Fabiana’s Case: A Case of So-Called Hysteric Suffering
This is a case of a woman diagnosed with hysteria. Analysis, which took place weekly for around three years, immediately brought out generalized relational conflicts manifested in her work relations and her affective-sentimental relations. Her life difficulties were linked to profound repressed aggressivity projected onto others, to an idealized self-image, and to structural Self-weakness, as she was ever seeking an impossible secure identity. The psychic aspects, including low mentalization and a tendency to externalize, influenced the analytic relation, which was interrupted when transference began to develop, i.e. the possibility of a more profound and transformative therapeutic relation. This interruption is read in terms of the actual possibilities underlying each therapeutic “exchange” characterized by the capabilities and limits of its individual protagonists. In a psychotherapeutic process geared towards fuller recognition of the subject, each psychic configuration claims a comprehensive interpretation, both in intrapsychic and in relational terms.
1. Fabiana’s Psychic Suffering.
Fabiana is a tall, slim, attractive 32-year-old woman with brown eyes and brown hair. She is married with no children. She has a husband her age that she describes as somewhat violent in manner. She came into analysis for problems of vertigo and tintinitus, for which she had already consulted an ear specialist, who’d ruled out organic causes, and a psychiatrist, who referred her to me after diagnosing her with “hysteria”. As well as these disorders she also has strong conflicts in her work environment, a multinational firm where Fabiana feels persecuted and abused by her demanding bosses who verge on sadism, and where she constantly finds herself in tense situations with her colleagues. She claims she came to me only because of her dislike for psychotropic drugs, and without telling her mother, whom she says rejects psychologists as “doctors who cure lunatics”.
Her analysis began in January 1998 and ended in March 2001, with a total of 130 weekly sessions.
In the first session she mentions her invasive mother, who is much more loving toward her younger brother, who still lives at home. She mentions her husband, left traumatized after a car accident and frustrated by his temporary redundancy. She also mentions her own sense of guilt over a five-month affair with a colleague who has been transferred to another office, and her financial difficulties in sustaining therapy. She agrees to pay me my standard fee.
She often stresses her economic difficulties, even though her compulsion to buy objects she likes (often cheap ones) slowly emerges, together with her decision to employ a household help several hours a week. The subject that dominates, outside of her ear problems, for which she occasionally sees a doctor, however, is the “quarrelling” she is forced into, the conflicting relationships with people in general: with her husband, who is nervous and doesn’t understand her, with her bosses who abuse her with inappropriate tasks and impossible workloads, and with her lazy colleagues to whom she always wants to appear kind and generous. Another aspect is that she always feels she needs to take extra care over her appearance, to the point of never leaving the house without make-up and somber yet elegant clothing.
She feels her suffering because of the outside world much more than she feels her difficulties with sex, which, considering her powerful inner sensations, she mentions with apparent nonchalance. She tells me she doesn’t have intercourse with her husband (who she married young, mainly because her mother was fond of him) because of the tensions between them. In fact she only spoke about two episodes of intercourse with her husband, one that took place a few weeks after therapy began and another a year and half later. She experiences intense sexual passion outside her marriage, albeit with extreme feelings of guilt and minimal direct sex. In addition to the affair with her colleague before her analysis began, she has two more affairs while I’m seeing her. The first happened six months after beginning analysis, with a same-age supervisor, for whom she developed an infatuation after he told her he wanted her only for her body. She wrote him endless impassioned letters, but never sent them; she leaves them with me “for safety’s sake” (to make sure her husband never finds them). When the affair ends a few months later she writes more letters, this time filled with her resentment that she had “given herself” to a man who only sought sexual gratification. The second, more peculiar but equally short-lived affair, begins after two years of analysis. This is between her and a stranger she corresponded with over the Internet while her husband was working nights. She secretly meets him in a hotel but then abruptly puts an end to the affair. It seems every time she accepts penetration she feels obliged, due to her sense of guilt, to end the previously highly idealized relationship.
