Thoughts on Clinical Case Conferences

Introduction

One of the central clinical activities of experienced psychoanalytic therapists and novice clinicians alike is the discussion of clinical cases. Case conferences are important yet complex, and are likely to form a turning point in the development of the clinician and/or treatment presented. Some clinicians view clinical case conferences as a kind of court room in which their work may be judged; others view it as an opportunity to escape the loneliness of the clinical work, experienced by many; while others still hope it will fulfill their wish for acknowledgement by the analytic community. Nonetheless, such narcissistic fantasies about case conferences may often lead to disappointment on the part of the therapist presenting the case.

Case conferences involve an extremely complex interaction that often turns out to be frustrating and intimidating both for the presenters and for the participants. The presenter may even feel traumatized, as he or she discloses intimate feelings, thoughts, and attitudes experienced during the course of analytic work. In such an event, participation can even delay development and professional growth as an analytic therapist. Indeed, at times, presenting at a case conference can be experienced as a low point in the therapist’s professional life. Similarly, group discussion in a case conference can also be a damaging experience for the other participants, who may feel embarrassed or guilty of being misunderstanding or aggressive towards the presenter. These dangers make it highly important to examine the structure of case conferences, to understand their complexity and to evaluate how both the presenter and the participants can make the most out of it.

There are many ways in which the social-professional encounter of case conferences can be studied, such as the influence of regressive, unconscious, personal and collective desires upon group processes, how individuals and groups can provide containment for the presenting therapist, and so forth. Yet, despite this variety of possible perspectives, case conferences have hardly been evaluated by psychoanalytic therapists and the literature rarely touches upon its issues. One of the few papers on the topic, by Tuckett (1993), emphasizes the need to evaluate three aspects of clinical case studies:

Herein, I intend to examine the construction and attribution of meaning by participants in case conferences and to assess to what extent these reflect current epistemological understanding and perception. Specifically, this article will evaluate ways of attributing meaning and constructing interpretation to transferential-counter-transferential events that seem both transformative and constitutive and that reflect vicissitudes in the analytic clinical process.

In most case conferences, therapists present their clinical work to colleagues in their professional community, be it as part of a discussion group within an institute, a meeting amongst colleagues set up for this purpose, or a working group within a public clinic. In many cases, a clinician’s motivation to present clinical work stems from a desire to receive recognition from peers for development as a professional and to share responsibility of therapeutic work. The presentation and discussion of a clinical case, wherever it takes place, is performed with the aims of assisting in the development both of the psychoanalytic therapist as a professional and the treatment he/she has chosen to present through better understanding of the analytic process, its components, and its development. Within the group setting, the course of the treatment is described in an attempt to fully portray the array of transference and countertransference events within it. This includes a depiction of the verbal and nonverbal contributions of both participants in the analytic encounter. From the listener’s responses to each other, their interpersonal communication, and the intersubjective field created between them, meaning of the transferential-counter-transferential events and the patient’s life narrative is derived and used as a therapeutic tool. This “meaning” is presented as a hypothesis regarding the development of the treatment, the intrapsychic structures of the patient and his/her relationship pattern. In the clinical discussion, participants are invited to raise their own hypotheses regarding these structures, patterns and processes from their perspective as external observers. At times participants agree with each other, while at others, they may disagree. Nonetheless, the diversity of opinions allows the presenter to examine his/her work from a variety of perspectives, to get to know new and different aspects of his/her interaction with the patient, and to set and work towards clearer analytic goals.

The success of such a conference, however, is dependent upon the level of knowledge and experience of its participants, as well as their willingness to present their opinions openly and frankly, and to consider different possible perspectives from which to provide meaning for the development of the treatment—all of which are not easy tasks. Furthermore, success is also dependent upon participants’ ability to form a basic common theoretical language that will allow them to examine the similarities and differences between the different standpoints raised.

