Ibid., pp. 618-619. 4 страница

The introduction of the concept of "expressive relationship" eluci­dates neither that which expresses nor that which is expressed. The term "expression" eliminates the possibility for genuine inquiry into the expressed as well as into that which expresses itself. From the beginning it stamps what is expressed and perceived as a derivative of something else. Thus, the phenomena cannot be investigated as what they are in themselves. For the same reason, neither the essence of the physical nor that of the mental become less opaque if they are thought of in an expressive relationship toward each other, or to a supposed third faptor. Here neither mind nor body are genuinely questioned. On the contrary, both are left in a predetermined, unreflected-upon division. Hence, any approach founded on an expressive relationship remains within the same type of epiphenomenalism which characterizes materialistic monism. By the same token, the X which supposedly underlies psychic and somatic phenomena remains completely in the dark. Whether it is called "unified organism," "uniform life process," or whatever, it cannot be characterized other than to say that its essence consists of its ability to express itself. Researchers who make such statements state nothing save that they have just completed a circle. It seems evident that everything remains as it was in this approach, which

⁸ See, for example, W. H. von Wyss, "Grundsatzliches zur psychosomatischen Median," in Schweizerische Medizinische Wochenschrift, Vol. 82, No. 40, 1952.

"Conversion Hysteria" and "Organ Neurosis" 137

we have called "spiritual monism." It is nothing but a more subtle causalism insofar as material substances—such as physio­logical processes—have been supplanted by the more ephemeral X as the etiological factor involved in the production of physical and mental phenomena.

The basic incapacity of the mechanical approach to understand the essential connection between physical and psychic phenomena is equally evident in the work of Harold Schultz-Hencke. He charac­terizes the relations between the two with the term "correlate of synchronism" [Gleichzeitigkeitskorrelat]. He admits that it has not hitherto been possible for psychological thought to do more than establish parallel courses of events in time.⁹ Mitscherlich is equally resigned. The best he can offer is to circumscribe the problems in question with the term "simultaneous psychosomatic occurrences" [psychosomatisches Simultangeschehen].¹⁰ While this term fits well into customary medical thinking, it is nevertheless useless to an actual understanding of psychosomatic phenomena.

One of the most disturbing indications of the inadequacy of the psychoanalytic concept of hysterical conversion is the quarrel about the distinction between hysteria and organ neuroses. This quarrel pervades all of contemporary psychoanalytic and psychosomatic literature and is still undecided. It is best illustrated by the con­troversy between Alexander and Fenichel.

Alexander opposes a meaningless overextension of Freud's concept of conversion. He suggests a threefold division of psychosomatic symptoms: symptoms which are substitute expressions of repressed emotions, symptoms which are essentially normal physiological ac­companiments of certain emotions, and symptoms which belong to neither of these groups.

Hysterical conversion symptoms are substitute expressions— abreactions—or emotional tensions which cannot find adequate outlet through full-fledged motor behavior.... Anger [for example] which cannot find expression through yelling, shouting, accusing, hitting, might lead to conversion symptoms in organs which are

• H. Schultz-Hencke, Der gehemmte Mensch, Leipzig, 1940, and Lehrbuch der enalytischen Psychotherapie, Stuttgart, 1951.

¹⁰ A. Mitscherlich, "tJber die Reichweite psychosomatischen Denkens in der Medizin," in Psyche, Vol. Ill, 1949-1950, and "Contribution a la Theorie psy-choanalytique des maladies psychosomatiques," in L'Evolution psychiatrique, Vol. Ш, 1953.

J 38 Daseinsanalytic Re-evaluation of Psychoanalytic Doctrine of Neuroses

used for the legitimate expression of rage—the larynx or the extremities—in the form of hysterical aphasia or paralysis. As Freud originally stressed it, these substitute irkiervations never bring full relief; they are only attempts at relief.... The important issue, however, is that the emotional tension is at least partially relieved by the symptom itself. We deal with a different psycho-dynamic and physiological situation in the field of vegetative neuroses.... Here the somatic symptoms are not substitute ex­pressions of repressed emotions but they are normal physiological accompaniments of the symptom. For example, the emotional states of rage and fear are connected with a physiological syndrome [of which elevation of the blood pressure is one of the symptoms]... These physiological processes are normal corollaries of rage and fear... They are a utilitarian preparation and adapta­tion of the internal vegetative processes to a specific type of be­havior which is regulated from the organism.