She fears giving herself, which for her is equivalent to “selling herself off”. She seduces, but she won’t follow through. When she’s rejected, however, she won’t give up, especially with the second adored and later loathed lover: She pursued him with emails and phone calls, tried to make him jealous by flirting with another “more harmless” workmate, and she even let on that she’d left her husband. She imagines her husband is having affairs (which is why she checks his cell-phone and home phone records, and his bank statements), but the possibility of him leaving her terrifies her, even though she won’t kiss him on those rare occasions when they do make love. (Her husband once phones me in a fury mid-analysis to report his wife has gotten worse, that she flipped out during their separate summer holidays). So much can’t she stand to feel abandoned, she even maintains a close friendship with her first lover, who is “so sweet” and who becomes her outlet for relieving her feelings during their long late-night phone conversations. She is terrified of being alone; she fears vertigo attacks where no one would be there to help her. When by herself she frequently goes out to buy cheap useless objects, or she spends massive hours on the phone. In her office she writes masses of private emails, and late at night she compulsively email chats, which is likely the only form of communication she perceives as emotionally safe.
She links her feelings of guilt regarding sex to the ominous and fierce figure of a nun, who had humiliated her at school before her classmates and who had terrified her with invasive condemnations of anything regarding sex. Nuns were often associated to her mother, who imposed the strictest and earliest curfew on her, forbade to make any male friends, and who “forced her” to move into a new house when she was a little girl. Yet she confides her dreams to this overbearing and sadistic mother, and only admits to her mother that she’s seeing an analyst a year and half after her treatment had started. (Her mother then accompanies her to a session and “recommends” her to me). It seems clear that, sexual prohibitions aside, her mother’s and the nun’s attitude gave Fabiana both a feeling of rejection and a lack of deep-down acceptance, which has led her to her current uncertainty about her feminine identity, for which she compensates by overly attending to her appearance. All this in the midst of deep inner conflicts, blamed (through projective identification) on the aggression of others or on their lack of sensitivity toward her, or on her father, who, although Fabiana says she’s always been in love with him, seems a vague, remote, or even an absent figure, going by her (non) account of him. She rarely talks about him, but she remembers one occasion, when she was seven, when he fainted with vertigo due to excessive stress. Once she too felt sick as a young girl, and “she wanted to faint” and so she did. She mentioned her only brother once, in the first session, when she’d spoken of how her mother had favored him over her.
The analysis ends (or is it interrupted) when, after nearly a year of her showing up late and speaking mostly about the endless quarrels and problems at work, I sense the transference is about to mature. Her official motivation for leaving is money problems, and she shows me a bank statement with an overdraft of several million lira, due to her husband’s “crazy” expenses that she knew nothing about, but also due to some of her own, that she hadn’t kept track of. I suggest she follow a path of greater attention to her inner experience and that she make the most of her achievements, and I tell her she’s welcome to call whenever she feels the need (as she’d done in the past).
Three years later, in May 2004, she calls me asking for a certificate to prove she’d been in treatment because of the victimization she’d suffered in her workplace. She’s been fired (or forced to resign) and she was suing the company. After an tense phone conversation, during which I try to convince her that giving such a document is neither scientifically nor professionally possible, and that a more descriptive report could be counter-productive to her aims, I offer to issue a document certifying the number of hours she was in treatment (provable by the receipts already in her possession). She accepts very resentfully but fails to pick it up. During our phone call she also tells me she is in group therapy, which is cheaper, with a colleague of mine who, she says, is prepared to supply her with the requested certification.
The latest news I have (June 2005) comes from the psychiatrist who originally referred her to me: she has gone back to her after the failure of the group therapy, and she has told her she would now be prepared to take drugs. Her husband has asked the same psychiatrist to help him leave her, without making her feel abandoned, so that he can finally get together with another woman.
