Patient Tales: Case Histories and the Uses of Narrative in Psychiarty

By Carol Berkenkotter

A look into communicating psychiatric patient histories, from the asylum years to the clinics of today

In this engrossing study of tales of mental illness, Carol Berkenkotter examines the evolving role of case history narratives in the growth of psychiatry as a medical profession. Patient Tales follows the development of psychiatric case histories from their origins at Edinburgh Medical School and the Royal Edinburgh Infirmary in the mid-eighteenth century to the medical records of contemporary American mental health clinics. Spanning two centuries and several disciplines, Berkenkotter's investigation illustrates how discursive changes in this genre mirrored evolving assumptions and epistemological commitments among those who cared for the mentally ill.

During the asylum era, case histories were a means by which practitioners organized and disseminated local knowledge through professional societies, affiliations, and journals. The way in which these histories were recorded was subsequently codified, giving rise to a genre. In her thorough reading of Sigmund Freud's Fragment of an Analysis of a Case of Hysteria, Berkenkotter shows how this account of Freud's famous patient "Dora" led to technical innovation in the genre through the incorporation of literary devices. In the volume's final section, Berkenkotter carries the discussion forward to the present in her examination of the turn from psychoanalysis to a research-based and medically oriented classification system now utilized by the American Psychiatric Association. Throughout her work Berkenkotter stresses the value of reading case histories as an interdisciplinary bridge between the humanities and sciences.

• Language: English
• Publisher: University of South Carolina Press
• Release date: Oct 10, 2022
• ISBN: 9781643364056

Carol Berkenkotter

Carol Berkenkotter was a professor in the Writing Studies Department at the University of Minnesota until her death in 2016. She is the author of Patient Tales: Case Histories and the Uses of Narrative in Psychiatry and coauthor (with Thomas Huckin) of the award-winning Genre Knowledge in Disciplinary Communication: Cognition/Culture/Power.

Book preview

Patient Tales

Studies in Rhetoric/Communication

Thomas W. Benson, Series Editor

Patient Tales

Case Histories and the Uses of Narrative in Psychiatry

Carol Berkenkotter

© 2008 University of South Carolina

Cloth edition published by the University of South Carolina Press, 2008

Ebook edition published in Columbia, South Carolina,

by the University of South Carolina Press, 2022

www.uscpress.com

Manufactured in the United States of America

31 30 29 28 27 26 25 24 23 22

10 9 8 7 6 5 4 3 2 1

The Library of Congress has cataloged the cloth edition as follows:

Berkenkotter, Carol, 1940–

Patient tales : case histories and the uses of narrative in psychiatry / Carol Berkenkotter.

p. ; cm.— (Studies in rhetoric/communication)

Includes bibliographical references and index.

ISBN 978-1-57003-761-0 (cloth : alk. paper)

1. Psychiatry—Case studies—History—19th century. 2. Psychiatry—Case studies—History—20th century. 3. Mentally ill—History. I. Title. II. Series.

[DNLM: 1. Psychiatry—history. 2. History, 19th Century. 3. History, 20th Century. 4. Interview, Psychological. 5. Medical Records. 6. Mental Disorders—therapy. 7. Narration—history. WM 11.1 B512p 2008]

RC465.B47 2008

Front cover illustrations: Frontispiece for an 1858 manual advancing the belief

that types of insanity could be diagnosed by studying patients’ facial expressions.

Courtesy of the Owen H. Wangensteen Historical Library of Biology and Medicine,

University of Minnesota

ISBN 978-1-64336-405-6 (ebook)

For Jim

Contents

List of Illustrations

Series Editor’s Preface

Preface

Acknowledgements

Introduction: Case Histories and Narrative Knowledge in Psychiatry

Part One: The Asylum Age

1Case Histories in the Hospital and the Medical Journal in Enlightenment Scotland

2In His Own Words: Using a Patient’s Utterances to Document an Unsound Mind

3Capturing Insanity: The Wedding of Photography and Physiognomy in the Mid-Nineteenth-Century Medical Journal Article

4Asylum Notes: The Historical Antecedents of Psychiatry’s Case Histories

5The Freudian Hiatus: Psychoanalysis and Narrative in Fragment of an Analysis of a Case of Hysteria

