'Fragment of an Analysis of a Case of Hysteria ('Dora')'
Dora commenced an analysis with Freud at her father’s instigation in October 1900. She abruptly ended treatment 11 weeks later. Freud wrote up the case study soon afterwards, but did not publish it until 1905.
Before considering the conclusions Freud drew from this case, I will summarize the facts relating to Dora’s personal history, her social and family circumstances and her symptoms, as set out by Freud.
Freud informs the reader that Dora was the second of two children, having a brother some 18 months older, that her father had a “dominant” personality, and that her mother was a “foolish, uncultivated woman” who had “housewife’s psychosis”, being obsessed with cleanliness. We also learn that the family was divided, with, on the one hand, father and daughter being in alliance, and on the other, mother and son. Dora’s father was said to have been proud of her precocious growth and intelligence and to have used her as a “companion and confidante”, even allowing her to nurse him on occasion.
Dora’s father contracted TB when she was six and the family therefore moved to the country where they formed an intimate friendship with Herr and Frau K. Frau K, like Dora’s father, was unhappily married and the two of them embarked on an extra-marital affair. Freud tells us that Frau K, in a similar way to Dora’s father, came to rely on Dora as a confidante and adviser in connection to “all her marital difficulties”. We also learn that Dora’s father suffered a detached retina when Dora was 10, being treated in a darkened room, and that two years later he experienced symptoms of “paralysis and slight mental disturbance”. Freud also informs us that Frau K nursed Dora’s father through these various illnesses, apparently at one point talking him out of committing suicide. In the meantime, Herr K was spending an increasing amount of time with Dora. Indeed, while Frau K was caring for Dora’s father, Dora was with Herr K caring for the couple’s two small children, “almost becoming a mother to them”. Freud tells us that Dora came to learn that her father had contracted VD in the past and, seemingly, had infected her mother.
In terms of Dora’s symptomatology, we learn that she had wet the bed until about the age of eight, at which time this symptom seems to have been substituted for that of chronic asthma. By the age of 12, Dora suffered attacks of migraine and nervous coughing. The migraine attacks grew rarer, but the coughing continued, lasting for several weeks at a time. In later years, Dora suffered complete loss of voice, as well as vaginal discharge. Freud describes Dora as being “entirely and completely hysterical” by the age of 14, asserting that she was “a source of heavy trials to her parents” by the time she was 17. At this stage, Dora was said to be on bad terms with her parents, socially withdrawn, and spending much of her time studying and attending “lectures for women”.
The case study reveals that Herr K set out to seduce Dora from an early age and that he persisted in this endeavour, presenting her with flowers and valuable gifts as she grew older. Moreover, we learn that he forced a kiss on her when she was 14, and attempted to have sex with her some three years later. Dora told her mother about the latter incident. Herr K denied Dora’s accusation and, with the support of Frau K, accused Dora, in turn, of being overly interested in “sexual matters” and of having “fancied” the whole scene. Dora’s father colluded with the K’s, telling Dora that her suggestions were a prurient phantasy. Following these denials, Dora wrote a suicide note bidding her parents farewell and saying that she could “no longer endure her life”.
Dora entered analysis aged 18 and was described by Freud as being a “mature woman of independent judgement”. He accepted that her story “corresponded to the facts in every respect”. He also concurred with Dora’s view that her father had handed her over to Herr K, using her as currency in his sexual barter with the latter so that his liaison with Frau K could continue undisturbed. Freud was also of the opinion that Herr K’s seductive behaviour towards Dora had caused the “psychical trauma prerequisite for the production of a hysterical disorder”.
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The theoretical premises informing Freud’s work with Dora hold that hysterical symptoms are an expression of a forbidden wish - that hysterical symptoms arise either as a compromise between two opposite affective and instinctual impulses: a wish and a defence against the wish, or because of ambivalent feelings of love and hate. Moreover, Freud maintained that hysterical symptoms represented a return to primary sexual satisfaction that is, to masturbation. For Freud, such activity indicated that sublimation was incomplete and that the repressed residues of once conscious masturbatory fantasies had returned in the form of psychopathology.
It may be seen, then, that although Freud appeared to be fully aware of the significance of Dora’s personal history and family circumstances, his theoretical frame led him to focus on intra-psychic neurotic conflict. Thus, the root of the problem for Freud was Dora’s unconscious infantile sexual fantasies and impulses towards her father. He concluded that these instinctual, repressed wishes had returned and that Dora was defending against the knowledge that she loved and desired her father and Herr K and harboured homosexual longings for Frau K. Freud went on to suggest to Dora that her childhood masturbation was the reason why she had fallen ill, and he interpreted her hysterical cough as representing her wish to have sexual intercourse with her father. For Freud, Dora’s cure was dependent on her awareness and acceptance of her infantile sexual and aggressive fantasies and impulses. Once these childhood amnesias had become conscious, they could be made subject to rational, realistic control.
