New Lacanian School debate
Samedi novembre 25th 2017
"Comment la psychanalyse opère", titre du Congrès de la NLS à Londres les 2 et 3 avril 2011, trouve sur ce blog un espace de débats et d'échanges. Les travaux de collègues de notre Ecole y trouveront place en respectant la limite de 3000 signes. Des textes courts, vifs et posant une question relative à l'opérativité de notre praxis pourront faire l'objet de commentaires, questions et remarques en direct, mais pas sans modération !
"How does psychoanalysis works", as the Congress of the NLS in London on 2 and 3 April 2011, on this blog is a space for debates and exchanges. The work of colleagues in our school will find place respecting the limit of 3000 characters. Short texts, and asking a question concerning the operability of our practice will be subject to comments, questions and comments live, but not without moderation!

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Alan Rowan

The Case Study – A Case of Scientific Delusion and Absence of Truth?

The significance and importance of “case studies” within psychoanalysis is undeniable. They are the means by which theory is “put to work” and from which it develops – particularly in terms of the necessary and on-going refinement of clinical technique. It is through such case studies that analysts come to grips with how psychoanalysis works in the real world of clinical practice, and yet, here one encounters a sort of paradox, namely, that from a so-called scientific perspective, case studies are given very little credit. The reasons for this are several though the main critique levelled at case study research concerns the so-called lack of generalizability from the singular case study to other similar or dissimilar cases and the difficulty in drawing cause-effect conclusions given that there is no contrasting intervention by which to evaluate the benefits of the specific therapeutic interventions outlined within the case study (i.e. alternative hypothesis for any change in a patient can always be generated). Critics of the case study method also point to significant problems of bias in the use of case studies that cannot be controlled for. These range from the inevitable selection of material presented, to the fact that the “researcher” is, in this case, both a participant in and observer of the therapeutic process and thus, even if well intentioned, subject to sources of conscious and unconscious subjective bias in their reporting of such material.

These are significant objections to the value of the case study as a tool for either producing new knowledge or critically testing existing knowledge/theory. Here it is interesting to note how Freud, many years prior to the rise of so called “evidenced-based practice” (which equates “knowledge” with findings from “randomised controlled trials”) could be seen to be – with hindsight – sensitive to this very issue. Thus, for example, we find that Freud is quite clear when it comes to stating what he sees as the value of the case study, namely, it exists either as a means to demonstrate (or illustrate) the work of analysis or it exists for didactic purposes. Two quotations from Freud’s “The history of an infantile neurosis” illustrate this; the first appears in footnote one on page one as follows:

“The case history was written down shortly after the termination of the treatment, in the winter of 1914-15. At that time I was still freshly under the impression of the twisted re-interpretation which C. G. Jung and Alfred Adler were endeavouring to given to the findings of psycho-analysis. This paper is therefore connected with my essay “On the History of the Psycho-Analytic Movement” that was published in the Jahrbuch des Psychoanyse in 1914. It supplements the polemic contained in that essay, which is in its essence of a personal character, by an objective estimation of the analytic material” (1918, p.7).

The second quotation appears on page thirteen and concerns the didactic function of the case presentation:

“It is well known that no means has been found of in any way introducing into the reproduction of an analysis the sense of conviction which results from the analysis itself. Exhaustive verbatim reports of the proceedings during the hours of analysis would certainly be of no help at all; and in any case the technique of the treatment makes it impossible to draw them up. So analysis such as this are not published in order to produce conviction in the minds of those whose attitude has hitherto been recusant and sceptical. The intention is only to bring forward some new facts for investigators who have already been convinced by their own clinical experiences” (1918, p.13).

In terms of the latter point it can be argued that Lacan’s elevation of the clinical case to the status of a “paradigm” is a logical extension of Freud’s position, in terms of, such cases serving as a guide for psychoanalytic practice that nonetheless recognises the singularity of each case. It is thus an approach that privileges the work of reason and judgement in what is – necessarily – a clinic of “unique outcomes” (i.e. reflecting the particularity of each subject). Of course it is precisely this real world “messiness” and complexity of the human subject that makes the question of what is to count as “evidence” for the efficacy of psychoanalysis so tricky, and indeed, it is something Freud was well aware of – almost from the beginning of his psychoanalytic work. Crucial to this was the break that took place between Freud and Fliess in the summer of 1900.  During this period Fliess made an undeniably damaging criticism (if true) of Freud and of psychoanalysis by claiming that Freud was merely a “thought-reader” and thus, effectively, merely “reading” his own thoughts into or onto the thoughts of his patients. As Meehl (1994) commenting on this incident says “Freud correctly perceived that this choice of content for the attack was deadly, that it went for the jugular” (p.4) Indeed Freud was so affected by this criticism that we find him a year later responding to Fliess in a letter in the following terms:

‘In this you came to the limit of your penetration, you take sides against me and tell me that “the thought reader merely reads his own thoughts into others”, which deprives my work ofall its value. If I am such a one, throw my every-day life (the paraprax book) unread into the wastepaper basket’ (quoted in Meehl, p.4).