Part Two: The Era of Biomedicine

6Case Histories and the Transformation of American Psychiatry: Near Demise of a Genre during the Rise of a Scientific Classification System

7Psychotherapist as Author: Case Reports, Classification, and Categorization (with Doris Ravotas)

8In Retrospect: A Case for Historical Narrative Inquiry

Notes

Bibliography

Index

About the Author

Illustrations

Figures

1. The psychiatric polarities and their textual forms

2. Title page for John Haslam’s Illustrations of Madness

3. James Tilly Matthews’s Air Loom

4. Frontispiece and title page for A Manual of Psychological Medicine by John Charles Bucknill and Daniel Hack Tuke

5. Religious Melancholy

6. Hugh Diamond’s photograph of woman suffering from Religious Melancholy

7. Chronic Mania

8. Order of the commissioners on lunacy, 1874

9. Front cover for an asylum casebook

10. Pages from K.M.’s case notes

11. Dora’s reported speech in Fragment of an Analysis of a Case of Hysteria

12. Number of case studies to research articles and total articles, 1965–2001

13. Percentages of case studies to research articles, case studies to total articles, and research articles to total number of articles, 1965–2001

Tables

1. Degree of narrator’s interference in Freud’s Fragments of an Analysis of a Case of Hysteria

2. Percentages of format (genre) type

3. Trends in terminology: neurosis versus neuronal

4. Trends in terminology: hysteria versus " DSM categories"

5. Contrasts between therapist’s and client’s membership categorization devices (MCDs)

Series Editor’s Preface

In Patient Tales Carol Berkenkotter presents a history and critical analysis of narrative in psychiatry—the narrative elicited from the patient, the narrative developed by the psychiatrist in a case report for colleagues, and the narrative case study that finds its way into scientific and popular publications. The story told by the patient is reshaped by the scientific and narrative conventions of psychiatry, where—already a double story—it takes on the double identity of a discipline that bridges biomedical science and humanistic narrative. Professor Berkenkotter illustrates the shifting disciplinary identity of psychiatry in a detailed and historical analysis of case stories spanning two and a half centuries. According to Professor Berkenkotter, at one extreme of the epistemological polarities competing within psychiatry, the scientific, positivistic approach is based on monistic and materialist assumptions, ideally reports its findings in the experimental article, and aims to discover knowledge that is generalized across contexts. The alternate pole takes a hermeneutic, romantic approach employing the narrative mode, typically in a single-subject case report that strives for understanding of one case at a time. Psychiatrists see us as brain and mind, object and subject, and organism and agent—united by processes that are still mysterious and can apparently still be imagined only through constructs with a long rhetorical history.

Patient narratives perform diagnostic, scientific, and teaching functions. They sometimes also act as therapies. Berkenkotter comments on the work of narrative therapist Doris Ravotas, who emphasizes the importance of co-creating with her clients a narrative that enabled them to externalize the sources of their mental anguish as an essential part of the therapy process.

In part 1 of Patient Tales, Professor Berkenkotter studies the rise of the case report from the mid–eighteenth century to the early twentieth century, from the Royal Infirmary of Edinburgh through Bedlam to Freud. In part 2 Professor Berkenkotter turns to the late twentieth century, describing the fate of narrative in the ascendancy of biomedical science and the counterrevolution against psychoanalysis. From the asylum age to the era of biomedicine, narrative has occupied a place at the center of psychiatric knowledge. In tracing the history of narrative in psychiatry and analyzing in detail a selection of case reports, Professor Berkenkotter offers a major contribution to our understanding of scientific discourse, the rhetoric of inquiry, the rhetoric of narrative, and the hopes and claims of psychiatry.

THOMAS W. BENSON

Preface

There were so many turns occurring in the human and social sciences in the 1980s, it was enough to make one’s head swim. In the introduction to this book I mention the narrative turn and the interpretive turn that characterized the period. And in his 1990 introduction to a collection titled The Rhetorical Turn, Herbert W. Simons describes the radical epistemological shift away from the positivism and foundationalism that were the sine qua non of the natural sciences and other academic disciplines and professions aspiring to the status of a science.

