"But read above all your own unconscious, that book of which only one copy has been printed, whose virtual text you carry everywhere with you, and where the script of your life is written, or at least its rough draft."
Jacques-Alain Miller, "Letters to an Enlightened Public".
Ever since the Seminar of the Freudian Field was created in Barcelona in 1985, its meetings have consisted of two different sections: a seminar on texts conducted by a lecturer, and a seminar on clinical cases, delivered jointly by the lecturer and two psychoanalysts who "present" a clinical case from their own practice.
Today, during this first meeting of the 2007-2008 Seminar, no cases will be presented, but we will attempt to generate a debate among the audience on the content and the form of cases and on their role in the formation of the analyst and the teaching of psychoanalysis. With this purpose, I have prepared "some" observations, some items, to encourage everyone to participate in a constructive discussion.
1. Every subject is a clinical case.
According to the María Moliner dictionary, a clinical case is "each individual manifestation of a disease, especially if it is not common". If I maintain my statement, I may ask: which is the disease shared by all human beings, of which each subject is an individual -not a common- manifestation? The human species is sick with language. Paradoxically, that which renders humans "superior" to other species -the presence and the power of the symbolic- is also their shared ailment: there is no sexual relationship, no fixed, written, determinate relationship whereby a man or a woman may identify his or her partner. For the other species, instinct suffices.
Each subject is a case of this "shared ailment", since each subject devises a particular solution to the problem, the symptom. When that solution finds a stop, an obstacle that leaves the subject bare to face "that which is unbearable", the clinical aspect of the case becomes evident –because even though one may have symptoms, as long as one is able to manage by oneself, such symptoms are not approached from a clinical perspective.
2. A clinical case is not a practical case.
The practical case is a tool for teaching something or for assessing established knowledge. It is used in several fields, as diverse as medicine, macroeconomics and cognitive-behavioral psychology. The practical case aims to "teach how to proceed", that is to say, to teach the way in which a concrete problem should be handled –or to assess whether this knowledge already exists- so that if such procedure is repeated in an identical way, it will yield the same successful results.
When Lacan said "do as I do, do not imitate me", he rejected repetition, imitation, copy as a model of analytic practice. The clinical case, then, does not seek to "teach how to proceed" but to pass on the unique "know how" of each psychoanalyst about each concrete case.
3. The clinical case points to that which is singular, not to that which is collective.
The question: "What may I expect [from analysis]?", is answered by Lacan as follows: "To make sense of the unconscious of which you are the subject". That is the distinguishing feature of unconscious knowledge, it is a knowledge that organizes the life of the subject so that he may confront the lack of a sexual relationship, a knowledge for which the subject is responsible and about which he nevertheless knows nothing.
Therefore, psychoanalysis is not the path toward assessing knowledge that is already present, an established knowledge, but –always- an encounter with new knowledge, unique to each subject, that concerns the singularity of his solution.
Lacan’s later teaching stresses the issue of singularity insofar as it removes the shelter previously afforded by clinical categories: foreclosure, now, becomes widespread to every speaking subject. A neurotic subject is nothing but a particular case in which the Name of the Father enables the knotting together of the three registers. Thus, the singularity of the case is related to the subject’s modality of jouissance and to his "know how" regarding this modality.
And then, there are particular ways in which a subject –unable to rely on that signifier– has found or invented as a solution, in order to knot together the real, the symbolic and the imaginary; one finds there an infinite variety yet to be explored.
Some of these peculiarities are accounted for in the clinical case.
4. The clinical case confronts theory and practice.
The entire theoretical grounds upon which psychoanalysis is based are at stake in each clinical case. There are no exceptions to this. However, there is a difference between clinical cases and presented cases, since the latter include a commentary by the psychoanalyst: his presentation emphasizes a specific point he wishes to underline. The presentation focuses particularly on a certain moment of the treatment, a point of inflection or change; it provides a retroactive point of view on what has taken place during the analytic work with regard to a concept or comments on the prospects for the work that may lie ahead… in any case: the case is never the whole.
If one may say that the psychoanalyst builds the case, this is precisely what he does: he provides a central theoretical axis -framed with quotes or readable between lines-, which the particular case of the specific analysand confronts, either by questioning it or by exemplifying it.
5. The clinical case shows that the subject is affected by his history, not by his biography.
A subject’s biography is of no use for building a case or for establishing the direction of a treatment. To begin with, because psychoanalysis is a treatment that may only be applied to the material produced by a subject, that is to say, subjective material, and is not concerned with that which is objective.
However, the subject’s history is indeed relevant because it brings to the forefront the subject’s responsibility –which, after all, is all we can count on- by outlining the marks left on the subject by his elders with his consent, the inflection points the subject allowed in his life, the repetitions he caused; from all of this, one may single out which elements of the real were experienced by him as traumatic.