2. Psychotherapeutic Co-transference
The way I feel about Fabiana in the end is bittersweet, full of hesitant uncertainty about an unfinished job. My impression is that this analysis has been a sort of coitus interruptus. I could easily blame this on Fabiana’s typical procedure in relationships: the moment she is penetrated, she has to run off. But this would be a unilateral reading, proper to a mono-personal psychoanalysis, which blames analysands and their pathologies for whatever is “unsuccessful” in the analytic experience. My relational vision of analysis (from an interpersonal, Hornian perspective) leads me to consider not only my own counter-transference (which is also subject to being considered separately as my “share” of emotional counter-reaction) but also the dynamics that I call co-transferrential(1), recently backed by the group-therapy perspective, and by the new intersubjective perspective in psychoanalysis(2). The latter views the transference and counter-transference pair as an inter-subjective system of mutual influence, where the analyst’s “decentralization” is useful only to “the understanding of the patient’s subjectivity” and to the vicarious introspection that makes possible, in dialog, both communication and sharing of perspectives. I suggest redefining this general sense [participation and the mutual game between patient and analyst] of co-transference, while reserving the term counter-transference for the analyst’s emotional memories, which interfere with empathic understanding and with optimal capacity to provide answers(3). Though I do not altogether agree with this inter-subjective perspective, because it reduces the impact of the relational model, making the intra-psychic experience of unique and self-determined subjects disappear into a generic and fluctuating co-construction, and canceling the dialectics of self-regulation and mutual regulation as a key dimension for mentalization(4), it does, however, seem to me that it stresses, as effectively as possible, that every therapeutic relation is co-determined by two (or more) subjectivities in relation, and by the very relational field established between analyst and analysand (or the subjects of the group).
Meanwhile, what really strikes me about Fabiana, and from the very beginning, were those very traits she employed to impress others, those which allowed her to survive her parents’ “non-recognition” of her: her wordiness, her attractive appearance, her attempts to break rules, and her constant attempts to assert herself and impose her will, mainly through seduction techniques, which were evidently the traits she put into play in her transference with me.
In my notes I describe her wordiness as “unstoppable logorrhea”, “speech blasting away”, “a river in full spate”, speech used seemingly to avoid stopping and thinking. There was hardly time to interpret even her occasional dreams, and I found this bewildering. I was sorry, filled with regret because it was impossible to go on to any type of elaboration; she was unwilling or incapable of psychically ‘going through’ anything. The feeling was that she was all about action, that she lived completely in an outer world, with her aggressivity projected onto others as the “persecutors” due to her very incapability of controlling herself within. And with a tendency, indeed definable as hysteric, to dramatize, on the open stage, her deep inner conflicts.
I did not, however, experience her as an hysteric, but as a person in distress and unable to recognize herself as such, however repressed, without aggressively attacking others. She managed to express her distress (due to primary non-recognition by her mother, who was her model for femininity) only through her somatic symptoms, reinforced by negative medical check-ups, which is also what happens with hypochondriacs. But, in contrast to hypochondriacs, her somatic symptoms were centered around a specific indisposition somehow based on her father’s symptom (vertigo). She also expressed her distress by wanting to run (physically and verbally) without ever stopping, like neurotics who try to flee from the conflicts they’re afraid to attempt to solve; a distress that she also expressed through her ever-sweating hands that she was so ashamed of (a symptom that was somewhat alleviated during analysis).
She expresses this distress in her dreams, which have as recurrent themes the difficulty or fear of reaching high places, the fear of dying in a car that falls into a valley, of falling off the Titanic or off a ladder after having been with the handsome Tom Cruise, and even of having exchanged heads with other people, noticed in front of a mirror, because of a mark on her neck.
To this total sense of “enduring” other people, corresponded her wish to “assert herself”, but without showing it, her “demands” (to the analyst too) were always through an artificial, fake gentleness. Indeed, she only consents to lying on the couch after a year and a half of therapy, because she feared I would observe her profile and notice her “bulging eyes and fleshy lips”, features she doesn’t like. She frequently asks me to let her skip sessions or she asks to change the time. Mindful of Kohut’s “optimal frustration”, I rarely agree to these time changes, although I do invite her to call whenever she really is in need (something she’s done several times, without overdoing it).
