations, that publishing his case of Dora would
not harm her: she lived outside of Vienna; only Fliess
knew that he was treating her; he waited four years
post-termination to write about her; he had heard that
her life had changed in ways such that she would have
faint interest in his write up of her analysis; and he
would publish his case study in a scientific journal that
non-scientists would be unlikely to read. He admitted
that he could not prevent her from pain if she were to
read his history of her case, but concluded that she
would learn nothing that she didn’t already know and
would be reassured that no one could identify her.
Thus, he made a unilateral decision about what to do
with the clinical material.
Any of us who have written case studies have most
likely considered many of the reasons for and against
publication that Freud did. The big difference for us
today, of course, is the internet. It is safe to assume
that our patients are highly likely to read anything that
we publish. Journals fear litigation. Taylor & Francis,
the publisher of our journal, Neuropsychoanalysis,
requires that authors have their patients or research sub-
jects sign a consent form, available on the T&F website.
The consent form states that they have read the article
and have agreed to its publication. The author must
keep the form in the event that T&F requests access to it.
There have been changes in the culture over the last
few decades – movements for patients’ rights and a
general challenging of traditional hierarchies and
power structures – that are having an impact on how
we think about writing about our patients. Relational
approaches to psychodynamic psychotherapy have
shifted from a one-person to a two-person model and
the therapy relationship is understood to be co-
created by patient and therapist – a collaboration.
There is a tacit, if not explicit, understanding that the
therapist no longer has the ultimate authority to
decide what becomes of a patient’s story, pointing to
informed consent as the only option for publishing
case material (Aron, 2016).
However, when we consider unconscious factors in
the transference/countertransference matrix, we can
see that informed consent is anything but a straightfor-
ward solution. Gabbard (2000) considers writing about
our patients as inherently a conflict between the thera-
pist’s and the patient’s needs and the request for
consent is a burden to the patient. He, along with
Aron (2000), raises the question of whether informed
consent is even possible, given the power differential
within the therapy relationship. Is the patient really
free to decline? Do patients agree in order to please
their therapist or to avoid the therapist’s anger or disap-
pointment? Moreover, consent at one point in a course
of treatment might feel different at another point in
the therapy or after termination. Even with consent,
patients might feel harm after the case report is
published.
The intention to write about a patient introduces the
analyst’s needs into the treatment – for recognition from
colleagues, for narcissistic gratification beyond what we
garner from the clinical work itself. It changes the inter-
subjective space. Knowing that her work with a patient is
going to be exposed through writing can result in the
therapist ignoring, repressing or denying countertrans-
ference responses. There is the risk that the content
that is brought into treatment by both patient and
therapist will be affected. In short, writing becomes

part of the dyad’s intersubjective experience. It is not
external to the treatment. Rather, a new third is intro-
duced into the relationship and into the work (Acker-
man, 2018; Gabbard, 2000). Aron (2016) asserts that:
… it is probably wise to think that all presentations and
publications of clinical material represent some form of
enactment of unconscious dynamics; enactments, after
all, are often played out through our technical interven-
tions and through management of the therapeutic
frame, and therefore it is advisable to give careful
thought and to seek consultation on all cases one con-
siders presenting, both at early and later stages of the
writing and publication process. (p. 289)
There are further risks to consider when writing about
our patients, even when we have consent and engage
in a collaborative process. Reading what the therapist
has written could short circuit the patient’s self-reflec-
tive process both during and after the treatment and
interfere with the construction of the patient’s own
narrative. Furthermore, our understanding of our
patients evolves. Writing at one point in time runs
the risk of concretizing the analyst’s version of the
patient’s story at that moment (Ackerman, 2018). This
could further interfere with a key benefit of psychody-
namic psychotherapy – the ongoing gains, after treat-
ment, from a continuing reflective process by the
patient (Shedler, 2010).
Patients have had a range of reactions to their thera-
pists writing about them: horror, outrage, narcissistic
pleasure, indignation, sadness, feeling honored and
feeling special. Some patients are reassured by
knowing that an analyst’s work is linked to a professional
community. The secrecy that we so carefully guard can
also be experienced as a lack of accountability. Patients
have expressed admiration that their therapists are com-
mitted to contributing to knowledge in their field. Some
consider sharing their case history as a way to give back
to us and to even out the power imbalance in the
relationship (Ackerman, 2018; Aron, 2016).
How do we assess the risk vs. benefit? Why should we
keep writing and how can we do it in a way that protects
our patients? We write for many reasons: to understand
our clinical work and clarify our thinking, to master
complex and difficult countertransference situations, to
teach, to be accountable through exposing our work
to our colleagues, and to transmit and collaborate in
the development of new knowledge (Ackerman, 2018;
Gabbard, 2000; Kantrowitz, 2022). This last point is par-
ticularly relevant in neuropsychoanalysis at this
moment, as we are working together to develop clinical
applications for neuropsychoanalytic theory.
How to write about our work is an ongoing discussion
in our field, even as journals dictate specific protocols.
NEUROPSYCHOANALYSIS 175
There is agreement that there is no ideal solution. We
can write detailed case reports, ask for permission and
show our writing to patients before publication with
the awareness of the complexities summarized above.
We can use case vignettes rather than full case reports.
This would mean developing skills to describe key
dynamics, like wishes, fantasies, conflicts, and enact-
ments without providing details about a particular
patient’s identity and thus not requiring consent. Thick
disguise would require the same set of skills as would
fictionalizing a case report. Gabbard (2000) reminds us,
“Absolutes in ethics guidelines … cannot possibly take
every individual situation into account. The analyst
must make a judgment call based on his or her best
assessment of the patient’s likelihood of reading the
report, the viability of a thick disguise, the impact of
consent and the potential harm to the patient that
might accrue from any decision made. When there is
considerable doubt, consultation with a colleague may
be of great assistance” (p. 1084). Ackerman (2018)
states, “I would think that every analyst writing about
a patient should be in a state of conflict and doubt as
she writes, aware of the risks” (p. 78). Aron (2000)
reminds us of Freud’s admonition that we accept the
inherent conflicts of the human condition. He then
applies this principle to the experience of writing
about patients. We must face the moral dilemmas and
the tensions inherent in this endeavor, making use of
our knowledge of the unconscious and the resources
available to us from the literature and from consultation
with colleagues, in order to continue the vital work of
writing case reports.
jabramsdsw@gmail.com
The literary genre of case studies – the case of
Dora
Iftah Biran
In the discussion of the case history of Fräulein Elisabeth
Von R., Freud states that “ … it still strikes me myself as
strange that the case histories I write should read like
short stories and that, as one might say, they lack the
serious stamp of science” (Breuer and Freud 1893–
1895 (1955), p. 160).
In this quote, Freud opens the door to understanding
psychoanalytic writing as a form of literature and to sub-
jecting his case studies to literary criticism. Here I look at
the literary genre of the report on the analysis of Dora
(Freud, 1905 [1901], “Fragment of an Analysis of a Case
of Hysteria”). I claim that it resembles a “coming of
age” story belonging to the genre of Bildungsroman
(Formation-Novel) and further argue that it is not clear
176 D. FLORES MOSRI ET AL.
to whom this Bildungsroman pertains – to Dora or Freud.
Is it Dora’s case story or the story of Freud’s case of Dora?
Following this, I will look at some issues related to
writing clinical studies, especially confidentiality issues,
and how these issues come into play in the Bildungsro-
man genre.
Ida Bauer, pseudonym Dora, came to therapy with
Freud at eighteen in 1900. He had seen her for a consul-
tation two years prior. She suffered from mental distress,
which manifested, among other things, in hysterical
physical symptoms. She was referred to therapy by her
father following his finding of a suicide letter in her
room, and she terminated the treatment of her own
accord three months later. Dora’s suffering might have
been related to a complicated family affair – Dora’s
family had a pair of close friends, Mr. and Mrs. K. Her
father had an affair with Mrs. K, and Mr. K. made
advances to her and had assaulted her a few years
before the therapy.
This case history is one of Freud’s most extended case
studies. It ties together his interest in the Oedipal
complex, dream interpretation, and hysteria. Over the
years, the case acquired seminal status in the psycho-
analytic canon, serving as a model in analytical training
(Jones, 1955). However, it has been a target for scrutiny
in the last few decades, mainly feminist criticism (Bern-
heimer & Kahane, 1990; Jennings, 1986).