In the wake of the various turns from foundationalism to social constructionism, it seems only natural that rhetoric would rise above its unfortunate depiction as the harlot of the arts to be characterized as a powerful resource for investigating the suasive functions of disciplinary discourses. Throughout the 1980s and 1990s a group of scholars in speech communication and English departments, often exchanging views with colleagues in other disciplines (for example, anthropology and economics), coalesced into an invisible college, whose members’ interests developed into two compatible directions or movements. One of these movements was constituted by the rich body of work being done under the aegis of the Project of the Rhetoric of Inquiry (POROI), which got its name from conferences held at the University of Iowa in 1984 and at Temple University (1980–87). These two conferences and the collections and individually authored books that followed suggest an efflorescence of critical inquiries into the tropes, lines of argument, and other rhetorical devices present in the texts of various academic disciplines.

This period of disciplinary reflexivity in the human, social, and natural sciences produced challenges to the various foundationalist assumptions of disciplines, namely that a discipline’s hard-core methodology, empiricist foundations, and rules of evidence established warrantable knowledge claims. Furthermore much of the work in the rhetoric of inquiry problematized the windowpane, realist view of textual and visual representations in the natural and social sciences by examining the rhetorical dimensions of the genres, texts, and practices of the academic disciplines in their historical contexts.

By the early 1990s some of the members of the first wave of the Project of the Rhetoric of Inquiry were seeking an annual forum in which to present papers and, as well, to showcase the research of Ph.D. students who were the progeny of the first-generation POROI scholars. Decidedly, something was in the air in November 1992 when I attended a preconference meeting of the Speech Communication Association Convention in Atlanta, Georgia. The purpose of this meeting was to establish a new division to be called the American Association of Rhetoric of Science and Technology (AARST). Present at this gathering were members of speech communication departments and a few from English departments. This first meeting engendered a number of lively debates about what constituted rhetoric of science and what were the field’s intellectual commitments and methods. Should the classical rhetoric canon and its concepts be the primary source for rhetorical criticism of the sciences? Or was it more germane to take a more eclectic and ecumenical approach that drew upon concepts and methods from other disciplines, such as sociology of science? There have been many debates since the early 1990s over the issue of how far to stretch the methods of rhetorical analysis and rhetorical criticism to admit outsiders such as genre analysis and discourse analysis to the armamentarium of classical rhetoric. In retrospect I can say that this debate has become moot over time.

Indeed, in the last twenty-five years many disciplines and genres have undergone close scrutiny for their rhetorical and social dimensions by rhetoricians, sociologists and historians of science, and other scholars whose home discipline (economics, history, anthropology) were the objects of study by insiders, their eyes reflexively trained on their own disciplinary practices. As well, linguists such as John Swales, M. A. K. Halliday, Dwight Atkinson, and Vijay Bhatia have conducted large corpus studies of disciplinary texts to examine the grammatical, lexical, and syntactic elements that are the microlevel constituents of disciplinary genres. The turn to reflexivity in the human and social sciences, coupled with the proliferation of close linguistic analyses of disciplinary genres, has resulted in the growth of an interdisciplinary research front. The genesis of my own rhetorical interest in the historical evolution of the case history in psychiatry can be traced back to conversations with colleagues who were members of the cohorts of scholars engaged in the 1980s in POROI and later AARST.

Acknowledgments

My knowledge of the conventions of acknowledgement sections requires that I be mercifully brief. At some point, however, this book took on the trappings of an expedition, and it is only fitting that I acknowledge the intellectual and personal debts I owe to colleagues, friends, and family members who helped me to complete the journey. First and foremost I should like to thank Doris Ravotas, a clinical psychologist with whom I took the first steps in analyzing several of her colleagues’ case histories and interviewing the psychotherapist-authors, all of whom were disturbed by what they saw as a disconnect between the notes they took in session with clients and the subsequent reports they wrote up in the professional jargon of psychiatry. Ravotas was especially helpful in explaining her nuanced understanding of the client’s narrative voice, a narrative of personal experience that becomes subsumed by the voice of institutional accounting, that is, the psychiatric nomenclature that dominated her professional reports of each therapy interview. As a narrative therapist, Ravotas also acquainted me with the literature on narrative therapy, an approach that helps clients externalize their feelings of helplessness and loss of control and thus begin the process of reconstructing their identities through the conversational interactions between client and therapist.

