Dan Jacobs, MD, is a Training and Supervising Analyst at BPSI. His remarks below originally appeared in the Spring-Summer 2020 issue of the BPSI Bulletin, which can be read here.
In writing a novel, one invents characters who are, as in a dream, varying aspects of oneself. The challenge is to bring these characters—these different pieces of self—together in a coherent story. In this way, writing is an attempt at self-understanding and self-healing. Inevitably, our difficulties in understanding ourselves seep into the stories we tell. The failure to realize a character fully, depends not only on one’s facility with language and capacity for imagination but on one’s capacity for empathy and sympathy. One also needs to have sufficient understanding of the character’s psychic conflicts and the manner in which she will attempt to resolve them. In addition, in storytelling, there is always a choice, as in any psychoanalytic dialogue, of what to tell and what to leave out in the service of clarity and forward movement.
Our stories, no matter how fanciful, are based on lived experience. When asked about the relationship between fiction and real life, one writer replied, “Fiction is to reality as dreams are to waking.” To write fiction, we must dream; but also wake from the dream, and through secondary revision, create a narrative that we, as well as others, can follow.
What is true for writing fiction is also true for writing about clinical material. We picture our patients’ lives through what they tell us about themselves, filtering that information through our own experiences, wishes, defenses, and learning. That is the wonder and the limitation of clinical case reporting.
Publishing case material, done by many of us to help further knowledge in our field, seems to me fraught with difficulties. Kantrowitz (2006), among others, has explored this topic and found division between analysts as to the procedures and ethics involved in case reporting. Certainly, it is an invasion of privacy and breach of trust to publish information about patients without their permission. If, however, one asks for permission, the analyst has then introduced an iatrogenic complication into treatment. The patient now has to contend with the analyst’s personal ambitions—something she did not sign up to do. Disguising the patients (changing their age, origins, religion, marital status, etc.) has its own difficulties. How much can we stretch the truth without distorting our understanding of the actual psychoanalytic process? When does a case report become a form of fiction? Aren’t “composites” just that?
Written case reports are an essential part of candidate education. Nevertheless, it remains a challenge to best convey a portrait of a patient that is not overly altered for our own conscious or unconscious purposes (to graduate, to be well thought of, etc.). Even the best report, like a dream, is an invention to be met with a willing suspension of disbelief. Such a happy suspension is often not my experience in reading our literature. Instead, the descriptions of patients’ difficulties and their resolution seem to stretch my credulity. These accounts have no real sharp edges, no splinters felt under one’s skin. Little is left unfinished or still dangerous. These reports become highly varnished pieces of immovable furniture sitting stubbornly in one’s mind, blocking the way to further understanding.
The difficulty in writing about patients has led me to an alternative approach. I turn to the study of characters in fiction to elucidate aspects of psychic function. What can we understand of sibling relationships when we study the interaction of Tennessee Williams’ Stella with her sister Blanche? (Jacobs, 2006). What might we learn about paternal ambivalence by studying the response of Stanley Kowalsky to his wife’s pregnancy? (Jacobs, 2019a) How do the psychic consequences of early maternal loss manifest in the choices made by my fictional character, Hannah Avery? (Jacobs, 2019b). Perhaps, like Barchilon and Kovel (1966), we should depend on fiction to describe psychic structures and analytic situations. They cite Freud who hinted at the same when he said: “[the creative writer] has from time immemorial been the precursor of science, and so too of scientific psychology […] the creative writer cannot evade the psychiatrist nor can the psychiatrist the creative writer” (p. 776). In other words, maybe it can be permissible to be less “scientific,” and compare ourselves and our patients to characters in plays or novels instead of relying on the DSM descriptions and our usual diagnostic terminology. We could describe certain analytic interactions in terms of “a Tom Sawyer talking with raft-mate Jim” or “a Nora Helmer dealing with Torvald,” each trying to reach one another from differing subjectivities and trying to co-create a psychic space in which both can survive. Or might we describe a patient as “an Anna Karenina”—feeling angry, lost, and abandoned— before her suicide? (Can you envision insurance companies dealing with such literary terminology?)
To talk of our patients or the analytic hours in these “fictional” terms would mean extending our professional reading beyond the psychoanalytic literature. It would mean immersing ourselves in stories and having playwrights and novelists teach us about ourselves. Wouldn’t that be fun!
References
- Barchilon J. & Kovel J.S. (1966). Huckleberry Finn–A Psychoanalytic Study. Journal of the American Psychoanalytic Association, 14, 775-781.
- Jacobs, D. (2006). Blanche, Stella, Tennessee and Rose: The Sibling Relationship in A Streetcar Named Desire. Desire. The Psychoanalytic Study of the Child, 6, 320-333.
- Jacobs, D. (2019a). Three’s a Crowd: Stella’s Pregnancy and the Arrival of an ‘Other’ in A Streetcar Named Desire. International Journal of Applied Psychoanalysis, 16(3), 174-180.
- Jacobs, D. (2019b). The Distance from Home. New York: IP Books.
- Kantrowitz, J.L. (2006). Writing About Patients: Responsibilities, Risks, and Ramifications. New York: Other Press.
- AUDIO: Jacobs, D. (2019, September 23) Meet the Author: The Distance From Home [Audio file]. BPSI Archives.
Dan Jacobs, MD, is a BPSI Training and Supervising Analyst, Faculty, and Director of the Hanns Sachs Library and Archives. He is the author of The Distance from Home: A Novel (2019), Grete Bibring: A Culinary Biography (2015), Edward Bibring Photographs the Psychoanalysts of His Time (1932-1938) (editor, 2005), The Supervisory Encounter: A Guide for Teachers of Psychodynamic Psychotherapy and Psychoanalysis (1995), several essays on the works of Tennessee Williams and numerous psychoanalytic articles and book reviews.
Dan Jacobs can be contacted by email here
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