... Peptic ulcer is neither a conversion symptom nor a vegetative neurosis. In some cases it is the somatic end result of a long­standing neurotic stomach dysfunction but in itself has nothing whatever directly to do with any emotion. It is not the symbolic expression of a wish or a self-punishment...^u

To avoid confusion, Alexander proposes that we restrict the concept of "hysterical conversion" to symptoms occuring in the realm of the voluntary neuro-muscular or sensory perceptive systems, whose function is to express and relieve emotions. The concept of "vegeta­tive neurosis" he wants to apply to the psychogenic dysfunction of a vegetative organ which is not under control of the voluntary neuro-muscular system.¹² Fenichel disagrees:

... unfortunately things are not as simple as diat.... No one who has ever analyzed a hysterical vomiting or a disturbance of men­struation, for instance, can doubt their function of expressing the idea "I am pregnant" and thus being of the nature of a conver­sion... [On the other hand] certain functional changes in the striated muscles [accompanying anger, for instance] are not conversions..,¹³

¹¹F. Alexander, "Fundamental Concepts of Psychosomatic Research," in The Yearbook of Psychoanalysis, Vol. I, New York, 1945, pp. 260 ff. Material in brackets added by translator.

¹² Ibid., p. 263.

¹³ O. Fenichel, "Nature and Classification of the So-Called Psychosomatic Phe­
nomena," in The Yearbook of Psychoanalysis, Vol. II, New York, 1946, pp. 27 ff.
Material in brackets added by translator.

"Conversion Hysteria" and "Organ Neurosis"

139

Daseinsanalytic Understanding of Psychosomatic Illness

Man's Body as a Partial Sphere of Human Existence. Alexander and Fenichel agree on one important issue. Both feel that it is of crucial importance to determine the quantities of emotional tension which hysterical symptoms can release, compared to the symptoms of vegetative neuroses. This unanimity of two authorities who other­wise profoundly disagree indicates the purely technical character of the main trends in psychosomatic thinking today. The inability of either author to arrive at a clear distinction between hysterical and organ-neurotic symptoms makes it probable that it is impossible to understand these phenomena sufficiently as long as we think in terms of psychodynamics; i.e., in a technical vocabulary. To break the deadlock created by the concept of "hysterical conversion," we reflect anew on the Daseinsanalytic understanding of man. Here it is plain to see that all the psychic "things" which the idea of hysterical conversion presupposes—conscious and unconscious thoughts, fantasies or emotions, body functions and body organs— do not, in fact, exist as primarily separate phenomena. Nor is there such a thing as an illness which exists by itself. The stomach and the stomach illness, the thoughts and the general paralysis are un­real abstractions. On the other hand, my arm, my stomach, our instincts, your thoughts are real. Strictly speaking, only mention of my, your, or their being ill refers to anything real. The possessive pronouns of daily language, used to characterize the reahty of being ill, all point to an existence which persists and unfolds in a life history. They refer to a human being never exhaustively de­scribed by reference to his "possessions," whether these are thought of as the constantly changing "substance" of his "body" or his equally inconstant instincts, feelings, fantasies, and thoughts. Nor is man identical with the sum of all these objectifications. If he were, it would be impossible to see how feelings, thoughts, or parts of the body could ever belong to an individual as his feelings, thoughts, or body-parts. Furthermore, if man were essentially an extant object among other mundane objects—an organic conglom­eration of physical and psychic things—how could such a thing ever be "touched" by another in such a way that he could perceive it, understand it, where it might even "move" him? Lastly, how could such a "thing" ever encounter a fellow human being and become aware of him as that particular being?

140 Daseinsanalytic Re-evaluation of Psychoanalytic Doctrine of Neuroses

Man's capacity to be touched by something—his ability to per­ceive and understand—presupposes a primary being-open to the world, a characteristic which extant objects lack. Man is not a "dead" object; nor is he merely a living subject which is closed within itself and which faces the objects of the external world, the latter supposedly a precondition for the subject's (completely un-explainable) "transcendence" to these objects so that he can make contact with them. We think of ourselves as subjects or I-things only if we (and insofar as we) have narrowed ourselves down in advance to an objectifying, reflecting attitude toward ourselves. But while we are giving ourselves to the unconstrained admiration of a symphony, or are carefully handling our tools while repairing a car, all of us experience ourselves as being completely and immediately with the things of our world, so completely indeed that we are contained, "body and soul," in our understanding relationships and our active handling of things.