For my part, I “felt” her force, through her seduction made up of trickery and her use of language. I experienced not her charm, but the pressure of keeping up with her unstoppable logorrhea and her only apparent helpfulness, experiencing the impossibility of finding a passage to be tiresome. Indeed, after the first two years of patient but unsatisfactory listening, and of blocked attempts to open up her symbolic representation, and of interferences from mother and husband demanding a “recovery” they kept referring to as distant, I sometimes wished that she would end our relation, which was more useful to her as an outlet for frustration than as a form of help.
But this may also be the reason why transference never fully occurred. To her it would have been as dangerous as all the relationships she wished for but at the same time feared: whoever possessed her could only be a persecutor, even the analyst, as she makes clear in a dream in which she sees me as a thief from somewhere near Naples. After a session when I told her that love implies identity and choice, she makes love to her husband, and then she brings him into my consulting room because “it’s cold outside”. She gets into a rage every time I lead her to a partial recognition of her difficulties in loving, and also when she attempts to look at it herself, with adequate “protection” from the analyst. She responds to my latent sense of dissatisfaction, but she can also see my patient and stubborn hope that something is moving inside of her.
Not incidentally, therefore, does the therapeutic relation come to halt just when transference is about to take shape. In her December 2000 dream: a dog bites her, then loses its teeth and becomes a fluffy pet. She makes no associations, but I interpret it and invite her to recognize how so many of her conflicts are just conflicts with paper tigers that represent her need to attack those who love her: the analyst who insists on punctuality in his own interest, the mother who assails her, insofar as she depends on her.
3. Psychotherapeutic Recognition
What was I really expecting from Fabiana? Like any other therapist would expect, some sort of change in the direction of an improved psychic functioning. But are analyses endless, as idealistic Freudians believe, or may they end, as Lacan thought? In retrospect the interesting aspect is that my sense of frustration in my analytic relation with Fabiana entirely contradicts what I believe in theory. It therefore expresses my narcissistic wound as a therapist who believes in his patients’ independent abilities, and who hopes with all his being to be able to activate them, and is thus “disappointed” if this doesn’t occur.
Using in my clinical practice the relational antipoetic model(5), I always bear in mind what my first inspirer Karen Horney once said: “The tempo of the process is mainly determined not by the analyst’s capacity to understand, but by the patient’s capacity to accept the insights(6)”. This conviction doesn’t aim to become an absolutionary tool for every “failure” in analysis, but rather the stimulus toward understanding and activating (with the analyst fully employing his or her own feelings, empathy and “love”) the residual internal constructive forces (the “real Self”, in Horney’s words), which are always present in a subject who has looked for analytic help. It is this new relation, consisting in the recognition of individuals, in all their abilities for development and potential: it’s not only a recognition of the suffering that blocks them, which they end up identifying themselves with, that allows for a reduction of anguish and access to their own genuine creative growth abilities. Psychoanalysis is the most creative space for the mutual recognition of subjectivity(7), or, to use Kohut’s words, mirroring in the welcoming, empathic and respectful figure of the analyst allows the introjections of a fundamental positive Self-objects leading to the reinstatement of real self-esteem and realistic ideals(8).
Once the analyst has put forth all his human and professional abilities, there can be no “failed” analysis. What has been achieved is all that could be achieved given the situation. Only an idealization of oneself as a therapist or of the therapeutic process leads to considering a therapy as a failed one as well as to imagining an ideal patient who will confirm our skillfulness. This threat of “failure” always looms unconsciously in all analysts throughout our work, and certainly did lead me too to that hope-disappointment-hope circuit that accompanied my commitment to Fabiana. Alternatively, “failure” is even more generically projected onto “non-analyzable” patients, because they belong to a specific category defined as such, also due to the still prevailing (psychiatric) trend of classifying patients nosographically (to make, they say, our therapeutic intervention more effective) in order to “objectify” it within conceptual grids, which easily become cages for our understanding of patients and alibis for when we are held jointly responsible(9). It is clear by now that difficult patients exist only within the difficulty of that particular relation, taking for granted that the psychotherapeutic process takes place within the continuous mutual “regulation” of ones’ self by the other, of the therapist by the patient and the patient by the therapist(10). Every analysis is unique, that’s why comparative analyses of cases among colleagues, or the co-vision of cases, represents an optimum tool for psychotherapeutic training, which could not be, with this case, endless.
