Revisiting, Rewriting, Reexperiencing: Clinical Writing Today

Psychoanalytic writing exerts a unique allure over me.

—Giuseppe Civitarese¹

Realistically, the analyst who publishes in 2024 should expect that his patient and others will read what he has written and recognize the patient whose analysis is described.

—Lucy LaFarge²

From the inception of psychoanalysis, with Freud’s first cases, clinical case presentations have been central to analytic writing and theorizing. Ricardo Bernardi and Monica Eidlin describe such cases as “critical for understanding the complexity of real situations, for guiding toward new discoveries and hypotheses about causal mechanisms, and for being the basis for case-based learning” (p. 35). And yet, as Giuseppe Civitarese puts it: “To raise the problem of writing in psychoanalysis is not to talk about writing, but to talk through or in writing” (p. 113). The flux between epistemological and ontological aspects of analysis, as described in Thomas H. Ogden’s contribution, is one way to understand the Möbius strip aspects of clinical writing, a metaphor invoked by both Civitarese and Gurmeet Kanwal.

The problem of writing is at the core of psychoanalysis, and each of these papers addresses the problem of clinical writing in different ways. One aspect is its changing nature: over the years, our notion of good clinical writing has evolved. Extensive, biographical renderings of the patient’s life have fallen out of fashion, replaced by detailed descriptions of key moments in the analytic process; and the patient’s own biographical details have receded, in part out of concern for confidentiality given online searchable databases and in part due to the shift in analysis to a two person model. But while there is broad agreement that the analyst’s depiction of the analytic process must include some sort of awareness of her own psychic state as well as of that of patient’s, this raises a myriad of questions. What measure of self-analysis informs clinical writing? Where should the writing analyst position herself along the spectrum of anonymity versus self-disclosure? Should the analyst describe her own associations only when they emerge from and illuminate the clinical process, or should analytic writing contain explicit reference to the analyst’s own rootedness in sociocultural reality and/or theoretical affiliations? Does clinical writing—like literary texts—need to attend to form, style, and language? With both a theoretical shift and an expansion of clinical writing’s accessibility, the writing analyst’s methodology, process, and understanding calls out to be conceptualized anew. We therefore asked psychoanalysts who have extensively contributed to clinical writing to share their own second look at contemporary clinical writing—described by Civitarese as the fourth invariant (along with the unconscious, the setting and the personal analysis) of psychoanalysis.

One way to take in this broad range of papers is to look at how each define the parameters of their revisit; while some of our authors are very interested in the implications for writing of external circumstances, particularly technological and cultural/social changes, others are more focused on aspects of the psychoanalytic endeavor—such as its ontological character, or alternately, its place in the scientific literature—that are arguably less influenced by social and cultural circumstances. And while technology and new attention to social context are relatively new prisms for clinical writing to grapple with, managing these is contingent on negotiating eternal conflicts between the ethics of protection and that of professional communication, with a long history, as Lucy LaFarge points out, of a striking neglect in published clinical writing of patient’s right to autonomy and anonymity. While the following papers are differently oriented around this axis, each author ends up developing, some more explicitly than others, an ethical foundation for clinical writing.

LaFarge makes a powerful case for the necessity of asking the patient’s consent before publication, observing that not only is this process beneficial to analytic work, but that publishing in its absence becomes a problematic secret within the treatment. LaFarge refutes the idea that psychoanalysis should be a special case, separate from general standards of professional care in not enlisting the patient’s autonomy. She also considers the issue of consent in relation to professional development: “If debate about asking the patient’s consent for publication has been heated, it is at least partly because the theoretical stakes of each position are high. In effect, when we ask ourselves which is the best policy, we are asking what is the most essential data in our understanding of analytic situation” (p. 97). Bernardi and Eidlin are also interested in essential data and in how psychoanalysis can arrive at its own version of evidence-based medicine: they write within the context of a research model, the 3-LM approach, describing a methodology meant to balance the subjectivity of clinical work with measures to enhance the reliability and trustworthiness of clinical material. Bernardi and Eidlin include transcripts of clinical material obtained within a TFP (transference focused psychotherapy) model, to which the writers (and the readers) can bring different theoretical models with patient consent obtained as part of their frame (and noted in the acknowledgements at the beginning of the paper); and LaFarge makes the point that asking for consent itself, and how this process unfolds in treatment, should be shaped by theoretical orientation. Both foreground ethical concerns. Bernardi and Eidlin write: “The term fidelity refers not only to the data but also to ourselves as researchers and to the readers” (p. 36).

