Case Study Writing in Today's Psychiatry
Case Study Writing in Today's Psychiatry
The poet must remember that it is his poetry which bears the guilt for the vulgar prose of life, whereas the man of everyday life ought to know that the fruitlessness of art is due to his willingness to be unexacting and to the unseriousness of the concerns to his life. The individual must be answerable through and through: all of his constituent moments must not only fit next to each other in the temporal sequence of his life, but must also interpenetrate each other in the unity of guilt and answerability-M.M. Bakhtin, 1919
On June I was asked to manage an annual writing competition in the department of psychiatry at the University of Illinois at Chicago (UIC). The Merton Gill Award is given to the resident who writes the best case study of psychodynamic psychotherapy or some related concern. It may have been accidental that I ended up presiding over this award presentation, named for the late, prominent psychoanalyst Merton Gill. But I do a lot of case study writing, and this experience helped me to reach a new understanding about the role of psychoanalysis in psychiatry today.
To prepare for this job, I spoke with several psychoanalysts who knew Merton Gill well. They said that they were less invested in constructing a static Merton Gill icon and more interested in moving on in the reflective, thoughtful, creative way that Merton so embodied. To that end, the June 1998 awards presentation was designed to hear the work of our young psychiatrist writers.
The winner was Dheeraj Raina, M.D. Other participants were Eugene Kuc, M.D.; Naomi A. Levy, M.D.; and Robert W. Marvin, M.D. All of the competitors were asked to present their writing not just because I felt they earned it, but out of the belief that psychiatry needs to hear from those who are trying to do this kind of work. They were asked to tell us not only about their case study, but also to speak of how they approached writing a case study.
Our young colleagues had struggled in their efforts to write. Struggle is completely necessary for writing. But they were disadvantaged by being insufficiently familiar with, much less connected to, the legacy of case study writing in our field. The residents had read very few case studies and had never had the experience of writing one.
The growth of psychiatry, and its shifts in new directions, has turned our field's attention away from close, detailed reports on the interactions in psychotherapy or other patient-doctor relationships. Psychoanalysis and psychodynamic psychiatry, reeling from these changes, sometimes responds by laying claim to all things psychosocial or even humanistic in psychiatry-warning that if we lose this, then psychiatry will lose its soul. Yet neither psychoanalysis nor psychodynamic psychiatry can truly lay exclusive claim to case study writing.
To address this, I put together a case study seminar last year at the UIC department of psychiatry along with psychoanalyst Jerry Winer and literary scholar Suzanne Poirier. Our aim was to expose participants to a heterogeneous range of case study writings and theory, from the realm of psychiatry, psychoanalysis, literature, psychohistory, cultural anthropology and sociology. We read Oliver Sacks, Robert Coles, Sigmund Freud, Heinz Kohut, Marshal Edelson, Daniel Levinson, Robert Jay Lifton, Inger Agger, Allessandro Portelli, Richard Selzer and others.
We tried to communicate a system of values that prizes a particular kind of writing. It is distinct from the kind of writing that we lazily do every day when we are "in the box'' (Thompson et al., 1998). This includes our case reports and psychodynamic formulations, in which we are essentially serving an externally given structure.
Instead, the viewpoint of case study writing should be from outside of the boundary, where a very different kind of space is occupied. It is dialogical, as several voices seek to emerge: the person of the patient, the person of the doctor and the person of a theorist or researcher being read. The reader makes contact with ideas, propositions and attitudes that become the real heroes in the sense that they are consequential for understanding and intervening in today's realities. You join a community of writers and readers, but must also strive for autonomy of thought. It is both profoundly humble and unusually bold.
How do you learn to do this type of writing? At the 1998 American Psychiatric Association meeting, writer/surgeon Sherwin Nuland, M.D., told his story of becoming a writer. He did not start his writing career until his mid-40s, when-through crisis and luck-he found himself in a position to slough off his surgical mentality and return to the world of his childhood: growing up in a Yiddish-speaking household, sleeping next to his dying grandmother. It was then that he discovered his writing voice and his subject.
Ironically, this can be hardest of all for psychiatric writers-we find ourselves burdened by huge mountains of "cramped, one-sided serious theories" (Bakhtin, 1984). Our theories enable us to explain human behavior and to construct effective interventions. On the other hand, we become so invested in them that we believe too much in our own explanations. When "in the box," what we grasp least of all is speech and language; how the words, sentences and utterances themselves shape our knowledge of reality. The experience of working with our residents in reading and writing case studies has driven me to ask whether we should consider this a basic task for all residents. Not all will become Sherwin Nuland, Richard Selzer or Lewis Thomas, but what is more basic than language? If we do not learn those habits when we are young, it does not get any easier to learn them later.