Analyzing the case’s thematic and formal literary
characteristics can enable, at times, a fresh analytical
view (Berman, 1993). Here I look at the literary genre
of the case. A literary genre is a class of literary assem-
blies defined by technique, length, tone, and content,
among other parameters. Accordingly, a particular
genre might entail a specific worldview, attitude, and
presumptions about the human soul and human devel-
opment (Abrams & Harpham, 2012; Baldick, 2015).
What does Freud suggest about the literary genre of
Dora? Freud alluded explicitly to two genres, roman á
clef and case histories which he confronts one with the
other:
I am aware that – in this city, at least – there are many
physicians who (revolting though it may seem) choose
to read a case history of this kind not as a contribution
to the psycho-pathology of the neuroses, but as a
roman á clef designed for their private delectation. I
can assure readers of this species that every case
history which I may have occasion to publish in the
future will be secured against their perspicacity by
similar guarantees of secrecy, even though this resol-
ution is bound to put quite extraordinary restrictions
upon my choice of material. Now, in this case history
– the only one which I have hitherto succeeded in
forcing through the limitations imposed by medical
discretion and unfavorable circumstances … (p. 9)1[my
emphasis]
Roman á clef is a genre in which real people or events
appear in a weak disguise (Abrams & Harpham, 2012).
It is a distant relative to current tabloids and their
obsession with celebrities and the juicy items and scan-
dals related to their romantic and sexual life. As
suggested by Freud, this is not compatible with a case
history.
Other genres come into mind in a less close-to-the-
text reading. In Freud’s scrutiny of the books read by
Dora’s governess – “every sort of book on sexual life
and similar subjects” (footnote 1, p. 36), sexual guides
and self-help books come into mind. This classification
by Freud is strengthened by Freud’s apologetic words
about the sexual material in the case. Moreover, isn’t
Dora’s case a guidebook by itself? At least for future
writers of case histories.
Dora’s case could also be regarded as a detective
story; see Spence (1987) and the reaction of Loewenstein
(1992). Freud himself hints at the genre of detective
stories. His archeological metaphor of psychoanalysis,
a metaphor that appears in Dora (p.12) and some
other essays (Bowdler, 2010), supports this notion. In
both an archeological excavation and a detective story,
there is an effort to find a hidden, unknown, covered
representation of truth. When Freud compliments Dora
on her insight into her father’s infidelity – “Nothing
that could help to confirm this view had escaped her
perception, which in this connection was pitilessly
sharp” (p. 32) and “ … the sharp-sighted Dora had
soon unearthed the fact that Frau K. had started off to
the same place to visit her relatives there” (p. 34) –
Dora can be regarded as a successful detective or
private investigator.
Marcus (1976), following Freud’s notion of roman á
clef and following the convoluted plot of deceit and
betrayal in matrimony, suggests that Freud immerses
us in a “classical Victorian domestic drama, that is at
the same time a sexual and emotional can of worms”
(p. 394) or a “late Victorian romance” (p. 396).
Marcus also suggests that Dora’s case resembles a
modern experimental novel – the narrative and the
exposition are not linear but rather involuted; it loops
back around itself and is highly innovative in its formal
structure. Freud also takes the role of an unreliable nar-
rator, typical in modernist fiction.
Brockmeier (1997) proposes seven possible narratolo-
gical models that could describe Freud’s case studies;
the second in her list is the Bildungsroman. The Bil-
dungsroman, or Formation-Novel, is a novel subgenre
that started to take shape during the eighteenth

century. A classic Bildungsroman is Goethe’s Wilhelm
Meister’s Apprenticeship (1795). Coined in the early nine-
teenth century by German philologist Karl Morgenstern,
the term denotes a positive growth process experienced
by the European man, which allows him to realize his
natural self by incorporating the inner mental world
and the outside world (Morgenstern & Boes, 2009). The
classic Bildungsroman stands for the maturation of a
young man, a process that involves different experiences
and conflicts, finding friendships, love, and interpersonal
relations; and it culminates when the protagonist,
having gone through these trials, finds himself and his
place in the world (Dilthey, 1985; Howe, 1930).
While the male coming of age sought to forge an
identity, with emphasis on social and vocational inte-
gration, its female counterpart, the Female Bildungsro-
man, had its focus on marriage and starting a family,
with education and knowledge relegated to a secondary
position, something that can be acquired through mar-
riage, at times ending in a character that is not formed
and integrative (Fraiman, 1993).
Dora’s case history, excluding the protagonist’s sex,
seems to coincide with the classic Bildungsroman
model. Hailing from a bourgeois family, this young
woman of about eighteen morphs from an adolescent
into a grown woman as she sets out into the world to
meet some characters that pose a challenge to her for-
mative process. With considerable reservations, her
encounter with Freud and Herr K. can be regarded as
the sexual-romantic exploits experienced by the
coming-of-age protagonist. She meets her cousin, visits
the museum, and becomes closer to Herr and Frau
K. Eventually, she strikes a romantic relationship that
seems mistakenly to have led to marriage. It can also
be formulated as a Female Bildungsroman. Accordingly,
one of Freud’s major concerns regarding Dora and her
fulfillment as a grown-up is the issue of her marriage
and turning away from her father to a mature matrimo-
nial relationship:
Years have again gone by since her visit. In the mean-
time the girl has married … … Just as the first dream
represented her turning away from the man she loved
to her father … … so the second dream announced
that she was about to tear herself free from her father
and had been reclaimed once more by the realities of
life. (Freud, 1905, p. 122)
However, the case could also be formulated as Freud’s
Bildungsroman. Ostensibly, the case history follows
Dora’s formative process. Still, it is interwoven with
Freud’s story as a clinician and theoretician who tries
to demonstrate and validate his meta-psychological
theory with a clinical case study and, perhaps, thereby,
NEUROPSYCHOANALYSIS 177
complete a professional coming of age and earn pro-
fessional recognition. Indeed, in the course of Dora’s
treatment and during the five years leading up to the
publication of the case history, Freud was already in
his fifth decade, well beyond the average age of Bil-
dungsroman protagonists. However, he was still busy
establishing recognition for himself and the psychoana-
lytic movement. This could nicely be demonstrated in
Freud’s discussion of Dora’s first dream, where he intro-
duces a quote from The Interpretation of Dreams (1900)
that addresses his dream of becoming a professor. More-
over, by the end of the case history, with his wish
fulfilled, Freud asks Dora if she has read about him in
the newspaper, referring to the newspaper announce-
ment of his professorship and suggesting that this was
the drive for her last visit with him:
… she had come for help on account of a right-sided
facial neuralgia, from which she was now suffering day
and night. “How long has it been going on?” “Exactly a
fortnight.” I could not help smiling, for I was able to
show her that exactly a fortnight earlier, she had read
a piece of news that concerned me in the newspaper.
And this she confirmed. (pp. 121–122)
I claim that Dora’s case is an amalgam of two competing
Bildungsromans – Dora’s and Freud’s. This entails that
Freud robs Dora of her story and history and utilizes it
for his own sake. The operations used for this are the-
matic, linguistic, and rhetorical. It is beyond the scope
of this paper to describe all these operations. However,
in line with the ethics of writing case studies, I want to
discuss the issues of disguise and confidentiality in
case reports in general, and in Dora’s case in particular.
There is an inherent tension between masking the
analysand’s identity to protect her, on the one hand,
and securing her confidentiality by robbing her of her
identity, on the other. Authors must navigate between
Scylla and Charybdis – the more the disguise, the more
the patient is stripped from her identity; however, the
more minor the camouflage, the more the patient is
exposed. The mask can come at the price of projecting
the author’s theory, themes, and ideas onto the
patient, while keeping the patient’s identity breaches
her very intimate and personal history and thoughts.
I want to look at two tools Freud used to disguise
Dora’s identity, a disguise that eventually failed as
Dora’s true identity, Ida Bauer, is well known. The first
relates to Freud’s allusion to Roman á clef and the
second to the choice of Dora’s (or Ida’s) pseudonym.