Finally, Lacan used to say: "What we teach the subject to recognize as his unconscious is his history".
6. The clinical case reveals the orientation towards the real.
It was not hard for Freud to discover that dreams, with their symbolic work of condensation and displacement, have the goal of satisfying an unconscious drive, jouissance, in Lacan’s terms. It took him a little longer to draw the following clinical conclusion from the fact that this satisfaction of drives is rooted in the symptoms: unraveling the meaning of symptoms through interpretation does not make them disappear. Therefore, that which leads a subject to seek analysis, the symptom, appears -in the context of the clinical case- to be the means found by the subject to deal through language with the jouissance that inhabits his body. And such real jouissance is what guides the analytic experience. Freud located it, Lacan formulated it, and Miller organized it into six paradigms. Thus, the Lacanian psychoanalyst is warned against the "furor sanandi", and his aim is to accompany the subject in his task of producing, reconstructing, or modifying a knotting together of the three registers that may enable him to bear the irreducibility of jouissance.
7. The clinical case encompasses the work of the analysand and the act of the analyst, in the context of transference.
The analysand uses free association as a tool to perform two tasks, reminiscence and construction. Memories, as well as constructions, are somehow signifying productions. Therefore, one cannot do without the other, since memories appear –or, if they have always been present, take on an unexpected value, a new significance- that result in a construction of the case according to the way in which these memories are approached in the context of transference. But such analysand´s work would be impossible to complete without the direction of the treatment determined by the act of the analyst, an act whose timing and form and whose effect on the analysand are typically unpredictable. Its efficacy can only be appreciated après-coup.
The clinical case, then, must reflect the orientation that the analytic act has given to the analysand´s work, and at the same time, the fact that the production of the Lacanian analytic act does not respond to standards but to the particularities of each case, individually considered.
8. The clinical case results from the three pillars of the formation of the analyst: analysis, education and supervision.
Obtaining a license to practice psychoanalysis is complex issue, since such license is not accredited by any degree or certification. Each analyst must authorize himself, but this does not mean that he should do so on his own.
The analyst achieves this through the subjective transformations produced during his analytic work, based on the lessons received from the School, by making a commitment to have his acts supervised and by agreeing to have his work checked by his peers. This is what Lacan recommended in his "Act of Foundation" of 1964.
Despite this, or precisely because of this, the psychoanalyst is the only one who can and should account for the clinical case he presents.
9. The clinical case is key for the transfer of knowledge within the analytic community.
The aim of clinical case presentations is to educate the analytic community. The psychoanalyst –as I have already stated- presents the analysand´s work and his analytic act, but in order for the teaching process to occur, it is essential that a third party become involved: the audience. The audience involved, then, also presents its views, through its questions, its contributions and even –why not?- through its discrepancies.
Certainly, the coordinates of a case are decided in the context of the privacy of the analytic relationship established between the analysand and the analyst; some seal the ethical commitment thus and develop their practice in solitude, but when one wishes and agrees to belong to a working community such as ours, one accepts and chooses that one’s practice be useful to other people besides one’s analysands.
10. The clinical case observes ethics and the law.
Freud discovered a law of data protection upon which he founded psychoanalysis, a law that renders the unconscious inaccessible to the subject: repression.
Repression is one of the paradoxes of analytic practice, as far as information is concerned: the subject asks the analyst for his supposed knowledge, and the analyst can only induce him to talk, hoping that the subject himself will eventually reveal such knowledge in his own words. So, regarding what has been said about the analyst, what could the subject think he may have access to, other than what he himself has confided?
Nevertheless, secrecy lies in the very foundation of the analytic relationship. The patient’s trust in the analyst is based on a fundamental rule of ethics: he may not speak about what he hears, and there are no exceptions to this: he may not tell... others what he hears regarding the subject, his relations, his history, or his daily life.
Given that today, in addition, we must abide by the "Law on the Protection of Personal Data" that has been in force in Spain since 1999, we must stress that the issue of the ethics of the analyst goes beyond the law.
How, then, should a clinical case be presented? That the ethics of analysis be observed during the presentation of a case and that this be done "according to the law" require that the construction of the case exclude any data that might reveal the identity of the analysand or –this is important- that might lead to his identity being found out: that is to say, "the person" should be neither identified nor identifiable. And at present, simply taking into consideration the specific audience for which the presentation is intended cannot ensure this; information circulates far beyond what we can imagine.
From the point of view of ethics, what matters is to protect privacy –details need not be revealed in order to show lines of force-; to refrain from passing judgement on a subject’s life choices or on the attitudes of those who are close to him, and to avoid stigmatizing his environment.
Presenting a clinical case, then, is a true work of writing that involves tact and discretion, and at the same time requires precision.
My observations, like the clinical cases themselves, are only a part, not the whole. I set out to write ten points, I believe you will be able to add some more.