Wittgenstein’s infamous criticism of Psychoanalysis is somewhat similar. He does not dispute, for example, that there may be therapeutic benefits for a patient who adopts a psychoanalytic way of understanding their life and suffering, rather, he holds, that in doing so they do not discover a hitherto unknown truth but are simply persuaded to see things in a certain way – which may be for the better – or not. Thus he writes:

“If you are led by psychoanalysis to say that really your motive was so and so, this is not a matter of discovery but of persuasion. In a different way you could have been persuaded of something different. One thinks of certain results of psychoanalysis as a discovery Freud made as apart from something persuaded to you by a psychoanalyst, and I wish to say that is not the case” (in: Moore, 1962, Wittgenstein’s Lectures 1930-1933)

Crucial to Wittgenstein’s argument is the notion that the criterion for the “truth” of any interpretation is – in the end – the analysand’s consent to or acceptance of it. Here, however, Wittgenstein’s criticism begins to unravel and precisely in relation to the fact that, as Miller in his article ‘Marginalia to “Construction in Analysis” (1994/2011), amply demonstrates consent was not for Freud a privileged criterion in relation to unconscious truth.

Nevertheless what is perhaps clear at this point is that this question of what sort of evidence can be produced to show both how and that psychoanalysis works was crucial for Freud and indeed remains so today. So returning now to the question of the case study we can ask, what legitimises our faith in it?  At one level we can of course go on the offensive and point to the many problems that form part of the “evidence based” approach to clinical practice, which, ultimately make so many of the randomised control based “findings” more or less irrelevant in the real world of clinical practice[1].  By contrast one can argue that the case study offers a potentially rich source of ideas alongside an in-depth and precisely illustrated account of the clinic that approaches or mirrors our actual clinical experience. By adhering to it we therefore value pertinence, and refuse the researcher’s constant temptation to reshape the world to fit his or her models, in what amounts to a “search for certainty” that is, it has to be said, simply misguided when we are dealing with the particularity of human subjectivity. In this context it is therefore interesting to note that a staunch defence of case-study research has been made from outside the field of psychotherapy, and by none other than a Professor of Major Programme Management at Oxford University (previously Professor of Planning at Aalborg University)[2]. In this article Flyvbjerg (2006) makes a number of points in relation to the “real world” importance and value of case-study research, though more importantly he consistently shows how case studies remain vital in informing us about this real world and how they effectively guide our actions in relation to it.  His telling illustrations come from many fields of human endeavour as divergent as academic research, science, medicine, town planning, anthropology and policy-making to mention just some. Based on this analysis he reaches five strong conclusions which I briefly summarise as follows:

  1. It is only through the case study that we have access to the richly descriptive and context dependent information that is essential to human learning and the development of true expertise. Indeed without such research we are left with a view of human behaviour as rule governed, predictive and based on universal knowledge, which Flyvbjerg argues, will precisely leave us in the position of always being “beginners” in responding to the complexity and reality of  “real world” practice.
  2. Contrary to the usually maintained critique of case study research, science, from Newton to Darwin and beyond, has consistently shown us that it is indeed possible to both formalize knowledge and to generalize based on the force of example from paradigmatic case studies (or in Popper’s sense to falsify particular claims via a critical counter-example) – leading recently for example – and within our own psychoanalytic field, to the development of the clinical category of “ordinary psychosis”
  3. Case studies are not just useful for generating hypothesis (as critics of this methodology maintain) but in fact offer an essential means by which the researcher can explore and test the links that are made between theory and practice. Here Flyvbjerg points out that case studies have the potential to be “information rich” in a way that randomised samples cannot be and thus the selection of  “critical cases” can in fact function as a crucial testing of theoretical assumptions (in identifying “critical cases” Flyvbjerg suggests we should choose cases that either clearly confirm or irrefutably falsify propositions and hypotheses).
  4. It is often claimed that case studies are particularly prone to subjective bias whereby the researcher invariably “selects” material that verifies his or her pre-existing understanding of the data. However, not only is this, in any case, a major problem in so-called objective research (e.g. the notorious finding that, for example, outcome studies in psychotherapy more often than not reflect the theoretical bias of the researcher(s)) but there exist numerous case studies where this clearly does not happen. Indeed Flyvbjerg claims that the case study researcher is actually in a strong position to avoid such distortion by simply letting the material speak for itself (i.e. in all it’s complexity).
  5. In the case study one has the possibility of encountering a rich and dense narrative in the form of a “virtual reality” that simply cannot be reduced to academic type generalisations (the latter seeks to strip out the small details – but – it is precisely such details that in many fields of research are of greatest interest). It is thus in this access to the particularity of a case that the case study offers us a unique source of learning – a form of “knowing” that is not otherwise open to us.

Based on the above it is clear that in relation to the case study we can afford as psychoanalysts to be far more insistent on their value than is sometimes the case and moreover insist too that they need to continue to play a strong role in evaluating and developing our practice and theory. In practice they represent moments when we can demonstrate and share our “know-how” – how we made the analytic act count – in relation to what was unique and particular in a given subject’s knotting together of the Real Symbolic and Imaginary. By way of conclusion we can note one further point, namely, that in presenting cases we are inevitably involved in a communal activity, the “audience” being thus, like the presenter, equally responsible for the future development of our field.


[1] I am assuming familiarity with the many problems associated with the so called “evidence based” approach within the field of psychotherapy and psychology – see for example – “The Perverse Effects of EBM and the Remedies that Psychoanalysis Brings” by Éric Laurent, available at: www.ampblog2006.blogspot.com

[2] Available at: http://flyvbjerg.plan.aau.dk/Publications2006/0604FIVEMISPUBL2006.pdf

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