Yet this relational vision claims a more convincing analysis of what doesn’t work, or of what works better, in a given therapeutic relationship. An adequate understanding of a patient, for example, requires more than just considering the concrete real and symbolic aspects acted out in the relationship. It also requires an understanding of the conceptual setting of psychic suffering, so that the therapist may better conform his actions to each specific psychic situation.
To what extent can Fabiana be defined a hysteric? In what sense may one say that hysteria is, I wouldn’t say un-analyzable, but at least hard to deal with in a strictly analytic relationship? How much did I effectively “recognize” Fabiana?
Perhaps I couldn’t recognize her in her uniqueness because she only recognized herself in the continuous negation of her real Self in the first place, as she had been effectively ignored by her father and castrated by her mother. Her sense of guilt seemed to me to be connected to this inability to recognize herself, rather than to her constantly sought sexual freedom, hardly ever fulfilled with “complete” intercourse. Perhaps it was this “inconsistency” of the self, of her real Self, that caused the analysis to finish as soon as the nucleus of the transferential dynamics was being formed, when Fabiana was beginning to find some relational space for authentic confidence in herself. And perhaps, because of this deep-down “inconsistency” of hers, what prevailed was her idealized image of ostentatious narcissism, her initial fantasy of making analysis the equivalent to taking drugs, her dependency-based identification with a mother who forbade both psychotherapy and drugs. But then how to explain the failure of group therapy too and her subsequent acceptance of drugs? By her total capitulation to her symptoms?
While I’m writing these observations I remember that Freud asked himself these same questions about Dora and he too wondered whether he could have done more, perhaps by forcing transference, or in other words by “playing a part” more actively or through having taken a “warmer interest” in her. He too concluded, however, that “every psychic influence must have some limits and I also respect as such the patient’s will and acumen(11). Hysteria, in my opinion, can be better understood with a autopoietic-relational paradigm rather than with a drive paradigm alone. It should no longer, therefore, center exclusively on the repression of sexuality or the non-elaboration of the Oedipal conflict (which does indeed play a central role, albeit in a wider relational key with the parental figures), but appears to be structured more “complexly” insofar as it manifests itself as a negation of one’s true Self in favor of the being considered the secret object of the other’s desire(12) and also includes, in variable amounts, symptomatic elements from other pathological structures (in Fabiana we have seen phobic-persecutory traits, traits of neurotic instability and dissatisfaction, and psychosomatic traits). If we also take into account the obstinacy of hysterics in their not wanting to delve into themselves and into their relationships, then the characteristic trait of hysteria emerges called “dilatation of the will”(13), a will turned arrogant, intrusive, left with no way out, with no more room for passions, imagination, humor, judgment, in subjects who ask “am I beautiful”? Or “am I virile”?
Hysteria can be considered to be an exemplarily feminine pathology only from the point of view of biology and drives. From this perspective, which makes conflicting relations between the sexes implode better than it explains them, a hysteric is a failed lesbian or a libertine who hasn’t yet found the rights of citizenship. In fact, from a Lacanian perspective it is already possible to read hysteria as the impossibility to enjoy pleasure because of the impossibility of finding identification with a single parental figure; as Benvenuto (2005) puts it, “hysteria practically consists in indulging in a culture of dissatisfaction… the hysteric avoids the pleasure she is asked to reach and that she herself claims she wants… [So Dora–just like Fabiana] presents herself to us… as a fugitive… The hysteric eludes the thousand identifications she carries out… this polymorphism, this uncertainty between identification and the correlative objects, seems decisive in hysteria”.