For every analytic therapist that has presented in such a case conference, the experience of standing in front of a group of fellow clinicians judging his/her personal clinical work may turn out to be threatening and overwhelming, and the attempt to reach an open dialogue and to feel effective in the assistance offered to the presenter may be highly complex for every participant. At times it seems as if clinical case conferences are an almost impossible situation. Hence many analytic therapists, experienced and inexperienced alike, consider presenting in case conferences to be overwhelming, damaging, and even traumatic. Some describe this experience as a social and professional encounter in which they feel helpless and misunderstood, with their clinical decisions and insights coming under attack. Even if there is no particular aggressive component within the group process, simply the attribution of new, deep and intricate meaning by an outside observer to the presenter’s work, places the presenter in the position of one that has neither thought deeply nor considered the analytic processes thoroughly. Therefore, and because of the significance and centrality of this analytic activity, it seems crucial to evaluate its components and to improve our understanding of these working groups.

The ability to reach a fruitful and effective dialogue in case presentations is partly dependent upon the working environment, the quality of the relationships among the members of the discussion group, their norms and attitudes toward one another, their way of communication, and so forth. Yet, this article argues there is also a structural component that accompanies a case conference beyond the specific characteristics of one group and the individuals that compose it. This component is related to the fact that the principles regarding the construction and attribution of clinical meaning within psychoanalytic case conferences have remained unchanged for many years and have not developed in the same way that they have developed in clinical theory. The attribution of meaning to transferential and counter-transferential events and to personal narratives of patients, has developed and has been assimilated within most current analytic approaches (Mitchell, 1998); the interpretations given to analytic interactions within case presentations have not gone through the same epistemological changes that have been accepted by many in the psychoanalytic community for interpretations within analysis. This may be attributed to the fact that a case conference forms a highly competitive space that does not enable participants to delve freely into the presenter’s subjective experience of the therapeutic intersubjective encounter. It shall be argued herein that this contributes to the paralysis and stagnation experienced in case conferences and leaves participants without the ability to work through these difficulties within as in psychoanalytic therapeutic framework.

Construction and Attribution of Meaning Within the Clinical Discussion

In a Clinical Conference, group members discuss a clinical case attribute and propose alternative meanings to the development of the analytic encounter presented, the structures organizing the patient’s world, and the schemas the patient formed regarding him/herself and significant others.

A principal part of these proposals is based upon the understanding of central transference and countertransference events that embody most of the clinical understanding of the case. The structures of meaning suggested by group members are derived from their theoretical understanding, their knowledge and clinical experience, and their own subjective organization of the world. Even if there is no significant disparity in their theoretical beliefs, it is clear that the perspectives proposed do not always agree with those of other members of the group or the presenter. Nonetheless, an accepted, consensual, version is often formed—a joint narrative that can be agreed upon—providing meaning that can be accepted by most of the participants. This narrative takes into consideration the patient’s associations, the therapist’s impression of the patient’s nonverbal messages, and the therapist’s reaction to all of these. It also takes into consideration the conference participants’ countertransference to the case and that of the therapist, implied from the way the treatment is presented. All of these are gathered and ordered into meaningful structures that describe the organization of the patient’s experiences and the analytic process experienced by the patient and therapist.

It is important to mention that a group discussion within a case conference differs in its essence from a supervisory encounter, in which the supervisor accompanies the ongoing development of the treatment. Within clinical supervision, through an ongoing empathic process, the supervisor gradually gets to know the intersubjective context of the treatment, the nuances of transference and countertransference, and the analytic thera-pist’s opinions and perspectives. This takes place as the supervisor gets to know the therapist-supervisee’s personality and strives to instill confidence in the supervisory relationship. In this way, the supervisory situation is completely different from that of a group discussion within a clinical case conference. In a clinical case conference, the treatment is presented once or twice, with members of the group having a partial understanding of the interpersonal and intersubjective processes taking place. The personal sense of security of participant and presenter can be more easily compromised than in an on-going supervision. Because of the additional time, in a continuous case seminars the process will resemble that of a supervision as the group is able to explore empathically and in depth the intersubjective environment of the analytic therapy discussed.

