Sigmund Freud’s cases are often held against him. What could be worse, it is argued, than his founding a would-be science – psychoanalysis – on the basis of his own case and those of patients he happened to treat in Vienna? He thereby contravened Aristotle’s ruling that “what is individual…cannot be an object of knowledge”. Yet we arrive at universal truths only by extrapolating from individual instances.
This is true of anthropology, where theory building results from interpreting a set of observations within an intelligible frame. So too with law, which, at least in England, proceeds through comparing cases, one with another. The physicist operates similarly. He uses past exemplars as means of learning, John Forrester observes, “to see his problem as like a problem he has already encountered”. And in medicine, doctors, faced with individual cases, consider ways they are akin to and different from those that they have seen before.
The same is true of psychoanalysis. Forrester illustrates this point by showing how the psychoanalyst Donald Winnicott’s treatment of Patrick, a patient who became ill after his 11th birthday when his father drowned, is both similar to, and different from, other cases. Although like many other cases it involved the therapeutic value of “the holding environment”, it differed from them by bringing to mind an image not of mothering but of Patrick’s father supporting the family when he was alive, and St Christopher holding, sheltering and protecting a child over water.
Forrester also considers an example that serves to illustrate ways that individual cases shape the thinking of both patients and their psychoanalysts. He focuses on a young woman named Belle, her experience of her psychoanalyst Robert Stoller, and his experience of her. He shows how Belle had a daydream in which, at the behest of a film director, she is raped by a stallion that turns into “a disreputable, ugly old man”; and how her experience led Stoller to develop a new theory about hostility generating and enhancing sexual excitement.
Forrester ends by considering another case history – that of Agnes, “until the age of 17…a boy”, but who at 20 had gender reassignment surgery. Stoller, her psychoanalyst, diagnosed her as an intersex patient who was born male, but who, after puberty, developed female breasts, waist and buttocks, and did not grow facial hair. Well after the operation, however, she revealed to Stoller that at the age of 12 she had started using her mother’s oestrogen replacement treatment. Why? Because, it seems, she had been adored by her mother as an effeminate boy and wanted to acquire a female body. Agnes’ case led Stoller to identify “major errors in [his] thinking” and abandon his previous theory that gender identity results from “an endogenous biological force”. Instead, he concluded that it was due to rearing.
Forrester presented this case at a June 2015 conference in Berlin, just a few months before he died. Thank goodness he left this insightful book in his wake. It offers an engaging and informative critique of those who, like Aristotle, reject individual instances as objects of knowledge, as well as giving a very welcome account of the value of thinking in cases not only in psychoanalysis but also in anthropology, law, physics and medicine.
Janet Sayers is emeritus professor of psychoanalytic psychology, University of Kent.
Thinking in Cases
By John Forrester
Polity, 220pp, ?55.00 and ?17.99
ISBN 9781509508617 and 8624
Published 14 October 2016
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Print headline: Fully examine the patient history