In the opening pages of his work, Freud addresses the
issue of masking patients’ identities, where he explains
how the masking was done. However, the very
mention of roman á clef, which alludes to celebrities,
178 D. FLORES MOSRI ET AL.
directs the reader to figure out who the masked patient
is. Moreover, there is some bragging about it, as by
alluding to this genre, Freud suggests that his patients
are not from the hoi polloi, but rather from the elite.
Very subtly, Freud uses the description of the masking
technique to glorify his name.
The way Freud disguises Dora’s identity posits her as
nonexistent and insignificant. Freud, the witness narra-
tor, who becomes omnipotent, can change her name
with a stroke of his pen. Interestingly, the pseudonym
Dora was also the name of a governess in the home of
Freud’s sister, Rosa. The appropriation of this name is
twofold, as the governess in question was a Rosa too,
just like Freud’s sister, but had to forego her first name
in favor of Dora, lest she is mistaken for her employer.
Lowering Dora’s status to that of a servant also
happens in therapy. When Dora announces she
intends to stop the treatment and leave in two weeks,
Freud makes her equal with a maidservant who gives a
fortnight’s notice. However, his interpretation overlooks
the fact that Dora determines the end date, and it is he
who is dismissed. I am wondering what Freud projected
on Dora by choosing this pseudonym.
In a neuropsychoanalytical formulation, the question
of whose Bildungsroman the case brings (i.e. Freud’s or
Dora’s) is suggestive of a PLAY system interaction and
of dominance issues (Panksepp & Biven, 2012) trans-
posed onto the text. However, these issues could be
regarded as faulty and dysregulated manifestations of
this system, whereas Freud’s narrative domineers
Dora’s narrative.
These pitfalls and the danger of exploiting the patient
for the author’s own purpose are stumbling blocks in
every case study. However, while seriously addressing
these dangers and the cautious words of Freud about
these issues and the theoretical incompleteness of
Dora’s case (p. 12-13) regarding it as only a “Fragment,”
I hope that the genre of case studies will continue to
flourish and enrich future generations of therapists and
enable better therapies.
i_biran@hotmail.com
What is the point of case reports in the age of
evidence-based healthcare?
Rudi Coetzer
Introduction
Stories are set in landscapes, with these landscapes
coloring the narrative of what is being conveyed.
A story sometimes heard amongst some clinical
neuropsychology colleagues is that there are obvious
differences between the professional landscapes of
senior healthcare leaders, academics, and practitioners.
At the heart of this story of unknown origin – perhaps
it is a rumor – probably lies the perception that there
is a conflict between “evidence” and “uniqueness”
when managing, assessing, or delivering, the care of
patients from a leadership, academic, or clinical, per-
spective respectively. In this story, the narrative suggests
that case reports constitute “the science of N = 1,”
whereas evidence – and science-informed healthcare
relies on the science of “N = large numbers.” As part of
this waxing and waning dialogue, some proponents
might even challenge whether case studies constitute
“real” science. What constitutes “real science” remains
undefined, but the main challenge appears to be that
case reports are made up of narrative, rather than objec-
tive scientific evidence.
What is Evidence-based Practice (EBP)? In a nutshell,
EBP sets out to combine the best research evidence for
treatment interventions, clinical expertise consensus,
and patient values, to provide research-informed
(including from, for example, randomized controlled
trials) clinical care to patients. Based on the research
design, sample size, randomization, control groups,
and other factors, hierarchical levels of robustness of
evidence are determined, which in turn are central to
the “currency” of the model. EBP is also referred to as
Evidence-based Medicine or EBM. The history of EBP,
and its evolution over time, provides some insight
into how the original skill of clinicians to write up
their novel patients for broader dissemination centuries
ago, before Google, became neglected in more recent
decades. With the advent of EBM and the likely bias
journals have towards publishing empirical, data-
driven papers, case reports went into decline. During
the 1990s access to information speeded up due to
the ease of availability via the internet, further accentu-
ating, and potentially biasing, the impact of those
articles published more frequently by journals.
However, in this interesting history, more recently the
green shoots of a “recovery” of the case report have
started to appear.
Case reports vs EBP
Are case reports dead? Kandara and Smida (2016)
provide an interesting overview of the seesaw ride of
influence on clinical practice and treatment guidelines,
between case studies on the one hand, and on the
other, empirical research. Case studies have many
benefits, for example the fact that they allow for in-
depth exploration and examination (Heilman, 2004) of
a condition or presentation that is rare, or not yet well

understood. Kandara and Smida (2016) highlight, and
provide a few examples, on how case reports can some-
times facilitate communication that allows medical
workers to identify new diseases (for example, West
Nile encephalitis) in a region, and as a result help
prevent an epidemic. These authors also describe the
hierarchy inherent to evidence-based medicine (EBM),
and how case reports unfortunately became neglected
by journals, almost purely based on their perceived pos-
ition in this hierarchy (Kandara & Smida, 2016). Further-
more, almost 20 years ago, Heilman (2004) went as far as
to suggest the death of the case report might be a possi-
bility in the near future. Fortunately, this did not materi-
alize – at least not for now.
Sadly, for case reports, in the age of tech, data
became king, and anything else had to be demoted, or
rehabilitated. As regards EBP’s drive towards data-
driven evidence, interestingly even case reports may
have subconsciously been given a “makeover,” by
increasing their use of data-driven testing of specific
hypotheses in single case experimental designs.
Perhaps as a result, single case experimental design
case reports become more frequently published in the
UK during the late 1990s. The popularity of these in clini-
cal neuropsychology increased with time. For example,
Evans et al. (2014) in an introduction to a Special Issue
of the journal Neuropsychological Rehabilitation
devoted to single case experimental case designs,
outline some of the benefits and limitations (including
how exactly to analyze data) associated with these. In
a world of EBP, this design, which does have many
benefits, may also perhaps cynically unintentionally
confer “scientific respectability” to the humble case
report. Whatever type of case report is referred to,
Heilman (2004) points out that the reader of a case
report should be cautious to not overgeneralize its
findings and insights to the wider population.
However, the same argument almost certainly applies
to empirical papers – the converse caution against over-
generalization from large datasets to the individual
patient, would be a wise investment.
Empirical papers can sometimes struggle to provide a
clear narrative of what is being communicated, and
many conclude with a generic “more research is
needed in this important area.” This in turn can make
the transfer of insights and knowledge to others a bit
more challenging. Traditional case reports, on the
other hand, are to some extent similar to conveying
stories to an audience. Storytelling is a time-tested
method for teaching the next generation of clinicians,
passing on knowledge, and facilitating problem-based
learning (Coetzer, 2017). Case reports vary from short
to lengthy. Perhaps one of the greatest case reports in
NEUROPSYCHOANALYSIS 179
the history of healthcare is the story of Lt. Zazetsky, in
a book written by Luria (1972) with input also from
Zazetsky, documenting the 20 years’ long journey of
caring for a soldier wounded during World War II. Luria
beautifully and vividly captures the patient’s story, by
pointing out that despite the fact that the physical
wound to the brain, sustained 25 years ago, healed,
the patient (Zazetsky) together with Luria, was still
working on completing it, and that the story most
likely had no end. Storytelling also has a rich history in
psychoanalysis, and many other health disciplines. Inter-
estingly, case reports do not replace diagnoses and diag-
nostic classification systems – they augment these by
explaining the “why” of a patient presenting with a diag-
nosis or condition. In other words, individual case
reports expand on diagnoses by identifying the unique
factors underpinning a specific clinical presentation.
Is the narrative that case reports have very little
influence or impact in healthcare really true? Perhaps
somewhat cynically, an example of an empirical study
suggesting the opposite would now be in order.
Albrecht and colleagues (2005) assessed their impact
by looking at how many times 64 case reports and 39
case series (N < 10) were subsequently cited in the
high-impact journal The Lancet over a period of 18
months. They were subsequently cited on average 17
times. Furthermore, it is interesting to note that at
present the paper by Albrecht et al. (2005) has itself
been cited 175 times, providing a metric reflecting a
robust level of interest among professionals to better
understand the relevance of case reports. Let’s now
return to the question at the beginning of this section
– Are case reports dead? It appears the story of the
death of case reports during the age of EBP was a
rumor, and as a result has possibly been greatly
exaggerated.