The clinical structures of meaning attributed to a case are also greatly influenced by the wider cultural context of the professional and scientific community, as explained by Molad (2001):

Indeed, each of these influences, alongside clinicians’ personality structures, contributes to the context in which the patient and therapist inputs are interpreted. However, beyond the wider social context, there is the specific cultural context in which the clinician functions, which further structures the understanding of clinical-analytic processes. In this sense, a clinical group discussion seems to include a greater cultural influence than does individual supervision because the group has room for more voices brought by members who represent different cultural backgrounds.

The structure of meaning given to individuals’ actions and reactions is largely determined through the affect expressed in them (Lyons-Ruth, 1999). Moreover, meaning is structured by the observer’s mental representations of others’ intentional states that are considered responsible for behavior—just as interpretation of literature requires the discovery of the author’s intentions in writing the text (Wakenfield, 1990). Interpretation, according to Wakenfield (1990), is the attempt to use language to describe the real content of an intentional state, and both the intentional state and its mental representation are clearly dependent upon the context in which they appear.

However, it is important to emphasize that context and all its layers may be the most important factor influencing the attribution of meaning to transference and countertransference events. Indeed, individuals draw conclusions and attribute specific meaning to verbal and nonverbal responses, messages and communication, dreams and associations, against a contextual background in which the phenomenon they wish to interpret emerges.

Boesky (2005) explains the importance of context in the attribution of meaning to associative material raised in analysis. He explains that the intellectual ability to infer meaning from raw associative material is related to contextualizing criteria that are usually at least partly conscious or preconscious. These criteria guide what the therapist filters from his/her patient’s communication, the emphasis he/she places on one aspect, and the de-emphasis on another. The therapist combines the emphasized components of the patient’s string of associations with his/her own internalized theoretical ideas to attribute meaning and draw conclusions about the patient. It can be assumed that Boesky’s depiction of the attribution of clinical meaning to a patient’s communication by his/her therapist can also accurately describe a group’s attribution of meaning to transferential—countertransferential events appearing in a presented analytic treatment. Thus, in a discussion group, varying conscious and subconscious criteria structure the clinical context and elicit interpretations regarding the development of the treatment.

Nonetheless, even if these working assumptions about participants in case conferences are accurate, the participants still have to struggle to gain sufficient knowledge of the specific clinical context of significant analytic interactions and to accurately identify those crucial mutative moments in analysis that indicate the analytic context embodied in the transference– countertransference relationship and the system of mutual enactments-re-enactments between patient and therapist. Participants have to gain enough knowledge on the interpersonal and intersubjective reality of significant clinical interactions by means of a thorough enquiry of the context.

It seems that participants often do not thoroughly consider the essence of the specific clinical context in which the critical and transformative events in the treatment take place. These events are those usually described as “clinical facts,” and inform of significant turning points in the treatment and are indicative, more than anything else, of the development of the analytic process. The reason for this lack of consideration is not a lack of good will or commitment to the clinical discussion, but only that it requires an active attempt by participants to reconstruct these events and an empathic and deep exploration of the presenter-therapist’s perceptions. In this article I argue that without such meticulous examination of the personal and intersubjective clinical context of the transference and countertransference issues surrounding these transformative events, it is difficult to create meaning that is relevant and useful for understanding them. Moreover, my experience from many case conferences shows that even if in their clinical work analytic therapists have internalized the importance of the interpersonal and intersubjective contexts for clinical understanding, they struggle to implement these principles in the interactions characterizing clinical discussion.

The importance of the clinical interpersonal and intersubjective context for the understanding of the treatment processes is widely accepted. It is supported by the principles and beliefs of two-person psychology, which has been accepted by many of the psychoanalytic community. Two-person psychology is a concept introduced into psychoanalytic literature by Balint (1950), Rickman (1957), and Ghent (1989), amongst others, which shows that interpersonal relations are those elements that construct the intrapersonal world. Spezzano (1996) summarizes the principle behind the two-person psychology as follows:

In other words, only an understanding of the context of the unique analytic encounter, as a whole, can clarify the unconscious world of the patient. There is no doubt that such an acquaintance with the complex dialogue, the messages conveyed, and the nuances of the different perceptions, is intrinsically accessible only for its participants: the patient and therapist. The only direct way to get to know it from the outside, by other practitioners, is through empathically inviting the therapist to its exploration within secure and known boundaries.

