This is a wonderful and evocative article.
The author has a deep scholarly familiarity with the Oeuvre of Freud as it is biblically edified in the twenty plus volumes of painstaking translation by James Strachey. And through his comments, the author provides us with a mastery of the Oeuvre of the founder of Psychoanalysis with occasional Talmudic interpretation of the text.
As one reads the article, one can't help but feel admiration with the author's mastery of the writings of Freud, and, at the same time, there is perhaps an inescapable but nevertheless a pervasive sense of frustration. This probably emanates from what feels like a difficulty in finding a tie between his theorizing and ordinary clinical experience and expertise. In sum, it is an impression, perhaps ill-founded, that the author has chosen for the sake of this paper, to remove himself from experience-near clinical practice and has instead emphasized a literary critique perspective on “hysterical/histrionic” phenomenon as it is depicted in various texts.
I am tempted to see the author's vision as a revolt. Psychoanalysis was, and quite likely, still is a revolt to the mainstream thinking. Further, in the recent history of psychoanalysis and psychiatry, there are quite established mini revolts against the dogma; like Szasz, anti-psychiatry, Laing, many of whom I am quite familiar with and feel a kinship towards, but at the same time, was inescapably, sadly disillusioned with these revolutionary heroes of mine over a short period of time.
On the one hand, the concept of “disease” as the author defines it, is bewilderingly simplistic, and, on the other hand, as the author suggests wisely, there is not an individual, but to paraphrase, as Winnicott suggested, there is a mother and a baby. This recognition that we are born into small and large groups sounded extraordinary in the dominating
world of ossified psychoanalytic ego psychology theorizing.
These interpersonal dynamics were known for millennia and were forgotten, remembered and re-brought to our attention by many, amongst whom were Freud, Winnicott, Fairbairn as persons of high-level theorizing and many schools of psychoanalysis like, Kleinians, Kohutians, Object Relations theorists and intersubjectivists etc., supported it through their work.
In other words, to counter the author's otherwise bold ideas, we are reminded that psychiatric illness is always in relation to an “other/others” and is partly shaped in the audience of the other(s). Just as transference, countertransference is evoked by and shaped by at least a twosome. As my teacher Martin Cooperman said, the building block of human psyche is not the individual person but the twosome, parent and child, therapist and patient. In the author's shorthand, psychopathology, and thus humans are not monadic but dyadic.
Within this larger context, we have the following comments on hysteria as it is depicted in this article. First, the clinical phenomenon of what is called “hysteria” or “histrionic” exists across many cultures in very similar forms. And it exists, probably for some millennia no matter what coinage we use to name and define the “symptoms” observed. We have a long companionship with “hysteria” as an illness and its appearance in relatively familiar forms.
It is not as different as the differences that the following genres depict; Kabuki theater, mime, puppeteering or a grand theatrical production of Les Misérables. So there must be a common human denominator of certain basic aspects of how we use nonverbal, bodily action and non-action cross culturally if the hysteria of a Turkish village in rural Anatolia and the hysteria of fin de siècle, relatively isolated, self-sufficient cities of Europe; Paris and Vienna have some profound similarities. They are closed in economies and cultures, villages with differing expansions.
But let us go back to our development as psychiatrists and therapists. When we entered the practice of psychodynamic psychiatry in Ankara, Turkey during the late 1970s, we had seen many patients who would come with hysterical paralyses of limbs, aphonias, fugues, arc de cercles, multiple personalities as described by European psychiatrists and
neurologists in wondrous detail in the 19th century and early 20th century. We would use a wide range of methods of treatment, including galvanic faradization for hysterical paralysis of extremities, hypnosis, barbiturate analyses and psychodynamic therapy.
None of these were on the stages of fin de siècles theatre/auditorium of Salpetrier under the directorship of charismatic masters like Charcot. But there was clearly a mime-like quality i.e., the actions or inactions, words or the lack thereof, of the patients could easily be interpreted along the lines of some activated conflicts or split off parts of the psyche, defensive constellations around centrally important affects of shame and guilt amongst others. So where was the stage?