Illustrative case
Presented briefly here, to illustrate some of the points
made in this article, is the story of Sandra (a pseudonym),
whose case (number 113) has previously been described
in greater depth elsewhere (Coetzer, 2017). Sandra was a
female aged 38, and who had unexpectedly (given her
age) suffered a stroke a few months earlier at the time
the author was asked to see her for an initial neuropsy-
chological assessment.
In essence Sandra’s baseline neuropsychological test
results revealed an impairment of her ability to retain
and recall visual stimuli (geometrical designs). As part
of her diagnostic workup, a computed tomography
image of the brain was performed, which showed evi-
dence of a right-sided fronto-parietal lesion, extending
180 D. FLORES MOSRI ET AL.
into the frontal region. Sandra was right-handed. After
the baseline neuropsychological assessment was com-
pleted, Sandra was seen for follow-up. This follow-up
appointment was in response to the referrer now
posing the question of Sandra possibly presenting
with features of mania. Neuropsychological testing was
repeated, and somewhat predictably Sandra’s test per-
formance improved on re-testing, but the impairment
of visual memory remained, and on this occasion with
her improved post-stroke fatigue it was possible to
administer additional tests, which revealed that execu-
tive difficulties were also present.
The striking feature at the follow up consultation,
though, was Sandra’s clinical presentation, rather than
her neuropsychological test scores. Sandra was now
faster in completing tasks whilst being tested, and a
lot more talkative, resembling pressured speech.
Sandra unexpectedly during this consultation presented
with what resembled reduced emotion regulation, alter-
nating between laughing and crying. Very significantly,
she then described a recent traumatic loss, the death
of her baby. The case report concludes with a brief
exploration of countertransference phenomena, for
example some of the emotions (including sadness) and
thoughts the author experienced in response to
Sandra’s tragic story of unexpected loss.
Returning now to some of the key ideas presented in
this paper, Sandra is of course not the first patient ever
described with a right hemisphere stroke. Not by a long
shot. But her altered presentation at follow-up was some-
what unusual, and difficult, if not impossible, to under-
stand in the context of her stroke alone. Large sample
group data would not have captured, nor explained,
these important phenomena. Some form of explanation,
or formulation at the individual level, of Sandra’s presen-
tation was needed to tie everything together. To very
briefly illustrate this point, in theory Sandra’s case could
potentially be formulated in at least four different ways.
The first posits that her neuropsychological test results,
in a right-handed patient, is compatible with a right hemi-
sphere lesion. The second hypothesis, or diagnostic for-
mulation, proposes that the aforementioned lesion area
is compatible with difficulties of affect regulation, includ-
ing reduced expression of emotions as observed during
her first neuropsychology appointment when baseline
testing was completed.
A third way to potentially formulate Sandra’s case is
to see her presentation in the context of Luria’s (1973)
theory of neuropsychological functions in humans.
Grossly oversimplified, at the heart of this proposal lies
an inability of the third functional system (Luria, 1973)
to efficiently “manage,” or regulate, perception,
emotion processing, and working memory functions
mediated by lower hierarchical systems, including
specifically the second functional system in this case.
Alternatively, a fourth case conceptualization might
suggest that there are also very significant psychoanaly-
tical factors and concepts to incorporate into the case
formulation of a patient with a right hemisphere
lesion. These include, for example, consideration in the
case formulation of the role of loss, and the superego’s
ability (or reduced ability) in the context of this patient’s
specific brain lesion, to contain the id, mirroring the case
formulation by Kaplan-Solms and Solms (2000). Indeed,
this latter formulation is part of the original reflections
briefly described in the original case report (Coetzer,
2017). While case conceptualization three at the time
informed treatment, it was conceptualization four
which later greatly enhanced the author’s reflective
practice about, and understanding of, Sandra’s case.
What are case reports for in the age of EBP?
To conclude, the question posed in the title of this article
now needs to be addressed. Perhaps a counter question
might be in order to inform how we think about the
statement captured in the title. How were individual
diagnoses first “discovered”? Case reports are not
about finding “patient zero,” but rather the quest – no,
duty – to find “the first patient,” and capture their
unique story. The point being that some clinician must
be the first to identify, describe, and conceptualize a
unique clinical presentation or diagnosis they observe.
It is patient 1 who sets us off on the path to finding evi-
dence for the many permutations of human novelty that
constitutes healthcare. Case reports, unlike for example
epidemiology, which uses big data from countless
people, identify “the first patient ever,” which is where
neuropsychoanalysis helps provide the rich, in-depth
explanation of our patients’ stories, within a scientific
framework.
Rudi.Coetzer@thedtgroup.org
b.r.coetzer@bangor.ac.uk
A tale of neuropsychoanalytic pioneers:
critical issues for neurological case reports
José Fernando Muñoz Zúñiga
I could hear a new call and see a new horizon, and
believe it at my young age.
Jack Kerouac, On the Road
One could, arguably, trace the conceptual origins of neu-
ropsychoanalysis to the very same text that was of

paramount importance to the origins of psychoanalysis
itself, Freud’s “Project for a Scientific Psychology”
(Freud, 1895/1950) (and see Solms, 1998). However,
the modern origins are to be found in Kaplan-Solms
and Solms’s seminal effort Clinical Studies in Neuro-Psy-
choanalysis (Kaplan-Solms & Solms, 2000). There, the
authors argued for a new take on the clinico-anatomical
method that had characterized clinical neurology and
neuropsychology since their beginnings, one that was
meant to build a bridge between higher mental func-
tions, as were understood in neuropsychology – specifi-
cally Lurian neuropsychology – and Freudian
metapsychology. That is, a bridge between the third
person of clinical neuroscience and the first person of
the patient’s subjective experience of his or her neuro-
logical lesion. Quite a bridge indeed.
Since then, neuropsychoanalysis as a field has given
plenty of food for thought to psychoanalysts, neuros-
cientists, philosophers, psychiatrists, and the like.
Slowly but surely, other authors have proposed
different bridges between the vast field of neuroscience
and psychoanalysis. Thus, it is reasonable to ask oneself
why we should keep studying patients with neurologi-
cal lesions from a psychoanalytic point of view. Before
that, it is wise to ask, with the benefit of hindsight,
what it is exactly that one attempts to bridge through
the clinico-anatomical method. This, of course, opens
a whole series of questions of deep philosophical and
methodological importance about the very nature of
the mind and its relationship with the brain, that go
well beyond the scope of this paper – but the reader
may want to read some important texts on this
matter (e.g. Boag, 2017; Karlsson, 2010; Northoff,
2011; Talvitie, 2009).
Suffice it to say that many authors concur that the
neuropsychoanalytic enterprise probably requires its
own transdisciplinary method. Northoff (2011) has
argued that it is impossible to link neuroscientific facts
and psychoanalytic concepts, as the former pertains to
the realm of neural algorithms and impersonal facts,
and the latter to the realm of subjective experience
and meaning. To escape from conceptual confusion
and context neglect, one should avoid a one-to-one
translation between neuroscientific and psychodynamic
concepts that may be intuitively linked at best. Instead,
an indirect translation may be needed, using a bridge
concept that links psychodynamic data on one side
and neural data on the other. Such a hybrid concept
would be then transformed into an experimentally
accessible variable that can be manipulated from a
third-person perspective (Northoff, 2011).
How does this apply to neurological cases? Using the
first-person perspective to illuminate etiological,
NEUROPSYCHOANALYSIS 181
syndromic and topographic levels of analysis in neuro-
logical lesions is common practice for behavioral neurol-
ogy and neuropsychiatry. It goes to the heart of the
clinico-anatomical method in medicine (Kandel, 2012).
Using the same method in neuropsychoanalysis has
different epistemological implications, since one is not
dealing with – mostly – direct correlations between
physiological or neuropsychological symptoms. Here
we are dealing, on the one hand, with the subjective
experience of the neurological patient, understood
through metapsychological concepts; on the other, we
deal with objectifiable findings, explained in neuroscien-
tific frameworks.