Experience from case conferences shows that, in most cases, participants do not openly and empathically invite the presenter to deal with and thoroughly describe the context in which the analytic encounter took place or the surrounding crucial transference-countertransference events. We usually do not inquire what meaning a specific dialogue between therapist and patient presented had for the analytic therapist at that point in time of his/her life and professional development. Our wish for factual accuracy and for a “realistic” description of events leaves the therapist’s subjective depiction of the interaction and experience with the patient unattended to. This empty space is then filled with the group participants’ perceptions and interpretations regarding the meaning of intersubjective analytic developments.

At this point, I would like to present an example relevant to the discussion above.

In a clinical case conference, a therapist presented her treatment of a young woman suffering from severe mood swings with suicidal ideation when feeling misunderstood and threatening to those around her. The patient had a strong avoidance of sexual relations and suffered from overwhelming anxiety at any opportunity of fulfilling her sexual needs. The case was filled with events of approaching and distancing between patient and therapist and with the mutual testing of boundaries and trust between them. The therapist chose to present this case, wanting advice about a problem she faced in the treatment. Although she did not view basic problem in the analytic relationship as threatening to the treatment, she was concerned regarding its repercussions.

The presenting therapist detailed an important session in which the patient asked the therapist to read a letter she had written but did not feel comfortable to convey verbally. In the letter, the patient described a sexual fantasy centered round the therapist. The fantasy led the patient to masturbate—something that she had avoided in the past, as it usually aroused feelings of disgust and dirtiness. The therapist described how the patient failed to arrive at the next scheduled session, telephoning at the intended start time, and explaining that she felt a need not to attend, and wishing to continue analysis only after a short break, should the therapist agree.

Participants in the case conference raised varying hypotheses, all of which gradually converged towards a consensual opinion that the patient suffered from anxiety following the reading of the letter. They further proposed that it was the very act of the therapist reading the letter (as opposed to discussing the difficulty verbally) that aroused the patient’s anxiety. Thus, the group members agreed that the therapist did not prevent transferring their interaction to a level of acting out, and this that contributed to the patient’s next manifestation of acting out—avoiding the next analytic session and forcing a temporary termination of the treatment. The group maintained that transferring the communication to actions instead of words, prevented working through the anxiety that overwhelmed the patient and led to her need for emotional regulation, which she expressed through avoiding sessions.

The therapist left the case conference with a heavy feeling that she was unable to explain until much later. She felt misunderstood and believed the group dealt with only one aspect of the episode and overlooked the meaning these events had for her. After not being able to let go of what had taken place in the conference, she gradually came to understand that in her presentation she had not managed to convey her own impressions and convictions: The moment of reading of the patient’s letter was one of great intimacy and true engagement between her and her patient. The therapist considered the session to be a seminal moment in the treatment, in which the patient tried to convey a sense of closeness with the therapist and security in the idea that she would not get hurt by revealing her fantasy. It was a moment in which she, herself, also felt extremely close to the patient, and considered this feeling to have perhaps played a part in enabling the patient to demonstrate on her part such an act of rapprochement. The therapist was gradually convinced that the patient’s announcement of a temporary break in the treatment was in response to the sense of closeness between them, which may have frightened the patient and led her to search for a way to regulate the threateningly close relationship. The therapist was certain that once she met with the patient to discuss this reaction, there would be a significant change and improvement in the patient. Thus, the context of these transference and countertransference events, of the patient’s request to read the letter and the actual reading of it, had an alternate meaning—one of reaching out, of forming a connection between them.