If man is never merely an extant object, his corporality cannot be just a body, enclosed in an epidermis and ending at its surface. Rather, the human body—including its so-called animal, vegetative, and hormonal arrangements—must be understood as a specific sphere of human existence, namely that sphere which exists in that mode of being which we call the "material" one. Because the human body is a proper realm of Dasein, it is one of the media through which the world-disclosing life-relationships which constitute exis­tence are carried out.

Being a partial realm of Dasein, the body is an inevitable, but not the sufficient, condition for the possibilities of human existence. It is true that man is incapable of seeing, hearing, smelling, or tasting, incapable of acting or going forth in the world, unless his sense organs, his hands, and his feet function properly, physiologically speaking; but it is equally true, existentially speaking, that the sense organs, hands, and feet function only because man's very essence is of a primarily world-disclosing and luminating nature, and because, owing to this essential condition, he already is, and always was, in the world with its beings. In other words, man cannot see, hear, and smell because he has eyes, ears, and a nose; he is able to have eyes, ears, and a nose because his very essence is luminating and world-disclosing.

If man's body is but the physically tangible sphere of his existence through which he "ek"-sists as world-disclosing openness as im-

"Conversion Hysteria" and "Organ Neurosis" 141

mediately as he exists also through the different medium of his thoughts, for instance, the biological approach is scarcely adequate. Likewise, the comparison of human corporality with the animal organism misses the point, all the more so because the concept of organism does not do justice even to the being of an animal. Even if one tries to paste a soul onto the biological body afterward, even if one adds a spirit to the soul and an "existential realm" to the spirit, it is impossible to save what is essential about the human body. The fact that it is possible to explain the human organism chemically and physiologically (among other ways) does not prove that such explanations touch an essential feature of human cor­porality. Such an approach probably hides rather than reveals the specifically human aspect of the body.¹⁴ But there are numerous indications that human corporality is an integral part of the ek-static relation of Dasein to things. The immediate experience of existing, for instance, includes no separate experience of the body. For example, I start out to meet a friend whom I am very eager to meet. Thinking of him and walking to the place of our ren­dezvous, I am with him from the beginning. I am not at all aware of my feet which carry me to him, although each foot carries around 150 pounds at each step. Nor does anyone reflect upon his hands while performing the trickiest task. If these parts of my body were not an essential and original part of my unobjectifiable existence (if they were organs in the sense of an instrument or an apparatus belonging to me as a person), it is likely that I would have to pay attention to them in order to use them. Therefore, Aristotle's charac­terization of the hand as the tool of tools is "correct" only within the framework of a theory about the world as a universe of causal interactions between objects. Such a theory is not "true," because it does not capture the essence of what a hand is. Similarly, the state­ment of many contemporary anthropologists, such as Plessner, Sartre, Marcel, and Merleau-Ponty, to the effect that man has and is his body at the same time, is unacceptable. If we attempt to take both halves of this statement seriously, we must switch from an "instrumentalist" horizon of understanding—within which one sees only utilitarian objects—to a horizon of understanding of being within which the essence of being human is disclosed in an existen­tial sense. In other words, "to have" and "to be" do not actually

M. Heidegger, Vber den Humanismus, Frankfurt, 1947, p. 68.

142 Daseinsanalytic Re-evaluation of Psychoanalytic Doctrine of Neuroses

refer here to a twofold character of man's relation to his physical sphere itself but only to two possible and different mental ap­proaches to this relation.

