What is a Clinical Fact?

When psychoanalysts reflect on what occurs within a session, they confront key epistemological questions, such as: How do we discern what is happening? Which facts are relevant? How do we recognize change, and from what perspective do we deem it desirable? These inquiries raise subjectivity, objectivity, and intersubjectivity issues in psychoanalytic theory and practice. In psychoanalysis, psychic reality is the conceptual terrain through which the mind interacts and interprets the world. Edna O’Shaughnessy (1994) highlights that this reality is formed at the confluence of unconscious phantasy, object relations, and subjective meaning. Drawing on Kantian philosophy and Dilthey’s hermeneutics, O’Shaughnessy identifies specific categories as fundamental structures that enable human beings to perceive and organize their inner and outer worlds. This essay explores O’Shaughnessy’s understanding of clinical facts, using R.D. Hinshelwood’s clinical material as a case study. Specifically, I will examine what I consider to be the clinical facts of Hinshelwood’s case to catch a glimpse of some parts of his session’s ‘immediate emotional reality.’

Facts reveal something about the world to our subjectivity. They “say how the world is, and depend on our species, language, theory, etc.” (O’Shaughnessy, 1994, p. 939). A clinical fact is a fact in the same way, but the ‘world’ that a clinical fact reveals is the world of the patient’s inner object relations to the analyst’s mind. O’Shaughnessy acknowledges that her Kleinian theoretical perspective is “infused with a particular hypothesis…that unconscious object relations and identifications will be found to underlie all mental and somatic phenomena…that in the mind are continual unconscious phantasies of an inner world of objects which, by identification, projection, and introjection, are constantly interacting with outer reality” (p. 945). She claims that her clinical observations “were not made by observing ‘basic data’ and then making inferences or invoking an hypothesis or a theory, but by experiencing phenomena in a certain way” (p. 945). External events and clinical enactments, such as a patient’s observation of a street quarrel and an analyst’s clinical observation of the patient, are imbued with intersubjective meaning derived from internal object relations and immediate emotional reality.

O’Shaughnessy emphasizes that clinical facts are neither purely objective nor entirely subjective; they are co-constructed through the interaction of the analyst’s and patient’s minds, grounded in the shifting dynamics of psychic reality. Clinical facts give an analyst access to a patient’s inner world and “manifest themselves in the form of immediate psychological realities between patient and analyst” (O’Shaughnessy, 1994, p. 939). This is how the patient’s inner world comes to life in the session. The emotional reality of the session is ultimately unknowable in its entirety. Far too much is happening within the session to know everything occurring at any clinical moment. O’Shaughnessy says, “In every session, observations would have been made and not been included because, though they were facts, I did not see them as clinical facts. Moreover, it is evident that as an analyst, I both observe and, through fallibility or understanding, contribute to making the clinical facts what they are” (p. 944). For O'Shaughnessy, the most critical aspect of the session is its immediate psychological reality, which is the space in which clinical phenomena occur.

Clinical facts are observable in a patient’s speech or behavior, either unprompted or as a response to the analyst. It is an occurrence that exists somewhere within and between inner psychic reality and an external event. A clinical fact comes into view in two ways: (1) through a patient’s interaction with an object or (2) through projective identification, which evokes countertransferential feelings and reverie in the analyst. As we begin our examination of Hinshelwood’s case material, it is essential to consider that countertransference, a phantasy-feeling mix of subjective and objective affective data that the analyst experiences subjectively, will be another important source of clinical data that will inform our analysis.

Clinical Material

Hinshelwood introduces his patient to the reader by giving a brief historical background of selected elements. We already have our first clinical decision in the case history: What background information should be provided? Like a photographer framing a subject for a composition, the analyst must selectively choose which elements of a patient’s history to include and—just as importantly—which not to. These subjective decisions help set up the framing for the clinical material’s presentation. Too often, this stage is easily seen as ‘objective data’ in a clinical presentation. However, we all have reasons for choosing the background information we do, though we may not know why. In Hinshelwood’s case, he decided to highlight a few key factors: the patient was not seriously disturbed; she was successfully coping with a stressful job in presumably a helping profession; there exists a link between grief and rageful acting out in her history; she has a “rather chronic depressed mood, a poor relationship with her mother, and certain isolated phobias” (2008, p. 512). We can see how Hinshelwood has begun to compose the portrait of his patient in a particular light. His framing of the patient brings the following emotional words to my mind: friendly, sad, angry, and afraid.

Now that Hinshelwood has set the analytic stage, he then fills us in on the immediate past of yesterday’s session, which he says “had ended with her feeling cross with me about an interpretation I had made in which I had suggested her chronic miserableness with me was in part actively cultivated” (2008, p. 512). Again, we have some epistemological guesswork to do here because he does not mention how he knew she was feeling cross. Of course, we can and should take him at his word that she felt cross. Still, it leaves the situation open to interpretation as to what a different analyst might have remembered from the previous session or felt in response to his patient’s ‘crossness.’ O’Shaughnessy might call this Hinshelwood’s ‘view from somewhere,’ which she says “is an individual way of seeing, hindered by my limitations, using what capacities I have, infused with theory, or with knowledge of my patient, or with memories of our psychoanalytic endeavors, sometimes devoid of theory or even contrary to theory” (1994, p. 945). For Hinshelwood to know that his patient had been feeling cross with him, he must have some emotional sense of what it is like for his patient to feel cross with him from his ‘view from somewhere.’