I also owe a huge debt to family members and friends who are clinical psychologists: Carol Berkenkotter, my sister-in-law, a therapist of many years, and her daughter, Erin Berkenkotter, a psychoanalytically oriented clinical psychologist, both helped me understand the extent to which psychotherapy (except for private patients) is determined by what and how long insurance companies are willing to pay for mental health treatment. Another source of information was my friend and running partner, Sharon Levine, a therapist who works with children. Levine also eloquently described the tensions facing therapists who seek to help and heal their clients but who constantly face the institutional constraints of working in a county mental health care system.

Next, I would like to express my thanks to two colleagues, Debra Journet and Lucille P. McCarthy, who in the 1990s wrote illuminating accounts of the tension between the hermeneutic and positivist elements in psychiatry and neurology. Out of the many conversations I had with these two scholars on their research in the early 1990s, I developed a sense of exigency, that is, a deep-seated need to walk through the door that had been opened as the result of their studies.

Over the nine-year course of the project, sabbatical and single semester leaves provided me with time to write, and two travel and research grants from Michigan Technological University and University of Minnesota enabled me to travel to England to use the archives in the Western Manuscript Collection at the Wellcome Library for the History of Medicine. A grant-in-aid from the University of Minnesota in 2002 provided funding to hire graduate student research assistants to help collect data for two chapters that contain microlevel discourse analysis. I am eternally grateful to the help on these chapters provided by Cristina Hanganu-Bresch, Brent Heffron, and Ann Madsen, and for many exciting discussions of the data we were analyzing. A single semester leave from the University of Minnesota in 2005 granted me with enough world and time to complete a draft of the manuscript. I am indebted to Laura Gurak, my department chair, for supporting me through the review process for the leave.

I was fortunate in having a number of colleagues as traveling companions at various stages in completing the manuscript. These individuals were kind enough to take valuable time to read and comment on the various chapters of the book. This list includes Charles Bazerman, Alan Gross, Tom Huckin, John Swales, Mary Lay Schuster, Debra Journet, and Osborn Wiggins. I owe a large debt to Drs. Bazerman and Gross for helping me find ways to focus my discussion on Sigmund Freud’s uses of narrative in his psychoanalytic case histories. Freud’s work represented a particular challenge, so rich is the history of his development of narrative techniques in his case histories. The feedback I received on drafts of this chapter from Bazerman and Gross helped me chisel the statue out of the stone.

During the several years that I was working in research archives in the Wellcome Library for the History of Medicine in London and the Wangensteen Historical Library for the History of Biology and Medicine at the University of Minnesota, I received invaluable help from Richard Aspin and Elaine Challacome, both historical archive librarians. Both Aspin and Challacome were courteous and professional and put up with my incessant questions and requests, and James Curley, Challacome’s assistant, was a godsend in always being there to find rare books and make computer-scanned photocopies of nineteenth-century texts. Catherine Draycott and Anna Smith from Wellcome Images at the Wellcome Library provided essential support in photographing images of patients and shipping me highresolution copies as electronic files.

Linda Fogle, the assistant director for operations at the University of South Carolina Press, was especially supportive and helpful guiding the book manuscript through the review process. Karen Rood and Pat Callahan at the press are to be thanked for supervising the production process through which a manuscript becomes a book. I should also like to thank the two anonymous reviewers for their insightful comments and suggestions as I neared completion of the manuscript, readying it for production. Each reader’s suggestions contributed to one final tweaking of the manuscript before it began to undergo the metamorphosis from typescript to book. As I neared completing the manuscript, Tom Wright and Roopa Sukumaran, two Ph.D. students took over the copy-editing and proofreading tasks. Together they provided the close editorial scrutiny necessary for spotting my infelicities, as we came to call them.

