What follows is a vivid and compelling clinical vignette that, among other things, testifies to the manner in which psychoanalysis proffers us “hope for better coping with life’s challenges, traumas, fears, and such.” It does this primarily through making available to us “a different way of attending to one’s lived experience by offering a place of refuge in which to go deeper into [the likely causes of our] suffering” (Sara L. Weber). In this instance, we have a brief glimpse into one person’s unique and—at first—rather opaque “emotional constellation.” (The bracketed comments are by yours truly.)
“The patient is a woman who hated her father. Apparently he accused her of things that she had not done, was rude and vulgar, and created scenes in the home. This ‘caused’ her to leave home as soon as she could, carve out a career for herself as a lawyer, putting no demands, financial or otherwise, upon her father. She married when she was 21. She had eczema, bronchitis and frequent bouts of coughing. She came to analysis because after she had tried a medicine chest of remedies her GP [‘general practitioner’] suggested to her that her condition might be psychologically based [for any number of reasons, I suspect many of us might strongly resist such a diagnostic interpretation, although we do not learn if she in fact first did so]. On undergoing analysis she found breaks in treatment either at weekends or during holidays panic-making [so it appears that the analytic setting, which includes first and foremost the analyst, provided a sense of security and solace] and she had bouts of tussis nervosa as soon as the analyst went away [‘dry cough,’ one of the ‘symptoms’ diagnosed and interpreted by Freud in the (in)famous ‘Case of Dora,’* the name being a pseudonym]. In his absence he existed in her mind as an object fixed in the consulting-room, and she knew for certain that she did not exist in his mind. The tie between her and the analyst was felt be her to be physical and not mental and this was strengthened when he gave her extra sessions at weekends and during breaks in the early stages of treatment [from the outside looking in, this change in the regular schedule may have been a mistake in clinical judgment]. She would often sit eating on a park bench near our London home. The interpretation that she was a baby clinging desperately to Mummy—holding onto her physically—made sense to her. ‘When the session ends and I push you out the door—out of the bedroom—little Mary is not going to be beaten and stays on Mummy’s lap (bench).’ This interpretation also enraged her because she hated the analyst being able to see the child in her. She believed she was a mature and independent woman [she certainly had acquired many of the outward signs of same].
Now these factors—a physical clinging to the analyst, inwardly tortured by believing that the analyst would seduce her sexually; an idealization of the analyst; an inner omnipotence; an indignant self-righteousness; the eruption of eczema; the absence of mental representation for outer figures and the consequent absence of a capacity for thinking—are all elements in an emotional constellation. It is part of psychoanalytical experience that it only becomes possible to understand an emotional constellation when it begins to cede to a different pattern. Now in this patient a different pattern did emerge. Its constituents were as follows: a de-idealization (seeing the analyst as a person who made a mistakes); a confidence that the analyst would not seduce her; an image of the analyst as a person existing with others; a substitution of humility for omnipotence; a capacity to accept responsibility for ‘bad’ things that had happened between herself and others; a significant decrease in asthma attacks and a diminution of eczema; a mental representation of the analyst and the development of a capacity to think [Some would argue these are, in the main, indicative of ‘mind over body’ placebo effects, a plausible view which I believe is in part true, and yet these effects can at the same time constitute or represent very real moral psychological and developmental insights into one’s character, mind (including the unconscious), and behavior that can be achieved with such therapy.] In light of this new pattern she sees that her previous perceptual system was distorted. However, in her new emotional constellation she becomes aware of realities which did not burden her before: regret that she had governed her life to date on these false perceptions; guilt about the way in which she had treated her husband, father and mother; sadness that she had been cut off from several avenues of ‘possibility.’ She had to bear personal regret, guilt and sadness. She was stuck in the first emotional constellation, feeling unable to bear these ‘dark’ emotions. This suggests some inner sense of their presence. There is here the emergence of truth and with it a dawning of hope. The change occurs in a decision to face pain [and suffering] rather than [attempt to] evade it. The analyst can witness a patient changing from evading pain to facing it but not the reason for doing so.” — Joan and Neville Symington, The Clinical Thinking of Wilfred Bion (Routledge, 1996).