The widely known phrase of “It takes a village to raise a child” has another, closely tied side to it—that villages, human ecologies we grow with the help, nurturing and boundary negotiations of a multitude of others are small theaters, where every person is being closely watched by all members of his immediate family and of the literal village as sources of pride, shame, envy and gratitude. So, one is on the stage and in the audience at the same time and all the time. Thus, it is a fertile ground for a mime-like hysterical illness to develop and be displayed on this stage of the village. Smaller Turkish towns were similar, perhaps the main difference was instead of the village being the stage, now neighborhoods were acting as the stage for the actor-audiences.
It was of interest that as the country became more urbanized in the globalizing 20th century world, as the local, self-sufficient, closed-in economies of villages and small towns were integrated into the market of the country and the country integrated with the global economy, hysteria slowly disappeared. With the risk of taking a tangent, one also wonders whether there is a parallel between the disappearance of hysteria and the fate of small traveling show troupes who would visit these small villages and towns and put on some short plays and puppetry and would occasionally display a few esoteric animals like a monkey or a python to the amazed eyes of the villagers.
Whatever we attribute to the causes of this sad phenomenon of attrition, in a similar and parallel way, the dramas of these tiny mobile theater troupes and dramas of hysteria slowly disappeared. It was stunning to
note that with the increased availability of local clinics that delivered modern medical care, patients with similar intrapsychic-interpersonal constellations began exhibiting classical depressive symptomatology. To expand the metaphor of the village as a stage – perhaps now there was no central stage to act on. It was gone for hysteria as it was for the small traveling troupes, and thus patients perhaps learned to talk.
It is an interesting fact that many years later, Lacan would hold similar demonstrations, not in action but more around the narrative of the patient in a verbal way in his weekly seminars in Paris. There was a shift from the theater of Charcot to literary analysis and the critique of narrative. Yet the demonstration of madness in visual or verbal forms to educated masses is perhaps a French tradition par excellence.
In the earlier phases of psychoanalytic theorizing, we had a concept of “transference neurosis”—which meant that the central conflicts, defenses, split off aspects of the intrapsychic organization of the patient were replicated in the relationship between the patient and therapist dyad. When the transference neurosis had fully evolved, the psychoanalyst was not just a transference figure but had become a real figure in his/her own sake and was a source of and taking sides in the conflicts that the patient had regenerated in the treatment situation.
Thus, the terms of transference; the brilliantly articulated countertransference possibilities by Racker; the idea of projection; the Kleinian concept of projective identification; and role responsiveness of Sandler. All of these describe a series of phenomenon of attribution of the roles from the story of the patient to therapist and the therapist joining the major scripts of the patient and vice versa to a degree. All of which are in sync with drama, theater, acting and enacting and the concept of dramaturgy.
The treatment of what we decided to refer to as severe pathology, after Kernberg, mainly goes through actions, counter actions, enactments, interpretations of actions. Not necessarily just interpreting words or narratives or resistances. As the work in psychotherapeutic hospitals, like Austen Riggs Center and Menninger where there is an abundance of patients with “severe pathology,” clearly demonstrates the therapeutic task is to translate the meaningful, communicative behaviors of the patients to words. And we must say “unconscious communication” which
is sorely lacking in the author's paper.
But this doesn't mean that hysteria is not an illness or that it is just an illness. In fact, it beautifully overlaps with the dilemma about the nature of psychoanalysis. Is psychoanalysis a medical science, where we have the algorithm of etiology that leads to illness, or is it a hermeneutic field, where human motivation and human communication, be it through words or actions, is essential? These, in my opinion, are not necessarily exclusive positions. Psychoanalysis straddles science and hermeneutics. So does Hysteria as a hybrid of illness and a script originated by the patient in his/her interpersonal and historical context.