To Jim Hefling, my partner, who over the long haul has made it possible for me to juggle the demands of my academic career with those of conducting research and writing—no amount of gratitude could possibly suffice. Without all of the daily tasks of living that he has taken on over the last several years, there would be no books. For the gifts of his help and his presence in my life, I am eternally grateful.

Introduction

Case Histories and Narrative Knowledge in Psychiatry

Narration is a manner of speaking as universal as language itself, and narrative is a mode of verbal representation so seemingly natural to human consciousness that to suggest that it is a problem might as well appear pedantic…. But it is precisely because the narrative mode of representation is so natural to human consciousness, so much an aspect of everyday speech and ordinary discourse, that its use in any field of study aspiring to the status of a science must be suspect…. A discipline that produces narrative accounts of its subject matter as an end in itself seems theoretically unsound; one that investigates its data in the interest of telling a story about them appears methodologically deficient.

Hayden White, The Content of Form, 1987

The fact is that illness does not exist apart from an ill person, and the use of case history has been invaluable in clinical education as a reminder of this fact.

Anne Hunsaker Hawkins, A. R. Luria and the Art of Clinical Biography, 1986

At first glance, most readers would be able to distinguish between a text that begins, It was a dark and stormy night, and a man and a woman sat around the campfire, and another text beginning, Ms. Hill is a forty-year-old Native American woman who states she has been having numerous triggers to physical and mental memories. In the first text the generic expectations of a fictional tale are immediately activated by the descriptive frame that places the reader in the setting. The reader of the second text, however, is more likely to recognize a tale of a different sort, given the lexical and syntactical cues that identify this text as a medical or psychiatric case history. The reader of the first text will also be likely to infer that it is of the fictional variety, again because the information provided in the first fifteen words constitutes a stock literary narrative frame. On the other hand, readers of the second text are most likely to recognize it as the introduction to an observational account of a troubled individual.

Each of these two short texts introduces a narrative; each uses genre conventions that function to position the reader in one of two very different kinds of discourse worlds. My point with these two examples is that narrative structures in discourse are immediately discernible; one needs to scan only one or two clauses to identify the discourse type or genre. This point is certainly not remarkable. What is remarkable, however, is that the second text’s narrative constitutes part of the observational data on which a medical or, more specifically, a psychiatric diagnosis will be based.

This is because psychiatrists for the most part cannot use a stethoscope or the variety of tests (such as blood work, electrocardiograms, and blood pressure readings) that other kinds of physicians routinely use as sources of information in making their diagnoses. Indeed the PET and MRI scans that are part of the armamentarium of neuroscience are mostly irrelevant to patients with mental disorders—as opposed to brain trauma, seizure, or other neurological pathologies. In psychiatry, clinical information is organized in narrative form as a case history. This text, which becomes part of a patient’s medical record, is constructed from the patient’s presentation—his or her narrative of the history of the present problem—as well as the patient’s observable bodily symptoms.

From a discursive perspective the clinical case history is actually a double narrative. The patient’s story, his or her narrative of personal experience, is subsumed into the narrative pattern and thought-style of clinical psychiatry. (This process is discussed in detail in chapter 7.) From a rhetorical perspective this narrative-within-a-narrative is noteworthy because of the linguistic and semantic devices the therapist uses to recontextualize the patient’s narrative of personal experience into a more encompassing narrative framework that has been highly codified within the psychiatric profession, including the mental health clinic. As a genre the case history has acquired a conventional structure, style, and lexicon that, over the last 250 years, has become the standard form of reporting in clinical medicine and psychiatry. Its organization, linguistic features, and rhetorical conventions function to guide the reader’s acquisition of knowledge in a scientific discipline that often must act upon incomplete and subjectively reported information (Hunter 1991, 51).