I foresee clear advantages in asking our future psychiatrists to do case study writing. It can be a tremendous experience to take a close, detailed look at one case, to see the world in a grain of sand, to see the words that have a grip on us. That can include psychodynamic psychotherapy, but it should not be only that. Case study can move in many other possible directions, such as investigations of the trauma survivor, the family, the nonservice recipient, the health care worker, the leader and the artist. The bottom line is that the case study should provide a close, detailed reading of experience in relation to some theory, argument, claim or question.
Case study can be used to face uncertainties and mistakes. We should encourage residents to use case study to probe the limits of our knowledge, and the problems and challenges of our profession. This means that we must get out of the box and write not only about pristine psychotherapies in consulting rooms, closed off to a world of tumult and transitions. Our young psychiatrists' case studies might just teach us something new about the realities of doing psychotherapy or psychiatry in dramatically new organizational and sociocultural contexts.
Case study writing also offers affirmative ways to address pressures put upon the speech genre of today's psychiatry. The managed care environment is forcing psychiatrists to talk and write about their patients in a new, commercially sanctioned language. Psychiatry has welcomed a large number of international medical graduates for whom English is a second language. Writing can help these residents inasmuch as it enables young psychiatrists to become better masters of the language and the subtleties of speech genres that are deployed in different dimensions of psychiatric work. What is the prospect for a profession that does not have mastery over the words that it uses to represent itself to the writer and to describe what it does?
Case study writing is conducted with a degree of what Bakhtin called "outsidedness" (Emerson, 1997). It recognizes the aesthetic and ethical value of entering into an awareness of something from the outside. (In this regard, we should not forget that the international medical graduate may actually have distinct advantages.) There is always the risk of being misperceived from those in the box as not being "one of us." The writer's response is to not fall into such traps and separate yourself from the work, but to stick with it and respond within the work, to deepen and multiply the dialogue with those others, especially the critical and accusing ones, who should be loved for all that they have to teach.
One seminar cannot address this situation. At the last APA annual meeting, we heard a range of curricular approaches for medical students and residents in psychiatry that center around case study writing. I can imagine a modest professional developmental line of experiences running throughout the four years of residency, designed to support these skills. It could be a part of being a cutting-edge training department in the current era. Doing so requires identifying faculty with writing experience, and getting them to see writing as both apart from and in relationship to clinical work and clinical theory. They must appreciate that writing is about speech and language, more than it is about psychotherapy or psychoanalysis, or any other theory. It can also help to bring in writers, literary scholars or humanists from outside of psychiatry and medicine to focus solely on writing issues.
More than anything else, learning to write requires mentoring. I had the great benefit of working with the Michael Jordan of mentors, Dan Levinson. My first conversation with Dan was a several hour, up-half-the-night phone call, initiating a heavenly seven-year marathon of nearly daily dialogue. What does it say about us and our times when residents and faculty rarely show such generosity, intensity and commitment? How else can residents possibly learn? If this is to happen, then we simply must think of ways to nurture and support the kind of mentoring that helps young psychiatrists learn more about writing and actually get writing done.
During the award presentation, we offered our congratulations to all the residents who had participated in this years' Merton Gill Award. Then the residents spoke of their discoveries in writing about one person who had crossed paths with them in the Veteran's Administration, the partial hospital or the community mental health care project. What they shared was a gift, inspiring and broadening, to all of us who feel the pessimism and narrowing in psychiatry today.
Sometimes we like to say to ourselves that it was not always this way before managed care and biological psychiatry, before drug abuse, poverty and crime and before foreign medical graduates. But we should remember that psychiatry has gone from being a highly insular and nontechnological practice to one that has been forced to confront tremendous societal challenges and embrace wonderful scientific advances (Coles, 1975). And we should remind ourselves that with those new challenges come not only new opportunities, but also the imperative of having to redescribe the world, ourselves and our place in it. It is impossible to conceive that this would not involve our work with words, sentences, texts, utterances. If this is our challenge, then those young psychiatrists engaged in this case study writing are doing something for all of us. As Bakhtin claims, we really must answer to one another. In that sense, I believe that our attitude today should be that case study writing and psychiatry need each other.
1. Bakhtin MM (1990), Art and Answerability: Early Philosophical Essays by M.M. Bakhtin. Holquist H, Liapunov V, eds. Austin: University of Texas Press.
2. Bakhtin MM (1984), Problems of Dostoevsky's Poetics. Emerson C, ed. Minneapolis: University of Minnesota Press.
3. Coles R (1975), The Mind's Fate: Ways at Seeing Psychiatry and Psychoanalysis. Boston: Little Brown & Company.
4. Emerson C (1997), The First Hundred Years of Mikhail Bakhtin. Princeton, N.J.: Princeton University Press.
5. Nuland S (1998), Ward stories: writing about medicine. Presented at the Annual Meeting of the American Psychiatric Association. Toronto, Canada.
6. Thompson KS, Lewis BE, Pollack DA et al. (1998), Challenges in resocializing psychiatric education. Presented at the Annual Meeting of the American Psychiatric Association. Toronto, Canada.