Introduction
In the words of Fyodor Dostoyevsky, “every man has some reminiscences which he would not tell to everyone, but only to his friends. He has others which he would not reveal even to his friends, but only to himself, and that in secret. But finally, there are others which a man is afraid to tell himself, and every decent man has considerable number of such things stored away” (Wedding & Stuber, 2010, p. 134). This case is about the reminiscences of one such young girl.
An 18 year old girl, Dora who, since 12 years of age had been suffering from headaches, coughing and aphonia (loss of voice), was brought to Sigmund Freud for treatment by her father, upon discovering a suicide note in her desk. Freud, after interacting with her discovered that in addition to the above problems, she was also suffering from depression, as reflected in her psychological symptoms comprising of social isolation, lack of concentration, fatigue, low spirits, poor self-image, hostility towards her parents and alteration of character. Dora, also explicitly mentioned to Freud about a recurring dream in which she sees her house on fire, and her father wakes her up. She also sees her mother trying to save a jewel case, but is unable to do so upon her (Dora) father’s insistence to save him and the children. Finally, the entire family is able to escape safely. Freud, later on, narrated Dora’s transference, during their interaction, towards him as passionate, amorous and furious.
Discussion
The given case is analyzed, in the light of current literature from a psychodynamic perspective, while attempting to understand the pros and cons of using this approach on Dora, considering her present condition.
According to Wedding & Stuber (2010), “psychodynamic theorists opine that the following four factors propel human behavior (pp. 135-144):
- Unconscious internal motivational forces - images, thoughts or feelings usually people are unaware of, and which determine their lives patterns of behavior; thereby, making them (theorists) discount individual capacity for self-reporting or self-awareness, over self-delusion.
- Unavoidable intra-psychic and interpersonal conflict experienced by a person due to incompatible goals or contradictory actions. At an interpersonal level the conflict may be simply ambivalent feelings towards someone (love vs. hate) or conflict towards one’s own sexual behavior (homosexuality vs. heterosexuality). A trivial dilemma between two career choices (medicine vs. engineering) is also common. However, intra-psychic conflict is a tussle between the demands of the three parts of human mental personality propounded by Sigmund Freud, namely; id - the ‘beast in man’, which is a storehouse of biological instincts including hunger, thirst, sleep and sex that operates on the pleasure principle i.e. seeks pleasure and avoids pain, and cannot tolerate the delay of gratification of its needs. It is driven by a primary process - a form of wishful and magical thinking. For example, when hungry, this primary process provides a mental image of food, a wish fulfillment. Next is ego - an offshoot of id that dictates realistic thinking and problem-solving as evident from its functions including, cognition, interpersonal relations, judgment and defense mechanisms that help in effectively dealing with one’s environment. It operates on the reality principle i.e. postpones id’s gratification till a suitable object is found. So, it will only accept food and not it’s mental image or any wish-fulfilling fantasy, and thus, is driven by the secondary process thinking. Finally, we have superego - an individual’s internal representation of values, norms and prohibitions of parents and society, that enable him to function effectively by balancing both bodily needs and physical reality while adhering to the societal norms. It consists of; conscience i.e. a sense of right and wrong that punishes a person from indulging in forbidden actions and thoughts, and at the same time rewards him for a morally acceptable conduct; and ego-ideal i.e. a moral perfection each one of us strives for but never achieves. When the demands of these three mental agents clash, an intra-psychic conflict in the form of anxiety arises. Consequently, when id’s demands become unmanageable for ego, it signals an impending danger, that is warded off using defense mechanisms i.e. outright denial of external realities in favor of internally generated unconscious wish-fulfilling fantasies. For example, a patient might project his/her sexual and aggressive impulses to the physician in a self-convincing manner that the latter is making such sexual advances towards him/her. Similarly, an angry employee who has just returned from the office after getting insulted by his boss might displace his anger by yelling at his wife and kicking his dog. Another example is the child’s identification with the same-sex parent, to quell the anxiety arising from sexual attraction to the opposite-sex parent, a condition known as Oedipus complex in boys, and Electra complex in girls.