Freud tells us that Dora’s refusal to accept his interpretations was “an indication of the strength of her repressed love and sexual desire for her father”. Furthermore, following Dora’s resistance, Freud described her as being “incapable of impartial judgement”, and suggested that her “No” signified “Yes”. Freud contended that part of the reason why Dora ended treatment precipitously was because she had become disturbed and excited by thoughts of wanting to be kissed by him.
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Mitchell (1993), in looking at Dora’s case from the vantage point of contemporary relational psychoanalysis, articulates our surprise at the lack of acknowledgement Freud accorded Dora’s subjective experience - her need to relate to her own experiences as real, meaningful, valued and valuable. She was, after all, profoundly betrayed by those she trusted most deeply. Mitchell (1993) contends that, to this extent, Dora’s analysis may be seen as a perpetuation of her victimization by the men in her life. As Gay (1995) reminds us, Freud’s original title of the case study was “Dreams and Hysteria”. Mitchell (1993) therefore questions the degree to which Freud acted out the countertransference, unconsciously exploiting Dora for the sake of obtaining confirmation of his new and controversial theories.
Mitchell (1993), however, makes the valid point that it is easy to criticize the case study when taken out of its own conceptual context. He argues that Freud’s model of the analytic process and set of theoretical premises concerning human knowledge and subjectivity made sense in his day. Indeed, as we have seen, Freud was well aware of the fact that Dora had been mistreated and seduced but, as Mitchell (1993) emphasises, he (Freud) did not think this mattered as far as the analytic process was concerned.
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What, then, might a contemporary psychotherapist make of Dora’s case? To begin with, greater weight would be given to the cumulative trauma Dora experienced as a result of her protracted, eroticized relationship with Herr K, and the lack of love, concern and protection she was afforded by her parents. As Herman (1992) argues, traumatic events shatter the construction of self that is formed and sustained in relation to others. The lack of a sensitive, attuned response to Dora’s trauma was, therefore, likely to have left her with a pervasive sense of alienation and disconnection in her primary relationships. Thus, today traumatic affect would be perceived not only as playing a part in organizing intra-psychic functioning, but also arising out of a specific interpersonal and intersubjective context. Dora’s painful affect and unresolved trauma would, therefore, be viewed as significantly motivating her neurotic symptoms and pathological reactions, such as attempts at self-soothing through masturbation, promiscuity, and self-harm (Tyson and Tyson, 1997).
The contemporary psychotherapist would see Dora as requiring a process of mourning within a secure environment (Bowlby, 1988). The therapeutic process would seek to facilitate the gradual integration of Dora’s split off affect and cognitions, and of the verbal and mental representations associated symbolically with her traumatic experiences (Davies and Frawley, 1994). As part of this overall process, the therapist would need to be alive to various clinical issues relating to Dora’s security of attachment, sense of basic trust, quality of object relations, process of separation-individuation, tie to an internal saboteur, constellation of mental defences, identification with victim, aggressor, rescuer or comforter, fear of death, and the use made of her as a parental child. Recognition may need to be accorded to the effect of the trauma and abuse on Dora’s latency and pre-adolescent sense of self, her tendency to carry guilt for parental transgressions, her self-organization in terms of activity/passivity, sexual orientation, gender identity, and body image.
From a relational perspective, the therapeutic process would be inherently interactive and thus require the active participation of both Dora and her therapist. Dora’s individual meaning would be understood by reference to her relational matrix and the context within which interaction takes place. These theoretical premises are based on infancy and attachment theory and research which indicate that the inner world developes through a process of intersubjectivity, and that mind or the sense of self is composed of relational configurations. It follows, therefore, that Dora’s relationships assume primary motivational status. Though issues of sexuality and aggression retain their significance, they would be understood as powerful physiological responses generated within Dora’s interpersonal field from which their individual meaning is derived (Mitchell, 1988, 1997).
The therapeutic process would focus on Dora’s subjective experience in the here-and-now which would be explored with the purpose of helping her to deal more objectively with “reality”. Reality would be viewed in terms of narrative intelligibility, rather than historical veracity, and be validated consensually. The relational therapist would openly acknowledge that his or her theories, patterns of thought and systems of ideas have an important influence on the therapeutic process, in that these would play a significant part in organizing and integrating Dora’s material, thereby providing shape and structure to her inner world (Mitchell, 1997).
