Thinking About Our Work: Case Presentations

Abstract

Thinking About Our Work: Case Presentations Walter N. Stone1 issn 0362-4021 © 2014 Eastern Group Psychotherapy Society group, Vol. 38, No. 2, Summer 2014 153 1 Professor Emeritus, University of Cincinnati, and Coordinator of Group Therapy, California Pacific Medical Center. Correspondence should be addressed to Walter N. Stone, MD, 23 DeSilva Island Drive, Mill Valley, CA 94941. E-mail: w_stone@comcast.net. I have often wondered whether providing clinical material has enhanced the articles I have written. Lewis Aron (2013) compellingly wrote about the place of clinical case presentations in the history and present-day status of psychoanalysis, and of course, it is the same in group psychotherapy. He cited Michaels, who argued that all case reports are written for a purpose, and they reveal this purpose either implicitly or explicitly, mirroring the analysis they described. . . . Michaels suggested that case reports that are offered as “pure” scientific data are illustrations of implicit, concealed, or disavowed intentions or purposes, while fabrications or fiction accounts of prototypical patients reveal pure intentions uncontaminated by case reports. (p. 552) It is clear that all clinical data are presented from the specific perspective of the author. Aron (2013) did not neglect two other very relevant issues, of exposure and of confidentiality. A therapist often will expose himself or herself to criticism for the manner in which the clinical process was managed—that is, he or she made subtle mistakes. No one likes to expose his or her misunderstandings or lack of clinical skill. Idealized case presentations, however, are seldom very interesting. The second issue is that of patient exposure. Confidentiality of the therapy is critical. Disguises may hide many obvious aspects of the patient, but every time I have shown the patient or the group a paper I was writing, those involved could identify themselves. Nevertheless, I would agree with Aron that preferably, if not actually mandatorily, patients who are discussed should have an opportunity to read the manuscript and give written approval. That is a high bar, but I believe it 154 stone also serves the author by containing anxiety about injuring patients or about possible legal action. Such presentations may be offered in the “spirit of learning, sharing experience and thought, and encouraging reflection and contrasting perspectives” (Aron, 2013, p. 582). They are not proof of a theory. They are open to discussion and controversy. Indeed, clinical examples invariably invite discussion, which, although at times acrimonious, is also the path to thinking more deeply about how we care for our patients and what we expect to share and/or teach about our work and theories. The history of the use of such narratives goes back to Freud and the brilliance of his case presentations. Kurt Eissler (as cited in Aron, 2013) described them as “the pillars on which psychoanalysis as an empirical science rests” (p. 563). Certainly, as a clinician, case presentations stimulate my thinking about particular situations I am facing or clarify aspects of a theory. When I first began writing about groups for the chronically ill (Stone, 1996), I wondered about their reaction to being subjects for my work. After discussion with several colleagues, I decided to show patients the papers and have open discussion in the sessions. Much to my surprise and pleasure, they became quite engaged in this task and reflected on some of their interactions and behaviors. Of course, there were members who did not want to be included, but it was their peers who seemed to lead the way, not just “forcing” them to comply but genuinely working to understand the resistance. The members also commented that, by my publishing examples of their work, they knew I was deeply interested and cared about them. That was a bit of feedback that, of course, pleased me greatly. There is an additional area that has been meaningful for me. I have found that, as a supervisor, by suggesting that trainees write up their interesting clinical material for publication, I can stimulate trainees (and even advanced clinicians) to think more deeply about their work. This includes not only helping them formulate the dynamics of the experience but also suggesting that they review the literature explicating their theories. This has often...