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Graeme Macrae Burnet on Psychotherapy and the Inspiration for Case Study

Posted on 11th October 2021 by Mark Skinner

With his Booker Prize-shortlisted His Bloody Project, Graeme Macrae Burnet announced himself as an enthralling literary talent to watch. Now, with his fourth novel Case Study, he places the complexities and contradictions of psychotherapy under the microscope in a dazzling study of the nature of sanity, identity and truth. In this exclusive piece, Burnet discusses the inspiration for the novel's themes and how a teenage obsession blossomed into a forensic analysis of psychotherapy itself.

I’ve been fascinated by psychiatric case studies since I came across a copy of Robert Lindner’s The Fifty-Minute Hour as a teenager. The lurid cover of the book declared: ‘I am a psychoanalyst. I meet and work with murderers, sadists—people at the edge of violence—and some who have passed that edge.’ It is a declaration that acknowledges the voyeuristic desire to peep behind the curtain of the psychotherapist’s consulting room, piquing the curiosity of at least one teenage boy. And judging by the million plus sales of the book, he was far from alone in his appetite for this kind of material.

Later on, however, when I read the case studies of Freud, Breuer and others, my attitude began to shift from prurience to scepticism. There’s an extraordinary moment in Freud’s famous (or infamous) case history of “Dora”. Not satisfied with the version of a traumatic incident that his eighteen-year-old patient has given him, he openly decides to embellish it. ‘I have formed in my own mind,’ he writes, ‘the following reconstruction of the scene.’ He then goes on to base his analysis on this ‘reconstruction’ or, to put it more accurately, fabrication of the scene. In other places, Freud’s interpretations of his clients’ statements or dreams involve such leaps of imagination that one might think he was in the role of client rather than therapist. 

Freud’s embellishment of Dora’s narrative is an extreme example perhaps, but it demonstrates that when we read a case study we are not reading an objective, unbiased account. By their very nature, case studies present only one point of view: that of the therapist. It is the therapist who selects what material to include and exclude, and their interpretation of this material is inevitably filtered through whatever theory they happen to espouse. The Swiss psychotherapist Alphonse Maeder cannot keep his own Christian beliefs out of his diagnoses, pointing out to a seventeen-year-old student, whose only ‘neurosis’ is a liking for jazz, the need for ‘acceptance of authority [and] the affirmation of a personal God,’ by which he presumably did not mean Miles Davis. 

I came to see these ‘studies’ less as factual accounts of an interaction between medical practitioner and patient, than as skewed encounters between a pseudo-objective ‘expert’ and a voiceless other.

All this led me to wonder what these encounters would look like from the other side of the therapist’s office. I began to seek out accounts of therapy written not by the therapist but by the patient. The so-called Wolf Man, one of Freud’s most celebrated cases (in reality a Russian aristocrat named Sergei Pankejev) wrote an account of his life in which he makes no mention of the incidents which Freud deemed to be of crucial importance. Mary Barnes, R.D. Laing’s most famous patient, wrote a book about her descent into madness and experiences at Laing’s experimental therapeutic community Kingsley Hall in the 1960s. A 1964 volume entitled The Inner World of Mental Illness provided further insights into how things looked from the perspective of those labelled as mad.

Increasingly, I began to question the assumptions that the teenager reader of The Fifty-Minute Hour had held. As A. Collins Braithwaite puts it in his own volume of case studies, Untherapy, ‘The crimes of psychiatry are legion, but they can mostly be ascribed to one thing: the idea that the therapist knows more than the patient.’

This then was the seed from which Case Study grew. From the beginning I want to present the story of a series of therapeutic encounters that called into question the assumptions I myself had once held, both about the objectivity of the account and about the relative sanity of the participants. Of course, once you get into the writing of a novel the tree that grow does not necessary resemble the acorn, but that’s how it started.

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