The continuous case, a mainstay of psychoanalytic institutions, is often a flawed educational experience, especially for early candidates. There are a number of potential problems it presents. Sometimes the purpose of the exercise is not clear to the candidates. It may promote passivity on the part of the candidates who are not presenting, particularly during long riffs of material. The format is often too focused on the presenter and what the presenter is doing and not doing, creating a source of anxiety for the presenter. Presenters may deal with the fear of criticism by leaving out material which does not show them in their best light, by making up material, or by trying to get as much material in as possible in order to cut down on time for criticism. Worst case scenario, the continuous case has the tendency to meander, to be boring, and is seen as something to be endured by candidates and to be avoided as a presenter.
At the APsaA 2010 National Meeting, a group of candidates and faculty from the Dallas Psychoanalytic Center described the focused continuous case, which is part of their second year curriculum. Although psychoanalysis may be the triumph of the unfocused mind, the same thing cannot be said for education. Good teaching requires learning objectives, and good execution requires careful preparation. Before the course begins, as coordinator of the Dallas project, I orient the presenters. I meet with them with several guidelines in mind. I tell them that this is not about them; i.e., I do not care how they perform as analysts. This is not a show and tell, nor do they have to feel that they will be the butt of criticism. I will protect them. I simply want them to channel psychological material, which consists of what the patient is saying plus what the presenter is saying, thinking, and feeling. In other words, the candidate presenters are ideally “educational self objects,” solely related to their function as vehicles for material. I also share with the candidate group the orientation to the presenters so that we are all on the same page.
Although psychoanalysis may be the triumph of the unfocused mind, the same thing cannot be said for education.
The course runs through the entire year, every other week for 16 sessions, and involves presentations by two candidates. The first module, which is five sessions, focuses on psychoanalytic listening. Candidates learn the concepts of the patient's surface, the analyst's surface, and the workable surface. This template is applied to clinical material. There is a list of companion readings by Bush, Levy and Interbitzen, and Paniaqua, which describes the above concepts. Companion readings are optional, not required readings. After these five sessions, we have our first Great Debate. It is formatted on the resolution: “Structural theory is the best model to understand clinical material.” The candidates divide themselves into affirmative and negative teams and go at it with energy and excitement that I have rarely seen in requiring them to write a paper. The purpose of this exercise is to promote critical thinking.
The second module, lasting four sessions, is on resistance. Candidates learn how to observe resistances, how to help the patient see resistances, how to categorize resistances, and how to interpret resistances to the patient. The companion reading for this section is Busch's book, Rethinking Clinical Technique. Following the module, we have our second Great Debate: “Be it resolved that object relations theory is the best way to understand the clinical material.”
The third module, which lasts four sessions, focuses on the transference/countertransference relationship. Candidates question what the patient's surface reveals about the relationship. What do the analyst's thoughts, feelings, fantasies, words, and actions reveal about the relationship? What can be said to the patient in terms of the relationship in order to understand the patient's mind? The companion readings consist of Gill's monograph, “On the Analysis of the Transference,” and the Betty Joseph article, “Transference, the Total Situation.” And finally, at the end of the year, we have the third Great Debate: “Be it resolved that self psychology is the best way of understanding clinical material.”
For the January 2010 APsaA workshop we attempted to demonstrate key features of the focused continuous case by conducting an abbreviated, three-dimensional continuous case conference. After Jennifer Unterberg, a second-year Dallas candidate, presented clinical material, we divided the group of attendees into three smaller groups.
Gerald A. Melchiode, M.D., is a training analyst with the Dallas Psychoanalytic Center and a clinical professor of psychiatry at Southwestern Medical School Dallas. He was co-chair of the COPE Study Group on Self-Disclosure.
The first group focused on psychoanalytic listening, the second on resistance, and the third on transference/countertransference. Unterberg floated among the groups. Then we reconvened and each group summarized its discussion. We left out the three Great Debates.
I asked Melody Moore and Jennifer Unterberg, Dallas candidates familiar with the Focused Case Conference, to comment on this educational approach. Here is their input:
Rather than the traditional model of one presenter bearing the responsibility of providing clinical material and the others acting as listeners, the focused continuous case affords each of us an opportunity to actively and purposefully attend to the material. Presenters feel less anxious about being in the spotlight and listeners feel more an integral part of the experience.
We find the Great Debates to be a new and creative way to collaborate with colleagues and bridge theory and technique. The teams meet privately to develop their strategy and outline the specified theory's strengths and weaknesses. Each team has 20 minutes to make its argument and 10 minutes for rebuttal. As a result of the Great Debates, we are able to articulate our case conceptualizations with confidence and clarity.