Kanwal guides the reader through a series of dilemmas and possibilities raised by different strategies around confidentiality and self-disclosure and considers how his identity and that of his patient can create unseen areas and culverts that if not written about, leave important information out, rendering a text opaque or illegible in some of its associative depth for the reader. When he declares that “As a reader you have to accept my truth as told in my writing and also accept it as the patient’s truth” (p. 139) he is pointing out a dangerous power dynamic in writing that can conflict with the aim for fidelity mentioned by Bernardi and Eidlin. Referring to Glick and Stern’s 2008 paper about communicating “the lived experience” of an analysis, Kanwal asks, “In writing about such a lived experience, how does one ignore writing about those aspects of identity that are integral to the experience?” (p. 138). For him, clinical writing incurs ethical dilemmas around the identification of various aspects of both the patient and analyst’s identity, without which some important truth is lost and some critical dimension of analytic reality is obscured. This pulls into a larger social and cultural context Ogden’s observation that “critical to Winnicott’s (1967) practice is his belief that experiences of being recognized by the analyst are pivotal to the analytic process” (p. 17). Kanwal comes close to autotheory’s premise that we can only understand a person by interrogating and politicizing the conditions through which patient and analyst come to inhabit their bodies and their lives (Colombo 2022). Kanwal sees no clear solution beyond exposing his own identity more than his patient’s and constructs a metapsychological experiment, a “choose your own adventure” (p. 154) escapade. Some choices, such as including the patient’s actual poetry, which could be seen as a collusion in allowing the patient to renounce their anonymity, leave the ethical realm of psychoanalytic writing entirely. Civitarese works in brief vignettes that reveal the field more than the patient and along with Collins and Ogden, focuses little on changing social or technological contexts, or on psychoanalysis’ research frame, locating clinical writing at the core of an ontological mode.

Indeed, in the papers by Civitarese, Collins, and Ogden, disguise, brief vignettes, and confidentiality are necessary but not sufficient for the larger ethical enterprise of communicating authentic experience. Ogden notes: “Understanding oneself feels real only when borne of experiencing” (p. 14). He foregrounds in his piece the ontological dimension of psychoanalysis and its equal importance for clinical writing. Civitarese, whose subtitle is “On the Ethics of Psychoanalytic Writing” works in this mode, noting the necessity of writing coming alive and arguing that analytic material can only be effectively communicated if the writer is able to affectively move the reader. Aliveness is opposed to a paranoid position which obscures the complexity of the patient in favor of conscious, and therefore limiting, alignments with external markers of identity or trauma.

Ethical writing is writing inspired by an “ontology of the we” (Nancy 2001). As in healing, the writer’s attitude to psychoanalysis should reflect a mature awareness of the radical social nature of subjectivity. If I can only be authentically myself if I am mirrored by the other and vice versa—if, therefore, the dignity of both the subject and the object is at stake, otherwise it would only be a falsification—then behaving ethically means developing as many antibodies as possible against the insidious forms of alienation that can contaminate the cure (Civitarese 2024).

Ogden, Civitarese, and Collins move between the epistemological and ontological frame, with Ogden structuring those two dimensions sequentially, Civitarese kaleidoscopically showing their interplay as perfusing the analytic field, and Collins enacting a more story-like, trajectory-oriented form, describing her move from experience to the belatedness of understanding within the context of a revisit of nachträglichkeit. In their writing, ethics resides within a frame that requires the analyst to be present with the patient, both in session and in writing about sessions. While Ogden does not suggest that writing itself helps understanding, Collins observes:

The act of writing, which requires organizing thoughts into communicable language with colleagues, enhances the process of metabolizing affect from a state of nebulous discomfort into clearer apprehension. In its final form, what is written contains a digested affect. Thus, the gap between the experience with, and the writing about, is a meaningful caesura in the course of the analytic relationship, affecting and enhancing it. [p. 173]

Civitarese also sees writing as “a factor in the analytic function in that it automatically enters the field of analysis simultaneously with the different fields of analysis of different patients” (p. 107) and as a psychoanalytic mode. Writing for them is a way to engage with the third.