As we have previously stated, the existential approach maintains that man's somatic aspect is inseparable from his being-in-the-world. Man also participates bodily in all his world-relations. Cor-porality belongs so immediately to man's existence that we always are the corporality also. Our corporality is that "sphere" of our being which exists in the mode of what can be perceived by the senses, i.e., the mode of the "material." Since the human body is part of human existence, it always and promptly gets in line with any world-relation as which existence may carry itself out at any given time. Such getting-in-line is swiftest in the sphere of the so-called nervous impulses and the voluntary movements of the muscles they control. It is slower within the hormonal realm and most sluggish in the "material" realm of anatomical tissue structures. If, for instance, the sight of a mouse produces panic in a sensitive woman and if (as the result of the fear this sight awakens) the woman's total being contracts into the one world-relation of flee­ing from the animal, this relationship also occurs somatically, within seconds. This panic takes the form of the sort of nervous excita­tion belonging to the phenomenon of running away, i.e., con­tractions of the corresponding striated muscles. After a few seconds, at the earliest, one can note an increased outpouring of adrenalin or adrenalin-like hormones. These constitute a further part of the same world-relation, this time that part of it which may be called the metabolic or endocrine one. If this "living in fear"—and the running away which pertains to it—were to last several hours, it would be possible to observe microscopically the first hypertrophic changes in the cells of the calf muscles, an indication that the relationship of fleeing from the mouse now begins to show itself structurally and in the realm of tissues. Even these most "material" and rigid media of the somatic realm thus participate in the oc­currence of human existence. Even there, the relations to the world which constitute Dasein exert their directive power; the "miracles" of many hypnotists and the phenomena which many saints of East and West exhibit bear eloquent testimony to that fact.

Gestures and Other So-called Physical Accompaniments of the Emotions. The Daseinsanalytic approach seems to be much closer to human reality than the "objective" approach of the natural

"Conversion Hysteria" and "Organ Neurosis' 143

sciences. This last fails even in the cases of such non-pathological psycho-physiological phenomena as the so-called expressive gestures and the so-called physical accompaniments of the emotions. We cite the old biologists who, following Darwin, considered the baring of the teeth, a gesture of hate, to be the residue of an aggressive act, a gesture which had been useful once in the phylogenetic past. To­day it is no longer necessary to have recourse to such completely unproved, unprovable hypotheses. We concentrate instead on the immediate reality of the furious and hating person—first, his specific pitch. The mood of rage and hate discloses the encountered to man only insofar as it constitutes a possible barrier. He perceives things and men as obstacles which resist his being-himself, which limit his physical and psychic expansion. This is why an enraged man always aims at the destruction of those things and people whom he per­ceives as hindrances. Rage and hate are so eminently hostile toward all form that they distort everything into something ugly. In Shakespeare's Richard III, for instance, Lady Anne's curses turn her husband's murderers into "creeping, venom'd things."

If Dasein is attuned to rage and hate, if it monotonously repeats a refrain of destruction and tearing-up, this tune is not restricted only to destructive impulses or wishes. It is equally apparent in the medium of that partial realm of existence called the body: the grimaces of him who rages, the distorted mimicry of hate. Similar­ly, if man's existence is attuned to anxiety, its shrinkage to a lost nothingness does not happen only in the realm of emotional ex­perience. The somatic realm echoes the prevailing mood. The whole body stoops anxiously, all extremities are pulled in in the gesture of fear. The throat tightens, the heart cramps,- the core of the body is pressed like a lemon by vehement contractions of the intestines and the bladder. In the elevated mood of joy, the heart throbs higher, the breast heaves. In such a mood the facial expression of the happy person is likewise lifted up. Even children draw the face of a happy man with lifted eyebrows and with the corners of the mouth pointed upward. The sadly depressed state of the mourner, how­ever, we designate with down strokes. We emphasize this direction by tears which fall to the ground.

The Essential Difference between So-called Hysterical and Organ-neurotic Symptoms. To suffer from hysteria or from an organ-neurosis means that one gives up the freedom to be open to the world:in all the ways available. Then those world-relations which

144 Daseinsanalytic Re-evaluation of Psychoanalytic Doctrine of Neuroses

are prevented from being realized appropriately in an intentional, interpersonal manner must carry themselves out in the dark, mute spheres of existence where there are no thoughts or words, i.e., primarily in the somatic realm. In such cases, the relationships which are not openly admitted do not flow through the bodily realm of existence in their movement toward the perceived things. They come forth and remain within the sphere of the body, so that there is a "jam" instead of vibration. Such an existence is bound to show a pathological inflation and/or distortion of its corporality. This holds true for all the hysterical and some of the organ-neurotic symptoms. Other organ-neurotic symptoms can arise even if no possibility of relating is prevented from being carried out openly, reflectingly, and voluntarily in worldly and interpersonal relations. They may occur when a narrowing down of existence occurs, when the whole existence of a person is one-sidedly—and more or less exclusively—reduced to one kind of relation to the world. Then the whole melody of this man's life has to be played on one string. Even if this one possibility of relating is admitted openly, it still amounts to an exorbitant demand on, an overtaxing of, one possibility. The somatic realms which belong to this possibility of relating to the world also start to function in a pathologically exaggerated manner.