In this example, the participants in the discussion group could have behaved differently. Together with the therapist, they might have examined how the therapist viewed the intersubjective context of reading the letter, how she felt the about atmosphere between her and the patient, how she felt about the messages of closeness or threats in the patient/therapist interactions, and what her associative process was, to the best of her recollection. The participants could have helped much more if, instead of attributing meaning from an external position to the specific and unique context, they had made a genuine attempt to understand the essence and meaning of the context for the therapist. It is important to mention that although part of the role of such discussion groups is, of course, to point out the therapist’s “blind spots” and unconscious components that interfere with the analytic process, this should not be the immediate goal. Without empathic and accepting exploration of the context in which the dialogue took place, from its intrinsic point of view, the proposed hypotheses regarding “blind spots” are not beneficial, since the goal is not to expose the “truth,” but to clarify a fuller intersubjective reality within the analytic relationship and thus to advance the analytic relationship.

Experience shows that case conferences have often remained in their traditional format with the working method often relying on irrelevant and uninformed ways of organizing and structuring clinical meaning. Although within psychoanalytic literature case conferences are often quoted as serious professional forums in which analytic processes are highlighted and core issues examined, the structure of case conferences, and the ways in which such important professional discourse is conducted, has rarely been discussed. In fact, until today, case conferences rely on the same format developed in the fall of 1902 in Freud’s waiting room, where four colleagues met to discuss his work. These “case conferences” led to the establishment of the first psychoanalytic community, which met on Wednesdays for an evening called the “Psychological Wednesday Society” (Jones, 1955). Yet, in contrast to the many recent changes that have taken place in the way that psychoanalytic therapists view therapeutic discourse, parallel changes have not taken place in the way they view and conduct clinical discussions regarding psychoanalytic treatments.

A Change in Approach

A substantial part of participants’ contributions to clinical discussions is often based on stringent and attentive listening to the associative material of the patient as provided by the presenter and the therapist’s reported associations at the time of the clinical analytic encounter. Such attention leads to the development of clinical inferences based upon the attempt to construct logical “bridges” of clinical data and a continuum of clinical impressions, personal experience, and theoretical understanding. This form of clinical analytic attention is, in its essence, no different from the day-to-day analytic activity performed by each of the participants in the case conference, as detailed by Arlow (1979):

For a long time, these were the recommendations for analytic activity that were adopted and used in case presentations as well. Participants in such a professional encounter brought with them their clinical knowledge and expertise, as well as their familiar professional tools for the organization of meaning, and thus they created the traditional format seen in many clinical case conferences.

However, the way we listen to, attend to, and identify conscious and subconscious messages conveyed by the patient, and the methods by which we allocate meaning to each of these within analysis has significantly changed. Today, we are still advised to be attentive to all the nuances of the patient’s expressions in the way described above, yet at the same time we study the “analytic third” (Ogden, 1994). Thus, at the center of our analytic attention we place the field formed as a result of the encounter between two subjectivities, that of the therapist and that of the patient. We increasingly tend to believe that clinical insights are part of the coconstructed narrative, created by the ongoing interaction between patient and therapist and the shared meanings they arrived at together. Knowledge about the patient’s emotional life and the perception of his/her world develops as each of the participants brings his/her own personality and the meaning structures he/she attributes in the world to this interaction (Molad, 2001). The way in which each organizes his/her external and internal worlds meets that of the other and creates an intersubjective reality unique to their encounter.

Further to the changes in the clinical analytic focus, there have also been epistemological-theoretical changes that have influenced the attribution of meaning by analytic therapists within the analytic process. A range of theoreticians—Dilthey (1926), Sherwood (1969), Ricoeur, (197), Leavy (1980), Stolorow, Atwood & Brandchaft (1994)—expressed the idea that psychoanalysis does not belong to the natural sciences, but is in fact a hermeneutical science. These authors argue that human sciences, and amongst them psychoanalysis, should observe the object of their investigation from within, and not externally, so as to construct its interpretation. In order to understand analytic material it is necessary to search for thematic moulds that repeat themselves in different areas of the patient’s life and experience, whereby the repetition is a kind of reflection of experimental replication seen in the natural sciences. These authors propose to adopt the hermeneutic approach, developed as a method for the interpretation of religious scripts, into the human sciences.