Bernardi and Eidlin also consider the gap between the experience with and the writing about and turn to Ogden in their discussion of the clinical material: “The analyst must be able both to dream the patient with their ability to dream, and to awaken from the dream and use the dream in their communications (Ogden 2022, p. 122)” (p. 37). Therefore, “By moving back and forth between the particular and the general, and between before and after, we sought to create a virtuous hermeneutic circle that would enrich the understanding of clinical phenomena” (Bernardi & Eidlein, p. 44). Our writers position themselves differently relative to the dream of the experience being written about and the awakening from it, and this may account for why the temporality of revisiting clinical writing now is more salient for some writers than for others–-in other words, why our writers have a different interest level in our current eras external developments. When Civitarese writes, “The connection with temporality immediately becomes apparent,” (p. 109) he is focusing on what occurs in the field; while when Kanwal argues that, “the feelings we are experiencing today about psychoanalytic writing are emergent from the culture we are embedded in today” (p. 144), he is drawing attention to a different, sociocultural, dimension of temporality. LaFarge’s noting that “the broader society has become much more aware of the potential for exploitation that exists in asymmetrical relationships; and a requirement that consent be given before any action takes place has become the prevailing standard” (p. 91) is an observation on a different metapsychological level than Ogden’s idiosyncratic and metonymic clinical vignettes. For Collins, also drawing from Ogden, temporality is experienced within the intersubjectively constructed third: “Writing about patients following a meeting with them involves a temporal belatedness” (p. 158). When Bernardi and Eidlin, working within foundational principles of research, state that “Our aim here is to deepen some of the traditional criteria of good psychoanalytic practice by relating them to the standards of quality of evidence developed by neighboring disciplines, thereby strengthening the attitude of research and the development of critical reflection” (p. 37) they “awaken from the dream” not only to do the work Collins describes as being potentiated by belatedness—by the third—but they also evoke and address another sort of third, the larger academic community; and they do so in a different sort of writing idiom than that of Civitarese, Collins, or Kanwal.

To summarize such papers inevitably falls short of the multiple conversations each has with the other—the reader leaps within and across these papers, paragraph to paragraph and between different points on the mobius strip, trying to structure them in relation to each other so as to keep all their observations in sight at once, all the while recalling Kanwal’s warning that “Psychoanalysis is…highly and unusually dependent on how one writes compared to other professional fields” (p. 139). Isn’t it, though? Thomas Ogden prefaces the clinical vignettes in his paper thus: “Each situation I shall describe is specific to a moment in analysis created by a particular analyst and a particular patient and would not occur in an analysis conducted by any other analytic pair” (p. 20). When he says he prefers, over the theory-stiffened term technique, “the term style to refer to the way the analyst has developed his or her own way of being an analyst” (p. 20) this could equally reflect his quite distinctive writing. It would be difficult for anyone reading, for example, Ogden or Civitarese to mistake them for anyone else, perhaps showing as well as describing the perfusion of analytic work and analytic writing with the analyst’s particular way of being.

With the exception of LaFarge, all of the contributors cite Ogden and orient themselves around his foundational observations. Nevertheless, each evinces his own trenchant writing style. In his master class on writing fiction, the novelist George Saunders focuses on helping his students find “the place from which they will write the stories only they could write” (Saunders 2021, p. 3). Some combination of desire, theory, and voice seem key. In an autobiographical vein, several of our writers share their own development as writers: Lafarge writes about “the evolution of my own thinking” (p. 98) about asking consent. Kanwal discusses changes in how he thinks about self disclosure—both in sessions and in his writing. Civitarese explicitly addresses the personal aspect of clinical writing: “we can see the autobiographical nature of analytic writing as another of its devices used to open up a new field of observation, while at the same time bringing us closer to the object of observation” (p. 122). He links this very autobiographical aspect to ethics: “writing is an ethical exercise in itself, since it implies a close confrontation, a process of (self-)analysis” (pp. 121–122). Indeed, no matter the explicit engagement with personal information, the voice of the writer in each of these essays comes through.

Unsurprisingly, the passages of clinical description reflect the analytic stance of the author in addition to communicating their personal style. LaFarge’s argument that our theoretical orientation should inform our approach to asking consent and, indirectly, how we write, begs the question of to what extent our writing style itself is informed by a theoretical orientation. Bernardi and Eidlin provide sections of transcripts, which is in line with their research model. Kanwal’s paper is peppered with questions to the reader he addresses as “you” as he writes of identity in flux, making his paper the most experimental—a sort of deconstruction of assumptions and choices in which the reader is complicit. LaFarge’s vignettes are nestled within a historical review of psychoanalytic writing, echoing her work on the movement between containment and interpretation and Civitarese has us join him in a richly populated, allusive, illustrated (Picasso’s drawings), and creative analytic field. Civitarese echoes LaFarge when he proposes:

Perhaps we could venture that just as there are different psychoanalytic models, there are also different styles of narrative. So, if it’s true that there are no rules, it’s also true that some rules can be found that are consistent with the theoretical frame of reference. [p. 128]

Indeed it seems inarguable that many of the same qualities we bring to clinical work are equally necessary in our writing, and that writing in turn may help develop analytic work–-another possible virtuous circle. Giuseppe Civitarese makes a powerful argument for “the key place of writing as an invariant of psychoanalysis and as a via regia to ethical renovation, for the need to put more emphasis on the impossible task of teaching it, and for the fundamental role that psychoanalytic journals, especially peer-reviewed ones, play in our field” (p. 132). Like Civitarese, Collins believes that writing itself should be considered as a key part of the psychoanalytic process, a place of useful reverie, and she sees writing as belonging within the “overarching scope of clinical processes” (p. 158). In how they describe their process, Collins and Civitarese show us something of how writing could be taught. Civitarese observes:

In fact, the text I wrote was, in a sense, gradually writing itself, and it took the form of a few paragraphs, like pieces of a jigsaw puzzle still waiting to be put together in a secondary processing, not unlike the processing we do to dreams, and of which I was curious to see what it would reveal. [p. 108]

LaFarge wonders if clinical writing with consent can be a positive development in psychoanalysis and very helpfully provides actual guidelines around asking consent, proposing some answers where Kanwal launches questions. Everyone seem to agree that writing is a developmental achievement that parallels that of analytic functioning. Psychoanalysis has been deemed the impossible profession and clinical writing may feel equally impossible—yet these papers proffer different models of how to do it.

In a sense, Ogden’s and Bernardi and Eidlin’s are the two papers within which all of the questions posed by the others papers are contained—the largest nesting dolls—to shift from the mobius strip to a different metaphor. Ogden’s lightning-bright moments of coming alive, within his larger metapsychological frame, are extended, discussed, and dissected in the clinical material presented within the rigorous frame of Bernardi and Eidlin’s paper. The interplay between an effective communication of aliveness on the one hand and a scientific or epistemological frame linked to clinical facts is, writ large, the enterprise of clinical writing.

Kanwal asks:

When we think about how a psychoanalytic paper should be written, perhaps we also need to ask the question: “who is the paper written for?” Is it for the analyst, for the reader, for the field, or for the patient (in the analyst’s mind)? [p. 140]

Civitarese underlines the importance of the analyst’s own desire: “An analyst should write something they would like to read” (p. 109) and generously includes his readers in the world of writing: “Even those who do not write participate in the work of writing in other ways, either as readers or in the form of collective writing, which is individual and group supervision, as well as scientific meetings of various kinds” (p. 107). This issue is as much for readers as for writers: a central pleasure of reading is the moments of surprise, whether that is a recognition of some aspect of emotional life, a reencountering of a familiar idea in an unexpected way, or a new way to understand the writer. Each of these papers reward the reader’s curiosity, and this is part of what make them all supremely readable: the pledge from writer to reader–-that the experience of reading will give the reader something of substance–-is unusually fulfilled in this set of papers. This is because we see how each of our writers succeed in their doing of clinical writing whether it be a “copulation” (Civitarese, p. 106) or a “cauldron” (Kanwal, p. 152) from which the writing springs. Each of their patients, even those glimpsed briefly, come alive for the reader in tandem with the writer’s ability to come alive him- or herself. As Ogden writes, “A principal measure of psychic change in the ontological dimension of psychoanalysis lies in the degree to which the patient comes to experience his very being in a way that feels more fully alive and real, more fully himself” (p. 17). Civitarese not only agrees but explores how this applies to writing: “In analytic writing, the aesthetic factor is paramount. Aesthetic not in the sense of merely ornamental or artificial, but in the absolutely essential sense of relating to sensations, corporeality, and bodily intentionality” (p. 110). Here, I put them—and our other writers and readers—in conversations with Saunders, who writes, “the true beauty of a story is not in its apparent conclusion but in the alteration of the mind of the reader that has occurred along the way” (p. 58).

Disclosure statement

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

Notes

1 Civitarese, G. (2024). Does it appear to ‘resemble’ reality? On the ethics of psychoanalytic writing. Psychoanal. Q., 93:109.

2 LaFarge, L. (2024). What we do, what we say, what we don’t say: confidentiality in the publication of clinical writing. Psychoanal. Q., 93:91.