- Past events, from our childhood tend to shape our behavior as adults. Freud refers to them as psychosexual development stages, wherein, the child, in Freud’s own words “experiences his sexuality as a primary, and distinctively poignant pleasure experience” (Wedding & Stuber, 2010) derived by stimulating a body area. During oral, anal & phallic stage this sexuality is infantile and pleasure is derived from oral activities like sucking, biting, swallowing; anal activities like expulsion and retention of feces; and activities in the erogenous zones in the genitalia like masturbation of the penis or clitoris, respectively. Post these stages, with which adolescence also ends, the infantile sexuality becomes mature and adult-like, with the capacity for mutually gratifying heterosexual intercourse developing the form of genital stage. An important issue in each stage is excessive gratification or deprivation, which if faced can make the child get fixated at that stage, thereby, carrying its left-over traces in his/her personality into adulthood. For example, during the anal stage, problems experienced due to pre-mature or post-mature toilet training can make a person obsessed with cleanliness and hygiene, while also presenting him as full of defiance, ambivalence, indecisiveness and stinginess.
- Finally, the anatomical differences in the body structure of boys and girls and the consequences ensuing from them such as masturbation, menstruation, lactation, pregnancy, etc., interest small children, who grow up fantasizing about them, and ultimately develop into specific personalities, both normal and psychopathological.
A patient like Dora, could be helped using the psychodynamic approach through the following main techniques:
Next, Freud also found that “her father once after being treated for an illness by Frau K. started an intimate relationship with her; which made Dora repress her homosexual feelings for Frau K., that started to manifest themselves in the same fashion for Herr K., but at an unconscious level; thus, acting as another cause for Dora’s hysterical symptoms” (Gatlin, 2010).
- Dream Analysis (Free Association) - Here, the analyst simply gathers information from the patient’s description about his dreams and whatever else he or she says, (free association) without interrupting him/her trying to look for continuously repeated ideas and themes that might communicate unconscious motives and memories. While interpreting the data collected, “the key is to examine the collected data by trying to understand how symbolic it is with respect to the issues faced by the patient’s in his/her unconscious mind” (Sammons, 2009). In Dora’s case, besides an explicitly mentioned recurring dream by her discussed in the case overview earlier, Dora claimed “to be furious at her father for trying to hand over her, at a time when she was 14 years old, to Herr K., in exchange for hiding his sexual relations with Frau K” (Peskin, 2012, p.196), and “openly accused him (Dora’s father) of using her” (Burgess, 2010); a feeling that made her pen the suicide note.
Putting together all the pieces of the puzzle, namely; Herr K.’s attempted intimacy with Dora; her father’s illicit relationship with Frau K.; and the recurring dream that she spoke about made Freud conclude that symbolically the “jewel-case in the dream was Dora’s genitals, that were deemed to be jeopardized because of Herr K., who actually represented her father in the dream” (Gatlin, 2010).
Finally, the case overview also talks about Dora’s passionate, amorous and furious transference towards Freud, which he defined as, “the attitudes, feelings and fantasies which patients experience with regard to their doctors, most of them being irrational, and arising from their own unconscious needs and psychological conflicts rather than from the actual circumstances governing the therapeutic relationship” (Wedding & Stuber, 2010). Actually, this was Freud’s landmark discovery made towards the end of the case study, which concludes with Dora leaving the treatment mid-way barely after 11 weeks, due to “Freud’s disbelief and perplexity as to the reason why a teenager like Dora did not feel genitally excited in response to Herr K.’s sexual advances, and instead felt disgusted” (Burgess, 2010), which in fact made Dora perceive “Freud’s conviction that she unconsciously welcomed Herr K.’s seduction in collusion with her father’s extramarital affair” (Peskin, 2012, p.196), and thus, walk away. An act, Freud interpreted “as vengeance on her part, towards the male sex, that included her father, Herr K. & now himself too, that manifested itself in a sort of transference acting out towards him” (Burgess, 2010).
