Patient Tales: Case Histories and the Uses of Narrative in Psychiatry (review)

Carol Berkenkotter’s Patient Tales is a meticulous examination of the psychiatric case study, beginning with eighteenth-century examples of the genre, working through Freud’s development of the case study as a framework for theoretical argument, lingering over the twentieth-century biomedical repudiation of the single case as a source of reliable knowledge, and ending with the recent marginal revival of the case. The approach is rhetorical: Berkenkotter is interested in how the case is constructed and in how it constructs the psychiatrist, the patient, and the discipline of psychiatry. She recovers the context of particular psychiatric cases: what purposes did they serve? Who read them? And she attends to the details of composition, narrative structures, nomenclature, intertextual relationships, and especially conventions for reporting the speech of patients. This book offers a very useful study of the fortunes of an important scientific genre; it is also a demonstration of the power of rhetorical analysis to frame broad theoretical arguments and also attend to textual detail.

There is, of course, a well-established line of research in the rhetoric of science, including work on the central texts of the scientific canon: Darwin’s Origin, Newton’s Principia, Crick and Watson’s “A Structure for DNA.” Scholars such as Alan Gross, Leah Ceccarelli, and Charles Bazerman have investigated scientific genres, disciplines, and controversies. Scholarship in the rhetoric of science focuses on the language of scientific texts: how they organize and construct knowledge, how they deploy metaphors and other figures to persuade, how they model scientific ethos for readers and writers. Scholarship in medical rhetoric has emerged in the past ten years, extending this analytic work and developing in relationship to medical communications, which has generated a body of knowledge about how patients and health care providers communicate or fail to communicate. Works such as Judith Segal’s discussion of health and medical rhetoric, Barbara Heifferon and Stuart Brown’s collection of essays, John Blake Scott’s study of the rhetoric of AIDS, and Elizabeth C. Britt’s study of the rhetoric of infertility have investigated the texts of medical care, including research articles, medical records, conversations, images, and public health messages, showing how these texts shape our understanding of illness and health. Scholars in medical rhetoric have been following Carol Berkenkotter’s conference presentations on the psychological case study for years: this book combines the historical scope of landmark work in the rhetoric of science with the contemporary immediacy of work in medical rhetoric.

Near the beginning of Patient Tales, Berkenkotter makes the unarguable observation that “In psychiatry, clinical information is organized in narrative form as a case history” (2). The rest of Patient Tales is an intelligent, creative, and very productive exploration of the implications of this observation. Berkenkotter holds that disciplinary attitudes toward the case history express the tensions between seeing mental illness as a material process or as a crisis of meanings. Different approaches to the case study reveal the friction—at times the overt conflict—between psychiatry as a positivist or a hermeneutic science, and between orientations toward empirical research or clinical practice. Patient Tales offers a history of the textual practices that accompanied the professionalization of psychiatry.

The first section of Patient Tales, subtitled “The Asylum Age,” contains five chapters that chronicle the historical development of the case study, beginning with medical journals in Enlightenment Scotland and leading to Freud’s Fragment of an Analysis of a Case of Hysteria. Berkenkotter begins by outlining how patient records were used as a tool for socializing medical students at the Royal Infirmary of Edingurgh. She compares the programmatically empiricist English journal Medical Observations and Inquiries (1757–69) to the more eclectic Edinburgh Medical and Surgical Journal (1805–55, with successor journals still publishing). Medical Observations was tightly focused on clinical papers, especially case histories; the Edinburgh Medical and Surgical Journal had a more “wide-angled” approach, including medical news and book reviews, along...