It must be remembered that psychoanalysis has both
a first-person and a third-person perspective, rep-
resented, respectively, by the intersubjective encounter
with the patient and the theoretical building of metap-
sychology. Dreams, phantasies, fears and hopes, that is,
highly personal experiences, are filtered through a
series of concepts; many of them dating back to
Freud’s lifetime. The resulting psychodynamic infor-
mation rests on one side of the bridge, while neuros-
cientific findings wait on the other. From this point of
view, correlating – let’s say – the neuropsychiatric mani-
festations of a limbic lesion with structural damage to
the id as an agency of the mind, simply won’t make
the cut. Bridge concepts will be needed, hopefully of
the kind amenable to operationalization and
experimentation.
What kind of information, then, should a neuropsy-
choanalytic case report of a patient with a neurological
lesion include? First, it should provide solid neuros-
cientific data – ideally, neuropsychological tests, struc-
tural and/or functional neuroimaging, neurological or
neuropsychiatric reports, and so on. Second, it
should give the reader sufficient psychodynamic
hypotheses. Third, it should have both a neuroscien-
tific explanation relevant to the clinical scenario and
a metapsychological understanding of subjective
phenomena. Fourth, the report should provide an
applicable analysis of how each set of data may
relate at a clinical and/or experimental level. Fifth, a
complete report contains an elaboration of the poss-
ible clinical and theoretical implications. Importantly,
these recommendations are not meant to be concep-
tual straitjackets, as any transepistemic integration
demands a good deal of creativity.
A few words about the formulation of psychody-
namic hypotheses are in order. There is currently no
consensus regarding which settings may provide the
most valid and useful psychodynamic observations in
these kinds of patients. Common sense indicates that
the best scenario would be for the patient to go
182 D. FLORES MOSRI ET AL.

through a full psychoanalysis, three to four times per Break(ing) on through to the other side: A
week, or psychodynamic psychotherapy, using psychoanalytic psychotherapist’s
proper psychoanalytic technique (Kaplan-Solms & observations on writing a clinical case report
Solms, 2000; Wiest & Brainin, 2010). However, patients for a neuroscientific journal
with neurological lesions may be medically ill, to the
Paul A. Moore
point of making a formal analysis impossible. Addition-
ally, they may present with severe cognitive, affective
and/or behavioral neuropsychiatric symptoms, Introduction
turning them into candidates for supportive psy-
The aim of this article is to relate what it is like, as a non-
chotherapy or diagnostic interviews at best (Muñoz
neuropsychologically trained psychoanalytic psy-
Zúñiga, 2015).
chotherapist, to work with someone who has experi-
Furthermore, due to the neuropsychological deficits
enced a brain injury, and in doing so to share the
they experience, these patients may benefit from
process of preparing a clinical neuropsychoanalytic case
approaches using different conceptual frameworks
report for publication in a scientific journal. The intention
and techniques, including psychodynamic, existential,
is not only to inform our community about how to write a
third wave cognitive–behavioral therapies, and so on
case study for publication in a scientific journal, but also
(Klonoff, 2010). The growing field of neuropsychother-
to encourage colleagues who might be interested in
apy teaches us that, due to the unlimited combi-
working with patients with neurological presentations
nations of personality traits, emotional conflicts,
to do so. To some extent, from the perspective of neurop-
neuropsychological deficits and functional limitations,
sychoanalysis, all clinical presentations can be thought of
it would be naïve to think a uniform approach might
as neurological – but that’s a whole different paper! This
do the job (Laaksonen, 2013; Yeates & Ashworth,
article will explore the initial period of clinical work when
2020).
working with this population, the issue of speaking
It is safe to say that not only psychoanalysis but most
different languages about similar clinical phenomenon,
of the psychotherapeutic approaches must be modified
and finally writing for neuroscientific publication.
in agreement with the patient’s neuropsychological
profile and functional level in a tailor-made fashion
(Ruff & Chester, 2014). Nevertheless, this state of affairs Psychoanalysis and neuropsychology
should not preclude the therapist from applying the
While the focus of this article is writing for publication, it
essential components of the psychoanalytic technique
is important to emphasize that it is not the most impor-
when considered useful and relevant (Kernberg, 2016).
tant thing. Most likely you do not need to be reminded
After all, our rich metapsychological constructs may
of this, but first and foremost the case is a psychoanalytic
capture subtle changes in mental functioning after the
treatment of a person. This is more important than any-
lesion.
thing else I am going to write about here.
Why keep studying patients with neurological lesions
The first time J.L. and I met (see Moore, 2021; Moore
from a psychoanalytic point of view? Because it rep-
et al., 2017) I was alarmed by how far out of my depth I
resents a precious opportunity for building transepiste-
was. It was confronting to be in the presence of another
mic bridges, and, through a process of reverse
human being who had this unusual and difficult experi-
engineering, it may give us new insights into the work-
ence, someone who had such a unique subjectivity as a
ings of the brainmind. Moreover, as psychoanalysts
consequence of experiencing a brain injury. Neurologi-
and psychodynamic therapists, we are well suited to
cally, J.L. had, as a result of an anoxic episode, extensive
listen to the changes that take place in the inner world
lesions bilaterally to hippocampi and surrounding para-
of the neurological and neuropsychiatric patient. These
hippocampal cortical areas. Neuropsychologically, he
changes are sometimes so subtle and uncanny that
had preserved executive functioning in the context of
they might be better understood in the light of transfer-
profound anterograde amnesia. Psychologically and sub-
ence/countertransference movements, defense mech-
jectively, his lived experience was one of overall temporal
anisms, psychic structures, and mental levels of
discontinuity punctuated by disconnected 30–50 s seg-
functioning. And, if all that falls short, because very
ments of brief temporal continuity, where typically he
much like the first psychoanalysts, we are stepping
was unable to form new (episodic) memories. J.L.’s
into terra incognita, both in the theoretical and the clini-
experience was so far removed from my experience, clini-
cal sense. Brave new worlds await us.
cally or otherwise, up to that time that I found it challen-
lucesdeeuforia@hotmail.com ging to access the state of mind required to reflect

carefully about and with J.L. In reality, it took several ses-
sions before I could eventually gather myself sufficiently
enough to function adequately in this regard.
My countertransference to J.L. was also significantly
different to anything I had experienced previously, and
it took me quite some time before I could begin to map
it out. It was the first time I had encountered what our
neuropsychologist and neuropsychologically trained
psychotherapist colleagues refer to as an “organic” trans-
ference phenomenon (Salas et al., 2013) – which mani-
fested in J.L. as an amnesic transference. J.L. left a trail
of forgetting behind him as he moved through life.
Care workers, nurses, psychologists, receptionists, taxi
drivers consistently forgot about J.L. and associated
tasks in many ways. I realized quite quickly that I too
had been caught up in J.L.’s wake and subject to these
transferential phenomena with an above average fre-
quency – forgetting changes in appointment times or
locations within the service setting, along with many
“tip-of-the-tongue” types of forgetting within the ses-
sions themselves. Working with this population requires
significant modifications to technique, although I will
not elaborate upon these any further here, as my col-
league José Fernando Muñoz Zúñiga writes about
these modifications to technique in detail. Suffice to say
that it is a significant adjustment to how you might
work with a non-neurological population.
Upon commencing work with people who have
experienced a brain injury, it is important to be prepared
for uncertainty, frustration, and anxiety, while at the same
time to place trust in your training and clinical experience.
When you settle into the work with the person, it will
become possible to formulate a hypothesis about what
is happening in the therapeutic relationship, but again,
this takes patience and time. It is unexplored territory –
very little is written or recorded in the scientific literature
about long-term clinical psychoanalytic work in the area
of profound amnesia or any other sequelae of significant
brain injury. An open-minded attitude is preferrable.
Detailed notes are helpful and if possible audio record
and transcribe the sessions. Pay particular attention to
your countertransference, and to how this transference
phenomena may be reverberating around and through-
out the person’s family, social circle, service team, and set-
tings. The big picture is important here too, in so far as
tracking how the transference relationship develops
and changes over time. In many respects these clinical
case studies are also longitudinal case studies.
