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Book Reviews |
Key Words: Books Reviewed
In his new book Hysteria, Christopher Bollas breaks new ground while skillfully tilling the old. He brings back the once-prevalent diagnosis of "hysteria" and defines it in terms that can help psychotherapists understand a number of high-functioning clients and some more difficult ones as well. Although there has been an overuse of the diagnosis "borderline personality" in the last two decades, sexual neuroses, oedipal issues, and hysteria seem to have faded from view. Freud's typical patient in the early years was frequently hysteric—often female, bright, sexually repressed, bursting with vivid dreams and fantasies, prone to psychosomatic symptomatology. We all have such clients today, do we not? But what do we call them? If they are on the healthier side, they are seen as having adjustment disorders (perhaps eschewing characterological diagnosis altogether), or as having a disorder of the self (self psychological perspective). If more flamboyant or difficult, they are seen as borderline and demoted to preoedipal status, lacking in object constancy and laden with pathological narcissism.
How could such a prevalent diagnosis completely disappear in just a few decades? Showalter,1 Micale,2,3 and others have shown that a particular type of psychopathology is a cultural artifact. Hysteria emerged from Victorian culture in which sexual suppression was the norm. First, with more sexual freedom and more freedom for women in general, the need for women in the twentieth century to express their sexuality in bizarre, dissociated ways may have been reduced. Second, some cases once classed as hysteria might today be diagnosed as actual biological illnesses such as bipolar disorder, hyper-or hypothyroidism, epilepsy, or assorted other neurological disorders. Third, the pervasive acceptance of the existence of an unconscious may have reduced the prevalence of somatization of psychological distress (although Showalter1 argues that some of the vaguer physical syndromes such as chronic fatigue syndrome are actually hysterical diseases existing on a societal level).
In his quiet psychoanalytic world Bollas has discovered that hysteria is alive and well, and at the root of it is sexual dysfunction that is based not in trauma or sexual abuse, but in a de-eroticization of the self that begins in the early oedipal years in the context of an otherwise loving mother-child relationship. Like the hysteric of yore, the hysteric of today is sexually repressed. Even though she or he may act the part of a sexual person or even in some instances be promiscuous, it is all for show. True sexual gratification is unknown to the hysteric or is accessible only in an inebriated or otherwise altered state of consciousness. The reason for this distancing from sexual feeling is that the mother of the hysteric discouraged and minimized the child's natural sexual curiosity regarding his or her own body, and the mother's, in the early years beginning at around age three. Instead, the mother of the hysteric reveled in the child's verbal and imaginative productions, encouraging performance, charm, and storytelling. The hysteric engages the other and is engaged in every way except the sexual, thriving on the drama of an interaction but lacking the capacity for true physical intimacy.
Unlike the borderline and narcissistic personalities, the hysteric is able to experience the other as a whole object. Even though the hysteric acts as the projection screen for the other, it is entirely for purposes of distancing him- or herself from the sexual pleasure so disapproved of by the mother. Unlike borderline patients, hysterics can maintain high- level jobs for long periods of time and can maintain a relatively consistent therapeutic relationship, albeit frequently characterized by acting out. They pull the therapist into their narratives, often activating powerful countertransferential responses. They fit themselves into the therapist's internal drama, often becoming the character they believe the therapist thinks they are or wants them to be, and they will push boundaries not because of poor self/object differentiation, but because they have learned at mother's knee to act if not for the delight, then at least for the intense interest of the other. The hysteric who becomes a parent behaves as his or her own parent did—attending to and encouraging most aspects of the child except the sexual. Therapy with the hysteric requires finding the authentic self separate from the drama, building sexual awareness through analysis of defenses against it, and setting appropriate boundaries when necessary.
The book is replete with cases from the author's practice, and those familiar with Bollas's other books will appreciate his inimitable empathy and intuition once again. They will also find the language less convoluted than in his previous books. I would recommend Hysteria to any therapist interested in the psychotherapeutic treatment of characterological problems.
Footnotes
Mary Nicholas in private practice in New Haven, CT, and is Clinical Instructor in the Department of Psychiatry, Yale University School of Medicine.
References
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