From an intersubjective perspective, the therapist’s work with Dora would consist of a subtle intertwining of both interpersonal and intra-psychic processes leading to the creation of a shared reality. By these means, Dora’s personal history, particularly with regard to the focus on her traumatic childhood experiences, would be co-created, being constructed and given meaning in the here-and-now of the therapeutic relationship. The intersubjective therapist would see Dora’s personal growth and change as occurring not in moments of perfect empathy, but in moments of empathic failure – a process involving inevitable re-enactments and the repair of disruptions in emotional connectedness (Benjamin, 1992). At such times, the therapist’s task would be to survive Dora’s omnipotent destructive fantasies without collapsing or retaliating (Winnicott, 1988). The significance of this form of “holding” response is that it may help Dora recognize the therapist’s existence as a separate person available to be used and related to intersubjectively (Benjamin, 1992). As seen from a more overtly hermeneutic perspective, the therapeutic process would require active engagement with Dora’s dissociated experience which, once represented symbolically by means of language, may be reflected upon, creatively interpreted and given a new and more resonant meaning (Stern, 1997).
In terms of technique, the major difference between Freud and a contemporary relational therapist would consist in the degree to which each interacted and participated with Dora in the therapeutic process. Interaction is manifested both in affective terms and by means of the transference-countertransference process. Freud subsequently came to view countertransference as consisting of the therapist’s unanalyzed unconscious conflict and, therefore, as an obstacle to the analytic process. He therefore advocated adopting an attitude of abstinence, anonymity and neutrality in relation to the patient, believing that this technique would prevent the analytic process from becoming contaminated with the countertransference. By contrast, a contemporary relational psychotherapist would presuppose that countertransference is an inevitable and integral aspect of the whole therapeutic process, consisting not only of unresolved experiences and conflicts from his or her own past or current life, but also as containing important information about Dora’s material that may provide clues about her unconscious inner conflicts (Mitchell, 1997).
The relational therapist would also expect clues and information of this sort to be communicated through an interactional process consisting of repeated cycles of projective and introjective identification. Thus, Dora may unconsciously induce states of mind in her therapist as a means of communicating aspects of her mental state that have been denied, repressed, split off or dissociated (Bion, 1990). Here, the therapeutic task would be to contain, transform and give meaning to the raw emotional pain associated with Dora’s childhood trauma. In this way, Dora’s untransformed psychic pain, dread and terror (beta elements) may become available for mental work, being reflected upon and symbolically transformed by means of thinking, imagining, dreaming and remembering (alpha elements) (Bion, 1984).
With regard to such unconscious interactional forms of communication, given the fact that Dora had been sexually abused, the therapist would need to be aware of any tendency by Dora to eroticize the transference (Blum, 1994). Moreover, in the light of the pain, neglect and disappointment that Dora has experienced, she may experience difficulty in trusting a more benign relationship and, instead, defensively rely upon old, malign but familiar internal working models of self-other attachment relationships. However, concomitant to Dora’s defensive need to repeat such negative patterns, the transference may carry an unconscious wish for change and the hope that the therapist would act as developmental rather than transference object (Hurry, 1998). Thus, in unconsciously asking the therapist to contradict transference expectations, Dora would be seeking an appropriate developmental object. Indeed, this search may be her real agenda and form the basis for a genuine, though predominantly unconscious, therapeutic alliance (Hurry, 1998).
In respect of the countertransference, the therapist should guard against enacting or re-enacting aspects of the original abusive relationship by blaming, victimizing or, indeed, seducing Dora. Seductive behaviour by the therapist may include a countertransferential wish to rescue or parent Dora, thereby encouraging a regressive dependency (Blum, 1994). Mitchell (1997) emphasises that awareness of countertransference tendencies of these kinds require continual self-reflective responsiveness to the material being presented. He suggests that the question for the contemporary therapist is not whether to share countertransferential thoughts and feelings, but when and to what extent. Selective disclosure of the countertransference may function to help Dora and her therapist connect on an emotional level and, thereby, open up and vitalize Dora’s subjective experience, providing her with a sense of being valued and understood. Handled insensitively, however, disclosure may close down and deaden her experience. Clearly, then, the decision to disclose requires a responsible, sensitive and judicious approach by the therapist that takes full account of the need to protect Dora’s personal integrity and boundaries. A delicate balance would need to be achieved, therefore, whereby the therapist is neither excessively emotionally detached from Dora nor excessively intimate and intrusive (Mitchell, 1997).
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