And, even if hysteric development can be rightly interpreted as a counter-reaction with increased exteriorization connected to the dynamics of suppression of the real Self in immature, insecure subjects, it is in any case characterized by a strong tendency to “keep everything inside” (indeed, very feminine characteristics), and the fact that it may equally arise in men can be interpreted in the light of “the bipolarity of the relational mind”, present in both genders(14). Therefore, the overcoming of hysteria must be found in that superior union of masculine and feminine characteristics of maturity (always very difficult to reach), i.e. in the need to overcome the suppression of Eros while recovering the unity of word and spirit (as de Souzenelle(15) says, basing herself on biblical reading), i.e. in the integration of love and psyche (as Neumann(16) splendidly puts it, basing himself on the Jungian interpretation).
We can also go into this hysteric dissatisfaction more deeply if we consider it as being linked to the impossibility of any constructive identification with a castrating mother, albeit adored in other respects, and an absent father. This leads to uncertainty regarding the choice of one’s sexual role. What’s striking in Fabiana’s case is the sadistic and pervasive domination of the mother, taken as a model, a mother who stops her from having relationships with men, a feminine model reincarnated in the traits of the nun who sinisterly recurs in so many of her dreams. “This antithesis between love and sex is a central trait of hysterics, which has meaning only when we realize that the hysteric considers sexuality to be a form of separation from motherly love”. This motherly love, never obtained but desperately sought, even through relinquishing the penis of a man who she married to please her mother, makes it impossible for Fabiana to have any vital identification with this mother, just when the absence of the paternal figure also makes it impossible for her to have any identification with the him. So, she ends up siding with the vulnerable aspects of the Self and denying the more adaptive parts of personality(17). This very condition leads to an all the more painful search for the love of a man in the same way as it is all the more impossible for her to obtain it in the integration of love and tenderness; it is a conflict that leads Fabiana to try to be loved totally, but beyond sexuality, by the second lover we mentioned, toward whom she also feels a carnal passion and from whom she wants a total love irrespective of her own body, something which creates “a psychic, if not practical, impossibility, between the Self and the other(18)”. But it is this same conflict that, leading to an exalted idealization of love, can only make the bodily fulfillment of love impossible. So, complete sexual intercourse becomes unattainable, thereby secondary or (in her perspective) worthless; and, in any case, the friendship relation prevails supreme, demanded by Fabiana, in her usual modality of deepness and fullness, from all people, her husband, her lovers, her analyst, as an adaptation, or as submitting others to her expectations and needs.
All these dynamics also appear in the intrinsically conflicting relationship with the analyst, not so much because therapy had begun against her mother’s wishes, but rather because the therapy was characterized by this impossibility of a basic positive identification, such that therapy too can only be restricted to, in Fabiana’s fantasy, a friendship relation, in order for her to safeguard her weak parts and protect herself from feelings of guilt, and without it being able to become, or having to become, a complete and transformative relation, also because her devastating and unrecognized distress makes any internal representation of the conflict impossible. The conflict is thus completely externalized, on the somatic plane but even more on the social (on the “stage” of her work environment) plane. Besides, negation of distress and a “difficulty to represent” are characteristic traits of the new “diseases of the soul” of today’s individuals who, not without reason, develop hysteric and obsessional behaviors(19) or narcissistic or psychosomatic disorders. (Kohut, therefore, confines himself to distinguishing only between narcissistic disorders, transference disorders and psychotic disorders, in order to “give a direction to our interpretations.”(20))
As to the problem of diagnosis, psychoanalysts, as opposed to psychotherapists in general, who often also rely on or are there to support a behavioral or cognitivist psychiatry, are committed to not giving a specific well-differentiated diagnoses on the basis of catalogue texts, but to using their full subjectivity to try and understand the full subjectivity of their analysands(21). This process includes “science”, science as phronesis, and thus employs a “method” and not a technique that would be valid for all its actors in all its situations, however similar(22). Each analyst’s attitude is, in fact. so broad and flexible as to allow him or her to recognize the absolute uniqueness and complex dynamics of each patient and the relation she/he is in, which thus always becomes coevolutional, within the limits and abilities of both subjects involved. So, even the “coitus interruptus” of the therapeutic relation with Fabiana represented an experience of mutual experiential development, which will have necessarily produced in her a constructive hybridization of sorts, in absence of a more productive fecundation.