Clinical writing in neuropsychoanalysis

ABSTRACT

As the knowledge derived from the dialog between neuroscience and psychoanalysis has provided relevant insights in topics such as affects, instincts, consciousness, memory, dreams, and many 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.

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 psychoanalysis and the neurosciences. The creation of suitable research methods is an ongoing effort of increasing complexity, even more when clinical implications of neuropsychoanalysis for non-neurological patients begin to be explored.

Many clinicians who have studied neuropsychoanalytic 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, clinicians are aware that all cases are unique. Freud heavily relied on case reports to develop his theory. He considered psychoanalysis to be a research method in itself, as every session with a patient was a way of exploring the mind and its unconscious quality. The latter is distinctive of psychoanalysis. However, publishing personal details revealed during psychoanalytic sessions is a delicate matter, as it involves disclosing sensitive information 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 generation of knowledge, this brief essay attempts to distinguish 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 psychoanalytic 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 particular 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 psychoanalysis have followed Freud’s method, there are numerous 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 potential. He underscored the inevitable bias of the clinician as an observer and claimed that the psychoanalytic situation is not a sufficient basis for a science of mind. Kandel also highlighted the need for testing psychoanalytic 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 neuropsychoanalysis has readily taken. But some still ask why psychoanalytic 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 successful 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 valuable. Considering the reasons of those who oppose and those who express excitement regarding applications of neurobiological knowledge in the clinical situation 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.

When some clinicians study the contributions of neuropsychoanalysis, 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 aggregate 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 original findings resulted in understanding a basic emotion system and its instinctual character. Subsequently, this perspective enabled important advances in comprehending 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 exclusively) 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 conclusions. 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 tendencies are acknowledged instead of ignored.

Research through case presentations: Addressing the difference between case reports and case studies

After covering some of the potential critiques of the suitability of case presentations, the basic differences between a case report and case studies should be addressed. Even when the terms can be used indistinguishably, there is a relative consensus in the literature suggesting that a case study entails more complexity than a case report (Alpi & Evans, 2019). The psychoanalytic case report has often not been considered academic because of a lack of agreement about theoretical and clinical issues (Kächele et al., 2009). When different clinicians look at the same case, they spontaneously think of the materials from their preferred perspective. While the latter keeps the richness of different points of view, it also means that no general conclusions can be drawn from that material. Clinical case reports thus are excellent for illustrating concepts and to express personal opinions, which at that level, do not require further exploration. It can become problematic when those opinions are used as general principles which would require to be tested using research methods. Case studies can thus respond to the need to take the case report up to a research context that considers both the clinical and the scientific aspects (Crowe et al., 2011; Kächele et al., 2009).

The clinical explorations of neuropsychoanalysis can benefit from case reports describing treatments as seen from this perspective without the need to conduct research on a specific topic. If also addressed as research, case study materials can be used to properly investigate the clinical situation and contribute to the development of theory and technique.

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 case, the source is the clinical situation. Some examples of clinical problems in need of further investigation may include corroborating or refuting concepts, testing suggested clinical models, and proposing alternative explanations to particular observations, amongst others. Once the problem is described, the pertinent literature should be thoroughly reviewed in order to document the problem and/or question. The project should then be designed using the most suitable method; if a case study is selected, it should be clear why it is the best option. Either quantitative or qualitative methods can be appropriate for case studies. Research can be based on a single case or multiple case studies. One of the outstanding advantages of collecting observation materials is that they come from the spontaneous context in which they happen, in this case, the clinical situation. Depending on the aims of the research, clinical materials can be recorded, filmed, or documented through notes of the sessions. Next, a report of the information is written in the best format to respond to the research aim, e.g. vignette, biography or clinical history. Once the clinical material is ready, an analysis of information should be conducted. Clinical reports frequently take qualitative analyses, for example, by using categories. However, quantitative analyses can also be used. What results from qualitative analyses are hypotheses. As tempting as generalizing clinical observations may be, clinicians should be reminded of the singularity of case study materials. This aspect does not lessen the value of the different qualitative methods used for case studies; it rather stresses the importance of knowing what type of conclusions can be made from this sort of research. A hypothesis will require further testing through other methods that generate results (e.g. quantitative/experimental). A rich discussion of both hypotheses and results should acknowledge limitations and suggestions for further research on the topic to promote knowledge.

A final reminder about the complementary aspects of quantitative and qualitative methods. Quantitative methods test hypotheses by using a controlled situation and they produce results. Qualitative research projects are suitable for comprehending and interpreting the results that quantitative research produces. The resulting hypotheses then will need further testing, restarting the cycle. In sum, neither method is better than the other; they serve different aims that can also be complemented by assessing the proposed theory that comes from different types of research projects.

Conclusions

Clinical case materials should be used with extreme caution. All personal and sensitive materials should be reported and published only if they have a clear aim, e.g. to conduct research on a particular topic. The clinical applications of neuropsychoanalysis represent a challenge of enhanced difficulty that requires much research (Flores Mosri, 2021a). Case studies are a suitable way to produce related hypotheses. Any author can expect to find limitations and errors in their work. If acknowledged, they can only mean progress, as it guarantees that they will become new research problems that provide research in neuropsychoanalysis with relevant input.

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Disclosure statement

No potential conflict of interest was reported by the author(s).

Correction Statement

This article has been corrected with minor changes. These changes do not impact the academic content of the article.

Notes

1 I refer to Freud’s paper (Freud, S. (1905 [1901]). “Fragment 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.