Psychodynamic Perspective - Why and Why Not?
Considering Dora’s case history and present situation, using psychodynamic approach to help her is suggested due to a number of reasons.
Firstly, the psychodynamic theory most logically explains adult behavior as a by-product of “the nature-nurture interaction i.e. our biological instincts and childhood experiences in the form of psychosexual stages” (Approaches in Psychology, 2009). Dora also experienced early childhood sexual conflicts and anxiety due to an orally repressed genital sexuality, due to her sexual fantasies about her father as a kid and rivalry with mother; result of oral fixation.
Secondly, it is a ‘first of its kind’ approach, that draws attention to hidden and complex unconscious motives as a valid explanation for some of our day to day irrational behaviors, leading to the development of many current mental disorder treatments such as “the talking cure”, that has helped many people, including Freud’s first patient Anna O. lead more fruitful and satisfied lives. In fact, this “talking therapy” helped Dora openly express her current situation which at least helped Freud back track her repressed childhood experiences as a cause for her symptoms (if not completely cure them since she walked away).
Thirdly, using psychodynamic approach only Freud could address the notion of transference, and also countertransference, wherein, “the physician’s own feelings get emotionally entangled with the patient” (Burgess, 2010). As per Freud, Dora’s transference was very much blatant in her abruptly walking out of his clinic, as a sign of an already existing anger against her father now transferred as vengeance towards himself for doubting her intentions.
On the other hand, on the flip-side the critics accuse it of being purely deterministic in nature, in the sense that “it presents human behavior devoid of free will and largely determined by innate childhood instincts and experiences” (Approaches in Psychology, 2009), portraying man as a mechanistic being.
Secondly, its biggest criticism is that unlike any good theory or hypothesis, it cannot be tested and falsified. Freud hypothesized all neurosis as an outcome of early childhood sexual conflicts; and Dora’s case only supported it, though it did not prove it right. The only evidence that could disprove it would be a case of hysteria or neurosis caused by reasons other than early childhood sexual abuse; a premise which is very much accepted today, as evident from “neurotic symptoms found in PoWs; as well as similar symptoms found in both men and women due to their traumatic childhood experiences of physical or mental abuse or both, which need not include sexual abuse” (Bacciagaluppi, 2011).
But this does not write off Freud’s theory, which has other more powerful reasons for acceptance. Contrary to the widespread belief about its empirical unsoundness, “the effects of psychodynamic treatment on the patients’ condition have been empirically proved to be at par with other therapies, with the patients showing longevity of improvement post-treatment (Shedler, 2010, p.98). Further, Ghijsens, Lowyck, & Vermote (2010), “after systematically reviewing literature on self-harm - a frequently appearing pattern of deliberate self-tissue damage inflicted without any suicidal intent often witnessed in patients with Borderline Personality Disorder (BPD), have discovered that instead of assigning a symbolic meaning to this behavioral pattern, the early psychodynamic approach, now perceives it as a way of their psychic functioning such as affect regulation, thereby, shifting the focus from the symptoms to a more broader psycho-therapeutic process, which endeavours to achieve a structural change in their personality, thus, making the researchers conclude that the described approach to self-harm plays an important role in the psychodynamic treatment of BPD patients, by providing a theoretical background for contemporary psychodynamic models of treatment; all of which are implementable in actual clinical settings”. Moreover, the very tenet of “partly unconscious maladaptation of the individual as being responsible for his irrational behavior, as held by the psychodynamic approach has allowed it to help in conjunction with the social learning theory not only mental patients but also those who are battling divorce from drugs and alcohol” (Walsh, 2008, p.35).
Finally, apart from the abnormal psycho-pathological scenarios mentioned above, the undisputed popularity of the psychodynamic perspective has also not failed to widely influence the normal contemporary corporate settings, attracting the attention of the companies’ Human Resources/Training Departments and Leadership Teams, worldwide. This is evident from an “increasing use of therapeutically-informed methodologies in the training industry for executive coaching that hire independent practitioners originally trained as therapists in various fields ranging from Gestalt psychology to Freudian psychodynamic approach, each of which are used as models for coaching executives with a focus on their personal development” (Brunning, 2007).