Case Histories in the Context of Psychiatry’s Polarities

Patient tales, or patient case histories (as they are more often called), played a vital role in psychiatry’s professionalization in Anglo-American asylums in the late eighteenth and nineteenth centuries. They are still used by psychiatrists and clinical psychologists in community mental health centers. The published case report based on institutional case history has met a different fate, however. As Hayden White (1987) notes, Viewing modern sciences [including medical/psychiatric science] … we can trace their development in terms of their progressive demotion of the narrative mode of representation in their description of the phenomena that their specific objects of study comprise (26). By the latter twentieth century, as psychiatry became increasingly associated with biomedicine in the United States, the published version of the single-subject case history was obsolescent, despite the fact that case histories remained the primary form of patient presentation in clinical rounds (Hunter 1991). The story of the rise of biomedicine is one that is well known to most psychiatrists and their counterparts in related professions such as neurology and clinical psychology.¹ The resulting crisis in psychiatry (Schwartz and Wiggins 1985), brought about by what the Russian neurologist A. R. Luria (1979) described as the ascendance of the classical paradigm of bioscience (175–76), has, according to these scholars, obscured the humanistic impulse of the clinical narrative in psychiatry and in psychology.² Why was this transformation a defining moment in the history of psychiatry as a profession, and why does it merit a book-length study of the uses of narrative in clinical psychiatry from the asylum age to the era of the Diagnostic and Statistical Manual of Mental Disorders III, III-R, and IV? My answer is fairly straightforward: It is in the history of the genre of the psychiatric case history that we can see the tensions at work between two rival thought-styles (Fleck 1979) with regard to mental illness—one foregrounding the world of matter and the other foregrounding the world of meanings. From a historical perspective on the rise of the professions, written genres, like pottery shards, bones, and rock strata, are material artifacts providing valuable information on how disciplines/professions that were initially undifferentiated established themselves as discrete knowledge-producing communities (specializations) with distinctive affiliations and forums. Through membership in such communities and by participating in community forums, physicians and, later, psychiatrists, like other professional groups, developed their professional commitments, identities, and allegiances. Some professions, however, are protean in the sense that they cut across the methodological and epistemological boundaries between the natural and the human sciences. Psychiatry can be seen to be one of these professions. By examining the history of the single-subject case report—the project of this book—the reader can uncover a central tension existing between psychiatry’s polarities: between nomothetic and ideographic forms of knowledge (Polkinghorne 1988); between romantic and classic science, in Luria’s (1979) terms; and between what Jerome Bruner (1986) calls narrative and logico-scientific epistemologies.

Figure 1 is a graphic representation of the polarities as described above, that is, the genres of the experimental article and the single-subject case history. Each genre is a textual realization of a historical tradition based on epistemological assumptions; thus the experimental article encodes assumptions that are rooted in positivist, materialist, and monist epistemologies, whereas the narrative case report instantiates assumptions that belong to the hermeneutical, holistic/phenomenological tradition. The goal of the experimental article is erklären, or explanation, in contrast to that of the case history, which is verstehen, or understanding. In both the scientific article and the case history narrative, formal features follow function. And function needs to be understood within the historical context in which the content of the form (White 1987) of the two genres of reporting developed and diverged. In each of these genres the interrelationship between content and form has developed over time and within the context of the processes of institutionalization and professionalization.

Fig. 1. The psychiatric polarities and their textual forms

Psychiatry and the Mind-Brain Problem

Psychiatry emerged in the late eighteenth and early nineteenth centuries as both a specialization within medicine and a profession whose practitioners were chiefly asylum physicians or superintendents. The need of this young medical specialty to develop a scientifically grounded discipline (based in neurology, brain science, or genetics, for example) has historically been counterpointed by the need of psychiatrist-practitioners to pay close attention to the phenomenological aspects of mental illness, that is, the patient’s subjective experiences (Kleinman 1988). These oppositional dimensions of psychiatry are best captured by the dichotomy between brain and mind. As psychiatrists Phillip R. Slavney and Paul R. McHugh (1987) report,

The polarity of mind and brain … seems intractable. No matter how much we learn about the brain, its links to the phenomenal world remain mysterious. Though we can sometimes correlate the occurrence of mental events with brain events, the transformation of neural processes into mental states (or vice versa) is unexplained. If there is to be a scientific accounting of the phenomenal world, it must reveal not only the mental underpinnings of that world, but also how it comes to be experienced. To obliterate the gap between mind and brain will therefore demand something more than the identification of neural systems and the description of their functional relationships to one another. If science eventually explains how the brain can generate that unity