Staying the Same While Changing: Reflections on Clinical Judgment

Having participated in more symposia than I care to remember, I've come to believe that regardless of whether an analyst is a writer or a discussant, the working definition of “clinical judgment” is always arrived at by hindsight—the writer defines it as what he did, and the discussant (no matter how sophisticated his efforts at tactfulness) defines it as what it would have been better to do. In this light, with apologies offered in turn to Jack Benny and Zero Mostel, I'm going to begin with a story that might be called “a funny thing happened to my title on the way to the symposium,” a story that turned out to be an unanticipated example of how I see the issue of clinical judgment.

When I received my copy of the agenda I discovered that the title of my paper read “Staying Sane While Changing,” not, the title I had submitted. It seemed that someone had already been exercising clinical judgment. In my fantasy, the “someone” was a copyeditor who found paradox difficult to appreciate. I could imagine the person looking at my actual title, “Staying The Same While Changing,” and saying to himself, “Bromberg couldn't really have meant that. A patient can't both stay the same and change. Ah, I know. I'll bet the title is ‘staying sane while changing,’ and his secretary heard him wrong.”

The most interesting part of the story to me (apart from the fantasy gratification of my real yearning for a secretary) is that the change in title actually does capture an important element of my own meaning but it overly narrows the conceptual frame of reference and loses the