2015年9月7日 星期一

新時代新譯本: Dora in the 21st century

Freud, S. A case of hysteria (Dora). A new translation by Anthea Bell. Introduction by Ritchie Robertson. Oxford University Press, Oxford; 2013

中文書 , 佛洛伊德/著 劉慧卿 , 心靈工坊 ,出版日期:2004-09-01

Dora in the 21st century - The Lancet
If Sigmund Freud were to submit his Fragment of an Analysis of a Case of Hysteria (“Dora”) of 1905 to a reputable medical journal in 2015, it probably wouldn't get past a first read. Interventional case reports with an n of 1 are regarded with suspicion; an attentive editor might look at the 5-year…

If Sigmund Freud were to submit his Fragment of an Analysis of a Case of Hysteria (“Dora”) of 1905 to a reputable medical journal in 2015, it probably wouldn't get past a first read. Interventional case reports with an n of 1 are regarded with suspicion; an attentive editor might look at the 5-year gap between data-gathering and publication, and wonder why the paper had taken so long to write up, or indeed if the manuscript had dallied with other journals before landing on her desk; and the author's attitude to consent for publication would have been found seriously wanting. “I am sure that my patients would never have told me anything if the possibility of scientific evaluation of their confessions had crossed their minds”, Freud explained in the introduction, “and equally sure that it would be wholly useless to ask the patients themselves for permission to publish”. But before sending the rejection letter, the editor, glancing through the submission one last time, might have been given pause by its most striking aspect: Freud's Dora, one of the seminal documents of psychoanalysis, is a thorough report of a negative result.
My intention here is to look at the case afresh and ask what a psychiatrist today can take from Dora. The past few years have been a good time for English speakers who wish to get acquainted with Freud; new translations are far less daunting, and far more readable, than the stodgy standard edition. Foremost among the translators is Anthea Bell, whose achievements include, in her Penguin edition of The Psychopathology of Everyday Life, replacing the word “parapraxis” with “slip”, much to everyone's relief. It is Bell's version of A Case of Hysteria (Dora), published by Oxford University Press in 2013, that I will refer to in this essay.
But first, a bit of background for the newcomer. Dora was the pseudonym given by Freud to Ida Bauer, a young woman aged 18 years at their first meeting in 1900. Dora, by Freud's account, was sent for investigation and treatment of a cluster of symptoms, some physical, such as a troublesome cough, and others behavioural, notably the expression of suicidal thoughts. The social backdrop to this case was complex to say the least; the sort of domestic experimentation which one would associate more with the 1970s wife-swapping America of Rick Moody's The Ice Storm than bourgeois, fin de siècle middle Europe. In brief, Dora had an older brother; a governess with progressive ideas; a father who had syphilis; and a mother who reacted to domestic unhappiness with obsessive cleanliness (the latter pattern of behaviour is defined with the unpleasant term “housewife psychosis”). Dora's parents were close friends with another couple, the so-called Herr and Frau K. Dora's father and Frau K were romantically involved; and, most importantly of all, Herr K made sexual advances towards Dora, the first of which occurred when she was 13 years old, although Freud mistakenly gives her age as 14.
It's this aspect of the case that is hardest to stomach. Even allowing for different social mores and concepts of the transition from child to adult, the account of Herr K's first assault on Dora is hard to read. Herr K contrives a time and a place where he will be alone with the girl: he then corners and kisses her. Dora is so distressed by this that she flees the scene. This is bad enough, but Freud's reaction makes things worse. He sees Herr K's unwanted attention as “exactly the sensation likely to give a virginal girl of fourteen a clear sensation of sexual arousal”—in other words, Dora's revulsion is a mark not of the wrongness of Herr K's actions, but of some abnormality on her part. Grim stuff, but essential to get through. Because it is at this moment that I think the first important lesson of Doraemerges. Awareness of Freud's presence in the clinical encounter, with all of his misjudgments and prejudices, is one of the most compulsive elements of the case. It is clear, as Ritchie Robertson points out in his introduction to the Oxford edition, that Freud does not actually like Dora all that much. It is remarkable that he pays so little attention to her intelligence, which might have been an important factor in her resilience under desperate circumstances. When, after Freud delivers his interpretation of her second dream (of which more later), she responds with a curt “What came of all that?”, she shows the deadpan comic timing of Aubrey Plaza in NBC's comedy Parks and Recreation, and Freud fails entirely to get the joke. The reader may reflect on how much personal and social prejudices might cloud judgment, or how, focusing exclusively on the symptoms of illness, a clinician might not see reservoirs of strength and talent within a patient's character.
On the subject of putting aside preconceptions, it will surprise the modern reader familiar with psychoanalytic criticisms of biologically orientated psychiatry to find just how organic Freud's thinking is. He even makes a foray into the field of psychiatric genetics, with speculation on the hereditary effects of syphilis. Later discussion of the interplay between bodily symptoms and intertwining psychological factors gives Freud the opportunity to use his gift for compelling analogies; in my favourite phrase in the book, he describes the mental superimposed upon the physical as being “like festoons of flowers over a metal frame”. Psychological symptoms require the underlying support of the body; yet to attend to this support structure alone is to miss the point entirely. Doctors today attempting to explain the illusion of mind–body dualism might do well to dust off a volume of Freud.
Yet Dora is also a warning about the risks of a mind too given to analogies, one that mistakes words on the page for real life. Popular portrayals of Freudian psychoanalysis have it using visual puns to interpret dream material—hence the apocryphal quote “Sometimes a cigar is just a cigar”. In fact, the notable thing about Freud's interpretation of Dora's dreams is that he translates visual images into words first, and then associates on this basis. His analysis of Dora's second dream is, in this regard, either a triumph of lateral thinking or an increasingly bizarre and tenuous set of assertions. I think it's probably both. In the dream, Dora is trying to get home for her father's funeral. She gets lost in a Brothers Grimm-style forest, which she associates with a Secessionist painting depicting woodland nymphs. Later she sits alone in her parents' flat, reading a big book. Freud thought the nymphs of Dora's dream had the double meaning of mythical creatures and nymphae, a technical term for part of the female genitalia; the dream therefore implied that she had been secretly reading racy passages from an encyclopaedia. Although it's true, as Blackadder the Third would point out some 80 years after Dora, that people tend to use reference books to look up rude words, this interpretation seems to me fanciful. Evidence from psychotherapist Anthony Stadlen that there were no contemporary dictionaries available to Dora which contained the term nymphae in the way Freud proposes reinforces this impression. But there is still something of value here. Freud's account shows how easy it is to get carried away by one's model of how the brain works.
A man of profound learning and wide reading, it is natural that Freud should think of the mind as handling thoughts and feelings in the form of words and text. Similarly, his analogies of pressure and release that explain the way that drives might seek release as symptoms identify him firmly as a man of the steam age. They might also reflect his medical training—after all, an awful lot of medicine involves dealing with blocked tubes, be they vascular, intestinal, or other, and a 19th-century doctor would easily assume that the nervous system malfunctions in the same way. The point here is not that mainstream psychology and neuroscience have moved on from Freud's way of thinking—although clearly they have, into forms that are more objectively robust, if less enjoyable to read. When dealing with the complexity of the mind, we are, as Dora was, still trying to find our way through a dark thicket, and it is natural to grasp for anything recognisable—something Freud did with his wordplay and analogies of pent-up forces, and something modern doctors and researchers do when they reach for analogies of networks and programming, for example to talk about cognitive behavioural therapy. Recognition of where the analogy ends and objective reality begins is a continuing source of difficulty. Maybe some future generation will be able to talk about the brain as the brain rather than as a special type of steam engine or computer, but I feel it is more likely that yet another new analogy will come into vogue.
Thumbnail image of Figure. Opens large image