According to the hermeneutic approach in psychoanalysis, the attribution of meaning to a transference and countertransference event within the analytic interaction is primarily achieved by constructing the context in which this event took place, and understanding it from an intrinsic point of view. This event then “joins” others to which meaning has been attributed, and together, they better explain and deepen the assessment of the context in which all of these events occurred. Deepening the understanding of the context enables a richer and wider attribution of meaning to any new transference-countertransference event. This circular thought process is called the “Hermeneutical Circle.” The “circle” is based on an empathic psychoanalytic exploration of the patient’s reactions and messages that appear in the clinical interaction. Each of these is attributed with meaning from the wider context of the analytic relationship, the patient’s narrative of his/her life, and the social and cultural context in which the analytic dialogue takes place. The validity of each insight is determined by its coherence and consistence with other insights regarding the analysis as a whole.

The meaning structures obtained during such a psychoanalytic exploration always appear within the psychological field created between the two subjectivities. The boundaries and size of the field are determined by the limits of the mutual influence of the two participants on the analytic dialogue. Conclusions drawn from this exploration process need to be dependent upon the intersubjective context in which they appear and its boundaries. The intersubjective psychoanalytic field of exploration is created by the interplay between transference and countertransference manifestations. The therapist needs always to be aware that each of his/her ideas regarding the patient’s experiences is dependent and limited by his/her own personal world perspective.

If we accept these changes in the attribution of meaning for transference and countertransference events within the analytic treatment, we need to consider what relevance they may have for clinical case conferences, and how they can be used productively in that context. It seems highly unlikely that case conferences relying on traditional epistemological analytic approaches will not match or meet the needs of an analytic process implementing hermeneutical principles. Therefore, the present paper suggests examining how it may be possible to conduct an analytic case conference while using current and updated analytic insights.

Components of Case Conferences Relying On the Current Perspectives

The hermeneutical circles described above reflect upon one another, and form a foundation from which participants can derive their interventions and reactions. This foundation provides the participants a way to understand and attribute meaning to analytic processes that are not founded upon ’objective’ universal clinical or theoretical knowledge.

The participants’ ability to create such a rich and complex work pattern is likely to have a further advantage—it may act as a work role model for the presenting therapist, thus also having educational value. Learning through identification with behaviors and thought patterns, rather than through the mental understanding of issues, is often a deeper and usually more transformative type of learning, which is likely to also advance the presenter as a therapist and the analytic treatment.

Conclusion

The present article proposes guidelines for effective teamwork in case conferences based upon epistemological changes that have taken place in psychoanalytic therapy. The guidelines emphasize the intersubjective and interpersonal contexts of both the case conference and the analytic relationship described in it, and thus, enable an understanding of the transference-countertransference events and the patient’s narrative of his/her life. As presented in this article, these contexts are likely to form hermeneutical circles with the presenter’s narrative of the clinical process and to help in the attribution of meaning to the analytic clinical material presented.

The model proposed is more consistent and fitting to the current clinical analytic perceptions, which step away from the “objective” understanding of clinical analytic processes. It attributes significant weight to the subjectivity of the presenting therapist. Indeed, the proposed model suggests a format much closer to the current language of many of contemporary analytic therapists in its understanding of transferential-countertransferential occurrences. Nonetheless, it requires a change from the model widely used today in case conferences, and it seems that convincing analytic therapists and group supervisors to create such a change in their familiar and routine behavior patterns is not an easy task.

One of the problems likely to contribute to a difficulty in creating such a change is conference participants’ apprehension of losing the authority of the discussion group. For many therapists, case conferences confirm their clinical abilities and professional achievements. To no less an extent, the discussion group also enables therapists to be influential in their community. Indeed, traditionally, clinical case conferences formed a professional forum for the founding of professional perceptions of reality and the instilling of knowledge that allows for firm analytic insights. Group concurrence usually acted as confirmation for the presenter’s knowledge or lack of relative knowledge, which was the source of the group’s authority. Therefore, the model proposed is likely to undermine this source of strength and authority of case conferences in their present form, and thus may elicit anxiety about change. Nonetheless, changes in scientific authority, and psychoanalytic therapeutic authority, in particular are likely to be reflected in psychoanalytic therapists’ perception of their therapeutic actions and impact (Mitchell, 1998).