Communicating across the interdisciplinary divide
In my experience it is not possible to do this work effec-
tively without the help of, and collaborating with,
NEUROPSYCHOANALYSIS 183
neuropsychology colleagues. In many respects it is like
learning a new language – I had only a rudimentary
understanding of human neuroanatomy or neuropsy-
chology when I began to work with J.L., and I was
really at sea with many of the concepts. It was a critical
source of support, and ongoing education, to have my
colleague Christian Salas, who is both a clinical neurop-
sychologist and a psychoanalytic psychotherapist, avail-
able to talk with. We met frequently – once or twice a
month. I would select excerpts of sessions of interest
and we discussed them from both psychoanalytic and
neuropsychological perspectives.
Good supervision helps too, and it is important to
have separate supervision for neurological cases, if poss-
ible, with a supervisor who speaks both languages or at
least one who is open to a cross disciplinary approach –
unfortunately and disappointingly, this is not always the
case. I was extremely fortunate in this regard, and still
am, to have Prof. Oliver Turnbull as my Ph.D. supervisor
for expert neuropsychological guidance and supervision
in this clinical work. Another issue to consider is author-
ship. While it is not at all unusual for psychoanalytic
papers to be published by one author it is, however,
unusual in the neurosciences for a paper to be authored
by only one person. Prospective researchers should be
prepared, and open, to co-author papers – I would go
as far as to say it is necessary, unless you are proficient
and expert in both fields.
Writing for scientific journals – “Always answer
the question!”
The age-old refrain from professors to their students, in
relation to essays or exam questions, is to “always
answer the question.” This is sage advice, and holds
true for clinical case reports too. The audience you are
writing for is, by and large, a scientific and clinical one,
and the exam question is, “What is the scientific question
here?” Psychoanalytic and scientific writing, while often
similar, differ in important ways. In writing for a scientific
journal, it is first necessary to frame the existing litera-
ture in your given field of research, and in doing so
identify the knowledge gaps therein. These “gaps” are
aspects of the field that are not well understood, or
sometimes even known at all. The task of the clinical
case report author is to make these gaps explicit by for-
mulating a testable hypothesis and scientific research
objectives, based upon the gap in the scientific knowl-
edge base. It is useful to imagine the knowledge base
as a multi-faceted entity containing everything that is
known, at a certain point in time, in relation to a topic
of enquiry, and we as researchers are adding little bits
of knowledge to that entity through our scientific
184 D. FLORES MOSRI ET AL.
efforts. The aim of the case study report is to develop an
argument that investigates how elements of your clinical
case might offer a possible solution to an existing scien-
tific question. In the discussion section of the case report
you can then reflect upon and speculate about how this
might relate to the existing scientific and psychoanalytic
literature – and in doing so generate new hypotheses
and potential avenues of future research. Again, collab-
oration with good colleagues can be really fruitful in for-
mulating and developing these discussions.
Stepping into the explanatory gap
In many respects clinical neuropsychoanalytic research
can be thought of as a lived experience and the embodi-
ment of occupying the Explanatory Gap (Chalmers, 2006)
between the physical processes of the brain and the
psychological life of the mind. Neuropsychoanalytic clini-
cal research explores questions such as: how do psycho-
logical states (consciousness) arise out of particular
constellations of nervous tissue? What kind of conscious-
ness is present in the people we work with who have
experienced a brain injury? How does the resultant phys-
ical configuration of their nervous systems, owing to
lesions from the brain injury, relate to their psychological
consciousness? What are the implications of this for psy-
choanalytic metapsychology? And finally, what might the
implications for clinical technique be? (For a detailed
example of this process please see: Moore, 2021; Moore
et al., 2017; Moore & Turnbull, 2022). One of the ways neu-
ropsychoanalysis tries to answer these questions is
through clinical case reports. An example of this
process is briefly summarized below for the reader.
In summary, the existing literature that framed our
research was contained primarily in the seminal book
Clinical Studies in Neuro-Psychoanalysis (Kaplan-Solms &
Solms, 2000) and in the data generated by Oliver Turn-
bull et al. (2006) investigations of some psychoanalytic
phenomena in patients who have experienced an
acquired brain injury. The existing knowledge base had
established that confabulation, where it occurred, had
a statistically significant affective basis as opposed to
the prevailing view that it was due to a deficit in execu-
tive (cortical) functioning. There was also evidence in
this literature of the capacity for the patients to
develop a transference relationship with their therapists.
However, these therapies were all brief in duration, thus
providing us with our knowledge gap. We were inter-
ested to explore how long-term psychoanalytic work
might look with these patients, and particularly in a pres-
entation where there were bilateral lesions to the hippo-
campus resulting in profound anterograde amnesia in
the context of preserved executive functioning.
Notably, it was the first time that clinical work with this
kind of patient had ever been researched in the history
of medicine. The questions we formulated on the basis
of the existing literature were as follows: Is it possible
to work psychoanalytically with patients with profound
amnesia? Are psychoanalytic dynamics present? (If so,
what might they look like?) Can people with profound
amnesia develop a sustainable and functioning thera-
peutic alliance and transference relationship? Is a psy-
choanalytic psychotherapeutic approach that places an
emphasis upon unconscious and affective processes
effective with this population? You’ll be glad to hear
the answer to all of these questions is a resounding yes!!
Finally, good luck with your journey in writing clinical
cases for publication. I hope it will be as interesting,
exciting, educational, and rewarding for you as it has
been for me.
moorep4@tcd.ie
Writing the neuropsychoanalytic case study
of the neurologically intact patient
Virginia C. Barry, M.D.
Psychoanalytic and neuropsychoanalytic case reports
attempt to conceptualize clinical phenomena from
different points of view. Whereas a psychoanalytic case
report references various models of psychoanalytic
thought, the neuropsychoanalytic case report additionally
aims to reference brain function. In writing up the case
study of a non-neurologically impaired patient in neurop-
sychoanalysis we are trying to bridge the gap between
the psychoanalytic frame and the neuroscience frame.
Or to say this another way, we are trying to expand our
knowledge of psychological functioning by looking at it
from the top-down perspective of highly sophisticated
language describing subjective experience and from the
bottom-up perspective of the organization of the
nervous system. This brief essay suggests how we might
bridge the gap between subjective and objective, effec-
tively correlate the psychological presentation with the
neurological functioning, and convey this to the reader.
Consider first some insights on how to write compel-
lingly about a case in psychoanalysis or psychoanalytic
psychotherapy. What distinguishes such write-ups is
precisely what differentiates a psychoanalytic treatment
from other treatments, namely attention to the dynamic
processes reflected in the patient/analyst exchanges, the
focus on the transference, and the evidence pointing to
the operations of a dynamic unconscious. Importantly,
through recounting the “he said/she said” interactive
process, a writer of a psychoanalytic case can present a
granular look at the dynamic exchanges between the

patient and analyst and make inferences from this data.
The writer of an analytic case report selects and organizes
segments of the analytic work to demonstrate how her
interventions have affected focal issues. In other words,
the writer of an analytic case presents experiential data
in the form of “when I said this, the patient responded
with that,” followed by reflections on how the analyst
understood the implications of such exchanges,
perhaps followed by some commentary or theorizing.
Neuropsychoanalytic case write-ups of non-neurolo-
gically impaired patients should aspire to something
more: a granular description of the process
accompanied by hypotheses about how and what
brain functions might be contributing to what has
been observed. Additionally, such a case write-up
should suggest how treatment and/or theory is altered
by understanding the neurobiological processes.
This is not an easy task, and it is one that is suscep-
tible to reductionism and oversimplification. By way of
example, let’s consider affective neuroscience and the
current focus on the innate emotion systems as ident-
ified by Jaak Panksepp. Certainly Mark Solms (2018)
cogently argues that we can guide our treatments by
identifying the emotional systems that are engaged in
the course of the psychoanalysis. Many authors
(Damasio, 2018; Panksepp & Biven, 2012; Solms, 2021)
agree that these emotional systems operate as evolutio-
narily-determined motivational systems essential in
maintaining the homeostasis necessary for survival.