Gustav Klimt, Portrait of a Young Woman (1916–17)
Galleria d'Arte Moderna, Ricci, Oddi, Italy/De Agostini Picture Library/A Dagli Orti/Bridgeman Images
Freud's way of seeing things was understandably unpalatable to Dora, who walked out, and it is to his credit that he was not afraid to discuss his defeat, and to reconsider what it meant for his practice—in this case, in terms of the phenomenon of transference. Perhaps this frankness, persistence, and ability to cope with setbacks by learning from failure is one of the reasons psychoanalysis is still going strong, albeit at some remove from mainstream psychiatric practice, of which it is frequently critical. Are those who continue to use it historical re-enactors, the mental health equivalent of the Sealed Knot society? I don't think so: whatever one's view on the clinical effectiveness and publically funded provision of psychoanalytic services, Freud's work is still relevant for modern mental health. That does not mean that Dora should be taken as an instruction manual. In his introduction Robertson invites comparisons with an Agatha Christie mystery, or a modernist novel; while I wouldn't go that far, I would say that Dora remains shocking, infuriating, enthralling, and inspiring. It is an indispensable text for anyone wanting to get to grips with psychiatry.

Further reading

  1. Freud, S. A case of hysteria (Dora). A new translation by Anthea Bell. Introduction by Ritchie RobertsonOxford University PressOxford2013