The authority of a group of colleagues participating in a case conference according to the model proposed here is not a result of the group composed of “objective” participants or of those less biased than the presenter and thus representing distinct, factual, and scientific knowledge. In fact, according to this model, the group does not necessarily have more knowledge about psychological processes or the patient’s relationship patterns than the presenting analytic therapist, and the universal clinical or theoretical knowledge of the group is not necessarily more appropriate or relevant either. The authority of such a group, according to this model, arises primarily from a different type of knowledge: the knowledge of how to hold an open dialogue that allows for genuine sharing and mutual influence between presenter and participants in the attribution of meaning to clinical material. This format undoubtedly focuses on cooperation and contributes to the consolidation of subjective knowledge, intrinsic to the unique clinical situation in which the analytic therapists play a part. Moreover, the authority of such a working group is also based on the fact that it represents a variety of opinions, as opposed to the one voice of a colleague or supervisor. The range of opinions, each representing a different perspective, is capable of creating richer and deeper clinical meaning than that of only one point of view.

Why does a range of opinions provide greater validation or authority? Because in psychoanalytic therapy we believe in the presence of many causes of behavior and motivation and of different forms of organizing human experience, that appear simultaneously and influence the individual’s opinions. Ogden (1989) explains, for example, that there are three forms of simultaneous experience, each one representing a different developmental pole of object relations and each in paradox with the other. Each form of experience is generated by one of three positions: the paranoid-schizoid, the depressive positions, and the autistic–contiguous position (which has, according to Ogden, an equal organizing significance). The three positions are characterized by specific types of defence, forms of object relatedness, quality of anxiety, and degree of subjectivity. Each of these forms of experience defines, delineates, and maintains the other, nears it and at the same time always stays parallel to it. If we accept this hypothesis regarding human experience, then the presence of numerous participants, each representing a particular perspective regarding the analytic process, is likely to enable a fuller and wider understanding of the patient’s experience, thus ensuring therapeutic authority.

Nonetheless, it is necessary to draw attention to the fact that groups often have the tendency to reduce the number of opinions voiced, converging towards agreement on the opinion expressed by those with the greatest level of influence. Thus, at times, opinions raised in a group will reflect more interpretative and conventional positions than independent and separate ones, which are often more genuine and sensitive. Nonetheless, it seems that having numerous points of view representing the discussion group usually allows for a deeper and more flexible understanding of the interpersonal and intersubjective analytic therapy reality. Such multiplicity provides the discussion group with significant authority, power, and influence.

I do not suggest that eliciting a change in traditional behavior patterns that have gained ceremonial significance will be easy. It is hard to expect analytic therapists, both senior and junior alike, to give up their familiar group roles, even if these are not always easy or convenient. Set and habitual roles often become part of participants’ professional identity and form some of the power that they take upon themselves and are allocated by their colleagues. Thus, for example, certain individuals choose to repeatedly represent a theoretical position and “delegate” themselves as representatives of that position within the case conference. Therefore, the demand to relieve participants of this habitual role and moreover, to choose a new and unfamiliar one, is likely to be too great and difficult for participants.

It is important to state that case conferences are used by members of the analytic community for more than the clarification of an analytic process or the contribution of the patient and therapist to the transference and countertransference events in the treatment. Clinical discussion provides us, as professionals, with an opportunity to meet others in the community, which is composed of individuals similar to us or looking for existential-professional meaning similar to ours. Within the clinical case conference we examine our reflection in the many mirrors present in the conference room, and at the same time, we ourselves provide mirroring for the significant parts of others. We examine the validity of our opinions, our own personal-professional development, and measure how it fits in amongst our colleagues. The encounter with colleagues, whether as individuals or in a group, often allows us to come out of the solitary confinement in which we often feel caged—confinement that is not physical, but often symbolic, in which there is no dialogue with our peers.

Therefore, it is hugely important to make the group encounter of a case conference a public field in which every participating individual can influence and mold, can tune in to others, and absorb significant messages that shall help him/her understand his/her own world. In this way, instead of case conferences being experienced (as they often are) as threatening and narcissistic situations, they shall be considered shaping and developing encounters.