Thus, one of the goals of psychoanalysis is improving
the patient’s effectiveness in using emotions in the
service of maintaining homeostasis. The corollary
theory suggests that maladaptive solutions to various
emotional challenges may have been prematurely auto-
matized (Solms, 2021) such that our patients repeatedly
fail to navigate certain situations; the expression of
negative affect is an error signal indicating that the indi-
vidual has diverged from her homeostatic set points; the
“prediction” (predictive coding is an organizing frame-
work) has failed and emotions point to which emotional
system has failed. Examples run the gamut of our psy-
choanalytic work. In our consulting rooms we hear
about and observe emotions – those predominating at
the beginning of a treatment and those that manifest
in the course of the treatment. We can think about the
neuroanatomical and chemical processes that instanti-
ate these emotions and entertain hypotheses about
what has gone awry such that our patient is experien-
cing unwanted emotions. But we have to use caution
in directly applying our knowledge of the innate consti-
tution of emotions. We all know that sessions filled with
rage and anger don’t necessarily tell us that the pro-
blems in the patient’s life are a function of the RAGE
NEUROPSYCHOANALYSIS 185
system. Clinicians know how often revving up anger
serves to support a vulnerable self-esteem in a person
trying to cope with a sense of helplessness and frailty.
It is only by examining the patient’s responses to the
analyst’s comments, and observing dynamic processes,
that we begin to decipher where the problem lies. Is it
primarily with RAGE or is the emotion used defensively,
as when rage defends against an affect generated by
feeling helpless or vulnerable? Furthermore, complex
emotions are combinations of the primary emotions
and need to be unpacked within the clinical hours.
What we see in our consulting rooms is a complicated
mixture of the workings of emotional systems in a
dynamic world. How we use the emerging information
about emotion systems is in its infancy, and yet it is
important to try to write systematically about how we
are trying to use the information. We can make progress
by tracking our patients’ emotions as they respond to
our interventions that are informed by our knowledge
of emotional systems and contemplate how we might
reconceptualize or expand our knowledge of psycho-
logical functioning. This begins to bridge the gap
between neurology and psychoanalysis.
As I said, it is necessary to identify how neuroscience
contributes to how we are thinking about our interven-
tions, how it makes more precise our understandings of
the operations of the mind, or how knowledge of neuro-
science changes what we actually do. For example,
when I develop a clinical hypothesis that a patient
suffers from difficulty within the PLAY emotional
system – e.g. needing to dominate rather than
knowing how to negotiate – my interventions will
often model, and thereby teach my patient a new skill
of interpersonal negotiation. More than interpretation
is called for. But if I have not conceived of an emotional
system that guides this kind of interpersonal process, I
will understand the process differently. The correlations
between brain functioning and psychological function-
ing in the neurologically intact patient do not rely on
the tests performed on patients with neurological
damage such as fMRIs, PET scans, EEG’s and whatnot,
and instead rely on our clinical observations that have
been informed by our neuroscience knowledge. This
renders hypothetical our neuropsychoanalytic infer-
ences. In truth, this is no different from the value of infer-
ences made from the presentations of single
psychoanalytic case studies, but the vantage point
from where the inferences are made differs.
There are not many neuropsychoanalytic write-ups of
non-neurological cases in the literature, but I’d like to
offer one that can serve as an example: Patrice Duquette
and Vivian Ainley’s report (2019 entitled “Working with
the Predictable Life of Patients: The Importance of
186 D. FLORES MOSRI ET AL.
‘Mentalizing Interoception’ to Meaningful Change in
Psychotherapy”).
The authors – one a psychodynamic clinician and one
a neuroscience researcher – present a patient who has
not learned to effectively use her body’s emotional/visc-
eral information and thus has many difficulties,
especially in interpersonal relationships. From the neu-
ropsychoanalytic viewpoint, the authors argue that a
foundational problem for the patient concerned her
impoverished ability to “mentalize interoception” (Foto-
poulou & Tsakiris, 2017). The authors explore research
about how predictive coding is used not only in extero-
ception – perception of the outside world – but also in
interoception. They focus on the essential role intero-
ception plays in the elaboration of emotional experience
and subjective awareness, and how the process of men-
talizing interoception can facilitate treatment. The
authors present their neuroscience model and describe
how it informs their clinical theory. In the clinical presen-
tation they observe the patient’s unconscious, unrepre-
sented emotional states including transferences to the
therapist and utilize their model of understanding to
organize their interventions. The authors present close
observations of the interactions often in the form of
“he said/she said” vignettes from different points of
the treatment to demonstrate how the patient
changed as a function of their interventions. They
make a clear argument for how neuroscience research
has altered their approach to the patient.
Duquette and Ainley’s paper can serve as an example
of successful bridging of the neuroscience-psychoanaly-
sis gap. The goals of a neuropsychoanalytic case write-
up of the non-neurologically impaired patient include:
1. Laying out the neuroscience information that is new
or relevant.
2. Articulating how knowledge of neuroscience informs
the technique and clinical interactions.
3. Presenting clinical vignettes or an entire case presen-
tation to illustrate the how technique or understand-
ing changes with this neuroscience information.
vcbarry@gmail.com
Research in neuropsychoanalysis: case study
materials
Daniela Flores Mosri
Introduction
Research in any field of knowledge is difficult
for different reasons. However, research in
neuropsychoanalysis entails enhanced difficulties, since
it attempts to promote dialectics between psychoanaly-
sis and the neurosciences. The creation of suitable
research methods is an ongoing effort of increasing
complexity, even more when clinical implications of neu-
ropsychoanalysis for non-neurological patients begin to
be explored.
Many clinicians who have studied neuropsychoanaly-
tic topics claim that it has changed how they work with
patients. Documenting those modifications is essential
at this stage. One avenue is through clinical case
reports. What happens with a particular case may
share some features with other cases. However, clini-
cians are aware that all cases are unique. Freud heavily
relied on case reports to develop his theory. He con-
sidered psychoanalysis to be a research method in
itself, as every session with a patient was a way of explor-
ing the mind and its unconscious quality. The latter is
distinctive of psychoanalysis. However, publishing per-
sonal details revealed during psychoanalytic sessions is
a delicate matter, as it involves disclosing sensitive infor-
mation about the patient and the analyst/therapist.
Hence, the aims of writing a clinical case report should
be clear for authors. It is not a decision that can be
made lightly. To understand how clinical materials may
represent an ideal opportunity to contribute to the gen-
eration of knowledge, this brief essay attempts to dis-
tinguish the contributions of case reports and to
advance ideas to conduct research through case study
materials.
The question of psychoanalysis and science
An exercise that any potential author can resort to is to
imagine themselves as the case to be presented. What
should be considered a strong reason for accepting
the disclosure of such personal information? Probably
the clear identification of the contribution that the
case material can make. For neuropsychoanalysis, the
only way to identify the way it is changing psychoanaly-
tic practice is by looking at the clinical situation. Whether
we are trying to apply a method designed to work from a
neuropsychoanalytic perspective or we are trying to
identify spontaneous modifications to eventually
design new methods, a systematized revision of our
technique is essential.
Any presentation of single case materials opens the
discussion about the scientific status of psychoanalysis,
which has been questioned precisely because of its
methods of data collection and reporting. Freud’s case
reports, as most clinical case reports do, refer to one par-
ticular context shared by two people that is impossible
to replicate. Furthermore, Freud sometimes wrote

about cases he did not even treat himself (e.g. Hans or
Schreber). He generalized the knowledge he inferred
from a unique experience, most of the times without
reporting the case materials. As many authors in psycho-
analysis have followed Freud’s method, there are numer-
ous analytic case accounts that report single isolated
experiences. While these are useful, few attempts to
describe a sample and analyze data derived from
similar case reports have been made. Kandel (1999)
warned us that the method based on clinical case
reports had probably exhausted its investigative poten-
tial. He underscored the inevitable bias of the clinician as
an observer and claimed that the psychoanalytic situ-
ation is not a sufficient basis for a science of mind.
Kandel also highlighted the need for testing psychoana-
lytic concepts as an attempt to save psychoanalysis from
going into a deep crisis against the preference for short-
term treatments based on particular objectives. These
critical problems in psychoanalysis are also highlighted
by Popper’s idea that psychoanalysis cannot be
falsified and is therefore not a science (Popper, 1963).
Is the status of psychoanalysis as a science important?
If so, why would it be important? These questions
have been discussed by many authors (e.g. Grant &
Harari, 2005; Grünbaum, 1979; Kächele et al., 2009;
Solms, 2018).