Conclusion
The above case discussion definitely presents psychodynamic approach as a fresh perspective to understanding man’s psyche by equipping us with a clairvoyant vision to look beyond the obvious’, at hidden and complex unconscious motives as a valid explanation for some of our day to day irrational behaviors like “slip of tongue”, which are hardly taken seriously, and thus, providing ‘food for thought’ to contemporary medicine. This makes me conclude that, though Freud always enjoyed the reputation of a “sex-obsessed theorist, who disrespected women’s narration of their sexual abuses” (Shaver & Mikulincer, 2005), but still his baby definitely did deftly attempt tying together the loose psychological ends of past and present; conscious and unconscious; and love and hate; a job no one else has done before.
References
Approaches in Psychology (2009). Folens Publishers. Retrieved from: http://onlineclassroom.tv/files/posts/the_psychodynamic_approach_free_chapter/document00/WJEC_AS_Ch_03.pdf
Bacciagaluppi, M. (2011). THE STUDY OF PSYCHIC TRAUMA. Psychodynamic Psychiatry, 39(3), 525-538. Retrieved from: http://guilfordjournals.com/doi/pdf/10.1521/jaap.2011.39.3.525
Brunning, H. (Ed.) (2007). Towards an Ecology of Systems-Psychodynamic Coaching. Executive Coaching: Systems-Psychodynamic Perspective (pp. 1-263). London (Great Britain) : H. Karnac (Books) Ltd. Retrieved from: http://books.google.co.in/books?hl=en&lr=&id=O3HzVqUvO_0C&oi=fnd&pg=PR1&dq=free+academic+journals+on+psychodynamic+perspective&ots=kBBYvr2ie0&sig=qiV0mpWhTLU7PXiC0zUSqHPUzwo#v=onepage&q&f=false
Burgess, M. (Producer). (2010, September 1). Case Study: Dora - The Girl Who Walked Out on Freud: BBC Radio 4 [Audio podcast]. Retrieved from: http://www.bbc.co.uk/radio/player/b00tjf56
Gatlin, A. (2010). Dora: An Analysis of a Case of Hysteria. Retrieved from Yale University: http://modernism.research.yale.edu/wiki/index.php/Dora:_An_Analysis_of_a_Case_of_Hysteria
Ghijsens, R., Lowyck, B., & Vermote, R. (2010). A psychodynamic approach to self-harm in patients with a borderline personality disorder (Abstract only). Journal of Psychiatry, 52(5), 321-330. Retrieved from: http://www.tijdschriftvoorpsychiatrie.nl/en/issues/425/articles/8157
Peskin, H. (2012). “Man Is a Wolf to Man”: Disorders of Dehumanization in Psychoanalysis. Psychoanalytic Dialogues, 22, 190-205. DOI: 10.1080/10481885.2012.666150
Sammons, A. (2009). Psychodynamic approach: the basics. Retrieved from: Psychlotron.org.uk: http://www.psychlotron.org.uk/newResources/approaches/AS_AQB_approaches_PsychodynamicBasics.pdf
Shaver, P. R., & Mikulincer, M. (2005). Attachment theory and research: Resurrection of the psychodynamic approach to personality. Journal of Research in Personality, 39, 22-45. DOI: 10.1016/j.jrp.2004.09.002
Shedler, J. (2010). The Efficacy of Psychodynamic Psychotherapy. American Psychologist, 65(2), 98-109. DOI: 10.1037/a0018378
Walsh, D. (2008). Drug and Alcohol Counselling from a Psychodynamic Perspective. Counselling, Psychotherapy & Health, 4(1), 26-36. Retrieved from: http://www.cphjournal.com/archive_journals/v4_walsh_26-36.pdf
Wedding, D., & Stuber, M. L. (2010). Behavior & Medicine (pp. 135-144). Cambridge: Hogrefe Publishing.