Hinshelwood continues, “She started this session by saying that yesterday, when she left me, she witnessed a scene in which a woman was arguing angrily with a man. The woman had a young child in a pram. She described her sense of being a bystander at the scene of the quarrel in the street” (p. 512). The patient describes feeling disturbed about what to do because it looked like the man and woman could go to blows. At this point, Hinshelwood remembers how, in their previous session, the patient had been feeling angry with him for his interpretation of her chronic miserableness. He then forms an implicit hypothesis: bringing up the quarrel in the street is a way of bringing up the hostility she felt toward him in yesterday’s session. But when Hinshelwood suggests this, she ‘seemed to have some trouble recalling her disagreeable reaction’ at the end of the previous session. She responded, “Um, you mean about the miserableness,” she then ‘remained thoughtful in her quiet way.’ Hinshelwood asserts that his hostility hypothesis was correct, citing evidence that the patient’s thoughtful attitude ‘cautiously indicated some true, though painful, insight’ (p. 513). But the patient remains silent and thoughtful, so Hinshelwood presses slightly by suggesting that she dare not risk the hostile feelings resurfacing in the room today. She stays silent and unmoving for a minute or so, then puts her hand to her brow as if perplexed and says, “That’s a minefield.” When he asks, “What is a minefield?” she says she doesn’t know what he said because she “chopped that up…and it went through the shredder.” Is this the result of a successful interpretation? How do we test our hypotheses regarding the clinical facts of a session?

By way of answering these questions, O’Shaughnessy posits her case with her patient, Leon. She claims that her patient showed her that her hypothesis was wrong by his response to her interpretation. She says that he showed an ‘immediate increase in anxiety and defensiveness’ (p. 942). She took this as the patient telling her ‘No.’ She admits that patients have many reasons for telling an analyst ‘No.’ But is this enough to disprove the clinical hypothesis that informed the interpretation?

O’Shaughnessy shows that our clinical hypotheses must have validation methods within the session; otherwise, anything we say could be taken for truth. She uses the patient’s reaction to an interpretation as the metric to determine whether the interpretation was connected to the immediate emotional reality of the patient and analyst at that moment and, hence, as a test of the clinical fact. In her work with Leon, she is attempting to lower anxiety in the patient by naming the immediate psychic reality as she sees it. I believe that O’Shaughnessy takes for granted the technical point that Kleinians believe that an encounter with truth calms people down, eventually. This is a nuanced position, but the essence of Kleinian interpretation is to tell the patient the truth of their psychic reality and let the chips fall where they may. This assumption is embedded within the Kleinian technique, where Klein herself is famous for direct interpretation at the deepest layer of the mind that she is capable of at any moment. Therefore, O’Shaughnessy sees her patient’s increase in anxiety as a sign that she was off the mark with her interpretation. She adjusted it, and he calmed down.

Hinshelwood’s patient tells him ‘No’ when she puts his interpretation into the ‘shredder’ and goes unresponsive. O’Shaughnessy would see this as her response to his interpretation centered on unconscious hostility within the patient. The moment of ‘No’ from a patient is a clinical fact. When something happens in a session, even when a therapist takes a wrong turn, the patient's response can become a new clinical fact only if the therapist is aware enough to catch it. When a clinical fact is observed, it gets used in the session. When it is not observed, it is bypassed and remains unconscious. Even when we are wrong, we can be wrong the ‘right’ way, which is ever-observant of the continual evolution of the moment-to-moment relation between patient and analyst.

Hinshelwood remains thoughtful about his patient’s mind, even when she puts thoughts in the ‘shredder.’ He says, “At first, my patient had used a chance occurrence of the arguing couple to substitute for her bad feelings. Later she annihilated the feelings, and with them a part of her ego that can recognize her own mind, her internal world and her own thoughts” (pp. 512-3). He found his way to curiosity about the state of his own mind, which he found to be composed of ‘annoyance, a sense of responsibility, and alarm.’ He then speculates that these feelings are just the ones that seem to be missing from the patient’s mind. Here, he relies on projective identification to inform his clinical intuition regarding his state of mind. A shift in the clinical encounter occurs when he speaks directly to her anxiety about where the hostility had gone. He interprets that “somehow she thought the hostility had got into me and, consequently, she was afraid of my anger and pressure, and of my capacity to be aware of all this” (p. 514). As a result of this interpretation, the patient’s mood changed, and she became restless. He says she seemed near to tears but remained quiet for a minute. Then, she associated to the baby in the pram. The ‘young child’ in the pram is now a ‘baby,’ and we have the demand/desire for comfort. Here, we have an essential clinical fact based on O’Shaughnessy’s understanding of Dilthey’s category of inside-outside. Because the hostility was now inside the analyst, and the analyst was aware of the patient’s fear of this, the patient was free to experience her ‘baby’ self, with its need for comfort. The patient’s connection with the feelings associated with the needed comfort may also explain her chronic miserableness. Perhaps she has been in chronic need of comfort all this time. If this is true, we have found the selected fact, which O’Shaughnessy says is “the ground of a mutative interpretation…highly time-sensitive: it must come from the immediate emotional reality between patient and analyst” (p. 945). The selected fact is a clinical fact that is mutative in the session. It is what creates a change in the patient. When Hinshelwood found the immediate emotional reality of the session—that she was afraid of his hostility toward her—the patient felt relieved and was able to access deeper emotions. This shows us that that clinical fact—and the selected fact—had more to do with anxiety about hostility and the need for comfort than active hostility at that moment in the session.

References

Hinshelwood, R. D. (2008). Repression and splitting: Towards a method of conceptual comparison. International Journal of Psychoanalysis, 89 (3), 503–521.

O'Shaughnessy, E. (1994). What is a clinical fact? International Journal of Psychoanalysis, 75, 939–947.