Some people find Kandel’s statements offensive to
psychoanalysis. Nonetheless, what he was trying to do
was the opposite of an offense; in order to strengthen
the crucial contributions of psychoanalysis, Kandel
suggested testing its concepts, particularly while
relying on knowledge from biology. Such an endeavor
represents an enormous challenge that neuropsychoa-
nalysis has readily taken. But some still ask why psycho-
analytic theory and technique would need to be tested.
Should neuropsychoanalysis aim to give psychoanalysis
a scientific status? These questions cannot be answered
without considering that there are reports of many suc-
cessful treatments conducted without the knowledge
derived from testing psychoanalytic principles or from
neurobiology.
Diverse opinions regarding these essential matters
related to psychoanalytic theory and practice are valu-
able. Considering the reasons of those who oppose
and those who express excitement regarding appli-
cations of neurobiological knowledge in the clinical situ-
ation is equally important. However, there is a high and
optimistic expectation that the more knowledge we
have, the better our work. Taking neurobiological
findings into account can enhance our comprehension
of what happens during the treatment and become
valuable information that helps to gradually understand
the laws that govern the mind.
NEUROPSYCHOANALYSIS 187
When some clinicians study the contributions of neu-
ropsychoanalysis, they feel that their clinical work
changes. One of the most widespread examples relates
to Panksepp’s affective neuroscience and its seven basic
emotion systems (Panksepp, 1998), upon which Solms
has proposed a clinical approach. Another example is
the identification of several memory systems and their
different roles. If the claim that clinical work has
changed because of the influence of neurobiological
knowledge, then we must conduct research of the clinical
situation. We believe that single case reports provide valid
pieces of data, that can then be considered in the aggre-
gate and further tested. The critique is that a case report is
not proper research, as it is subjective and, hence, biased.
Nevertheless, it can be argued that all types of research
are vulnerable to biases because they are conducted by
people and their very subjective perspectives. To
mention two brief examples, take the case of Olds and
Milner’s (1954) findings on what they called the reward
system of the brain; their observations of the electrical
self-stimulation behaviors of rats made them think they
were looking at the pathways of pleasure in the brain.
When Panksepp (1998) studied this same circuit as the
SEEKING system, a whole new interpretation of the orig-
inal findings resulted in understanding a basic emotion
system and its instinctual character. Subsequently, this
perspective enabled important advances in comprehend-
ing closely related topics, such as addiction (e.g. Flores
Mosri, 2017, 2019, 2021b). A second example is Allan
Hobson’s work on sleep and dreams (McCarley &
Hobson, 1977). As dreaming is more likely (but not exclu-
sively) to occur during REM sleep, Hobson equated REM
with dreaming and disregarded Freud’s dream theory
by asserting that dreams have no motivation and no
meaning. Solms’ work (1997, 2000) on the topic provided
a different approach, as he found errors in Hobson’s
interpretation, and instead made a case for dreams
being associated with motivation because of the brain
regions that tend to be highly active in dreaming, some
of which correspond to the SEEKING system. Personal
biases may have led Hobson to distort and ignore data
that were available at the time he published his con-
clusions. The latter does not diminish the value of
Hobson’s contributions, but rather is a reminder of how
any method is vulnerable to our personal biases. In
both examples, it is also possible to conclude that the
right observations were made. Overall, then, I suggest
that case presentations are not unique in being subject
to bias, since all research may be biased. We can try to
control those subjective tendencies, but we will probably
fail. Hence, clinical case materials can still be valued as
powerful sources of knowledge if our subjective ten-
dencies are acknowledged instead of ignored.
188 D. FLORES MOSRI ET AL.

Research through case presentations: Addressing materials is that they come from the spontaneous
the difference between case reports and case context in which they happen, in this case, the clinical
studies situation. Depending on the aims of the research, clinical
materials can be recorded, filmed, or documented
After covering some of the potential critiques of the suit-
through notes of the sessions. Next, a report of the infor-
ability of case presentations, the basic differences
mation is written in the best format to respond to the
between a case report and case studies should be
research aim, e.g. vignette, biography or clinical
addressed. Even when the terms can be used indistin-
history. Once the clinical material is ready, an analysis
guishably, there is a relative consensus in the literature
of information should be conducted. Clinical reports fre-
suggesting that a case study entails more complexity
quently take qualitative analyses, for example, by using
than a case report (Alpi & Evans, 2019). The psychoana-
categories. However, quantitative analyses can also be
lytic case report has often not been considered aca-
used. What results from qualitative analyses are hypoth-
demic because of a lack of agreement about
eses. As tempting as generalizing clinical observations
theoretical and clinical issues (Kächele et al., 2009).
may be, clinicians should be reminded of the singularity
When different clinicians look at the same case, they
of case study materials. This aspect does not lessen the
spontaneously think of the materials from their pre-
value of the different qualitative methods used for
ferred perspective. While the latter keeps the richness
case studies; it rather stresses the importance of
of different points of view, it also means that no
knowing what type of conclusions can be made from
general conclusions can be drawn from that material.
this sort of research. A hypothesis will require further
Clinical case reports thus are excellent for illustrating
testing through other methods that generate results
concepts and to express personal opinions, which at
(e.g. quantitative/experimental). A rich discussion of
that level, do not require further exploration. It can
both hypotheses and results should acknowledge limit-
become problematic when those opinions are used as
ations and suggestions for further research on the topic
general principles which would require to be tested
to promote knowledge.
using research methods. Case studies can thus
A final reminder about the complementary aspects
respond to the need to take the case report up to a
of quantitative and qualitative methods. Quantitative
research context that considers both the clinical and
methods test hypotheses by using a controlled situ-
the scientific aspects (Crowe et al., 2011; Kächele et al.,
ation and they produce results. Qualitative research
2009).
projects are suitable for comprehending and interpret-
The clinical explorations of neuropsychoanalysis can
ing the results that quantitative research produces. The
benefit from case reports describing treatments as
resulting hypotheses then will need further testing,
seen from this perspective without the need to
restarting the cycle. In sum, neither method is better
conduct research on a specific topic. If also addressed
than the other; they serve different aims that can
as research, case study materials can be used to properly
also be complemented by assessing the proposed
investigate the clinical situation and contribute to the
theory that comes from different types of research
development of theory and technique.
projects.
As a source of research data, the basic aspects of case
presentations can be briefly reviewed. A research project
needs a problem and/or a question to be solved; in this
Conclusions
case, the source is the clinical situation. Some examples
of clinical problems in need of further investigation may Clinical case materials should be used with extreme
include corroborating or refuting concepts, testing caution. All personal and sensitive materials should be
suggested clinical models, and proposing alternative reported and published only if they have a clear aim,
explanations to particular observations, amongst e.g. to conduct research on a particular topic. The clinical
others. Once the problem is described, the pertinent lit- applications of neuropsychoanalysis represent a chal-
erature should be thoroughly reviewed in order to docu- lenge of enhanced difficulty that requires much research
ment the problem and/or question. The project should (Flores Mosri, 2021a). Case studies are a suitable way to
then be designed using the most suitable method; if a produce related hypotheses. Any author can expect to
case study is selected, it should be clear why it is the find limitations and errors in their work. If acknowledged,
best option. Either quantitative or qualitative methods they can only mean progress, as it guarantees that they
can be appropriate for case studies. Research can be will become new research problems that provide research
based on a single case or multiple case studies. One of in neuropsychoanalysis with relevant input.
the outstanding advantages of collecting observation
dannmos@yahoo.com

Note
1. I refer to Freud’s paper (Freud, S. (1905 [1901]). “Frag-
ment of an Analysis of a case of Hysteria.” In
J. Strachey (Ed.), The Standard Edition of the Complete
Psychological Works of Sigmund Freud (Vol. 7, pp. 3–
122)). London, UK: Vintage The Hogarth Press and the
Institute of Psycho-Analysis) as Dora’s case. Page
numbers in brackets refer to this paper.
Disclosure statement
No potential conflict of interest was reported by the author(s).
ORCID
Daniela Flores Mosri http://orcid.org/0000-0003-3126-8344
Iftah Biran http://orcid.org/0000-0001-5205-4586
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