One lesson the Symingtons would like us to derive from this clinical case involves a critical appreciation of Freudian ideas, one is obligated to separate the wheat from the chaff, or the living from the dead, in the Freudian corpus. Thus the factors active in the inner life of the individual are not, strictly speaking, “compatible with drives or instincts conceptualized as impersonal forces that cause this condition or that symptom” [it is still arguable that Freud actually believed in such a form of unmediated or direct causation in these matters].
Freud was devoted to the relief or amelioration of suffering, not to its elimination (as the Buddhists, among other Indic worldviews believe possible) insofar as it thought to be intrinsic to the human condition. Thus, unlike Buddhism, psychoanalysis does not have as an ultimate goal the elimination or transcendence of suffering (the ‘fourth noble truth’), but rather, to paraphrase Freud, an exchange of ordinary “unhappiness” for neurotic misery or suffering. This does not mean of course that Buddhists would have no interest in such amelioration or relief insofar as that can take place short of absolute transcendence. Put in positive terms and in the words of Ernest Wallwork, Freud sought to “enabl[e] the patient to enjoy life as fully as possible and to ‘make the best of him[self] that his inherited capacities will allow.’” In this regard, Freud was committed to the modern or European Enlightenment notion of moral psychological notion of “autonomy” (this concept is often misunderstood and abused, particularly when the various situations and contexts of its use are ignored or ill-understood, as when it is conflated or confused with crude or ideological conceptions of individualism or thought to be in fundamental conflict with, or even subsumed within, community; importantly, it is what animates if not undergirds the democratic ideal of ‘self-rule’**):
“Once the analyst’s interpretive work succeeds in relieving suffering by improving access to and control over disavowed motivations, the analyst leaves it up to the patient to decide what he or she wants to do with the newly one self-knowledge. The analyst refrains from directing the analysand as to how to act, out of respect for the intrinsic worthy of patient autonomy, or self-determination. This means that even if the analysand chooses to acts as a scoundrel, the analyst will not intervene, in order to allow the patient to act in light of who he has come to be. The assumption is that the patient is an autonomous person with his or her own values and that he or she deserves the respect which autonomous persons are rightfully accorded. As Freud says regarding the value of autonomy: ‘The analyst respects the patient’s individuality and does not seek to remold him in accordance with his own—that is, according to the physician’s personal ideals; he is glad to avoid giving advice and instead to arouse the patient’s power of initiative.’” — Ernest Wallwork, Psychoanalysis and Ethics (Yale University Press, 1991): 212-213
See too, passim, Jeremy Holmes and Richard Lindley, The Values of Psychotherapy (Oxford University Press, 1989) and especially, again passim, a brilliant philosophical and psychological analysis of autonomy in Freudian psychoanalysis by Ilham Dilman in Freud: Insight and Change (Basil Blackwell, 1988). There are some excellent essays on autonomy and mental illness in Lubomira Radoilska, ed. Autonomy and Mental Disorder (Oxford University Press, 2012).
* For this early case, these studies are the crème de la crème:
- Bernheimer, Charles and Claire Kahane, eds. In Dora’s Case: Freud-Hysteria-Feminism (Columbia University Press, 2nd ed., 1990).
- Decker, Hannah S. Freud, Dora, and Vienna—1900 (The Free Press, 1991).
- Mahoney, Patrick J. Freud’s Dora: A Psychoanalytic, Historical, and Textual Study (Yale University Press, 1996).
** As Meta Mendel-Reyes writes in the abstract for her article in the journal Polity, Vol. 32, No. 1 (Autumn 1999), “The tension between the individual and the collective within the concept of self-rule has significant implications for democratic practice, but has been neglected in democratic theory. Democratic theorists have yet to explore thoroughly the distinction between the rule of the self over itself, and the rule of the self as a member of the collective over itself and other selves. Democratic movements have tended to conflate the two dimensions of self-rule in practice, leading to extremes of individual independence or collective solidarity.” For exceptions to this rule, at least with respect to democratic theory, and in addition to the works of J.S. Mill, see David L. Norton’s Democracy and Moral Development: A Politics of Virtue (University of California Press, 1991), Alan Gilbert’s Democratic Individuality (Cambridge University Press, 1990), and Raghavan Iyer’s Parapolitics: Toward the City of Man (Oxford University Press, 1979).
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