All adequate investigations of the existence of ulcer patients, for instance, present the following picture. These patients' relations to fellow humans and to things are one-sidely and exaggeratedly oriented toward seizing, overpowering, and taking possession. They want to subjugate everything they encounter and to rob it of its individuality. The condition of such patients is—for external and internal reasons—so completely and excessively reduced and nar­rowed down to this one relationship to the world that their somatic realm behaves the same. Among the total inner corporality of man, stomach and duodenum belong specifically to the world-relation of seizing and overpowering. These parts of the body (owing to motility, hydrochloric acid, pepsin, and the enzymes of the pan­creas) really attack the food which has been grasped and cut up by the teeth. They rob the food particles of their individuality, dissolve and demolish them so that they are brought under the power of one's self and made part of its physical realm.

Wherever organ-neurotic symptoms result—as all hysterical symp­toms do—from an arresting of interpersonal possibilities for living in the sphere of the body, it is still possible to distinguish such

¹⁴⁵

"Conversion Hysteria" and "Organ Neuro_Sts

^ptoms ^^^^ZS^^ 0^0^
in hysterical symptoms too, thepauen ^ ^

«^^M-»l-^l^^^_to ы^. _Neverthe-
of gestures, even if their J^anmg _as «_gestation"-always

_less, gestures^ -^J^ J^^
are meant to bring someuuug nartner. Hysterical

„e fuU of meaning in «^ton «° Xlte^_SS7comLmca-
bebavior occurs within * ""P™'¹™? °^/^Р_{Ье pnysica}l presence
_U„n and bterp.rsonalrelat.on,Л £££££/„ J_{er much}
„fotherpeop^mce'tadie^.^.^ ^

more "bvronslyjo snect«or ^ ^

topressrve-than org^™ У F ^ _{no meaM},_ost

acter of being with tag» thoroughly dis-

* "ТшГе^по tagL carries itself on, in gestures which uTbth^yCa^an audilnce of concrete feilow human bemgs,

unaoasnemy W, uncommunicative.

but it is muted and seexmngiy _{hether h terica}i _or

organ-neurobc-tha^appea £ ^ ^^ _fa

SX^5 ^Sli how far a given world-relation was

? fl tS from its appropriate manner of being carried out in open,

S^nS^^pe^ behavior. For this reason, it is

L for each particular behavioral phenomenon to retreat to
possible for each par ^ _Qr ^ ^ ^ _more

Ше realm оJ^^h^^^ ⁸p_henSnena. What matters most,
hidden realm of organ neuro p ^ ^^ ^

however, is that both «tog» yj^ ^ ^ ^.^ ^

ГаГо ga^uroГъoily symptom belongs immediately to one or
each organ n _lat/_onshi_p toward something in the world of

another ^^^^e afflicted bodily spheres fluctuate, so
Ж^f^rrsTrt inlse relationships! although in a patho-
olal way better still: in all of these instances there are some
logical way ^D encounters which occur only as

й£ы о gllelrotL symptoms. Nowhere, however do we S any bdication that these symptoms are a return of some p!yclnc^yfo^ati₀n which had hitherto been repressed into an un-

TTutderstanding of man contained in Daseinsanalysis has per-JtSCto bcate the distinction between hysterical and organ-

146 Daseinsanalytic Re-evaluation of Psychoanalytic Doctrine of Neuroses

neurotic symptoms. But this settlement only leads into an even more difficult problem: the problem of the so-called choice of neurosis in general. The contribution which a given theory of neuroses can make toward the solution of this problem determines, more or less, how adequate and how practical it is. The problem of choice of neurosis is of decisive importance and must be pursued at least to the point where the equally important problem of "choice of organ" comes into view. The psychoanalytic dogma of "meaningful hysteri­cal symbolization" versus "meaningless organ-neurotic functional disturbances" also has to be scrutinized. We deem it best to deal with these problems within the context of the two case histories that follow.

7

A Patient Who Suffered Alternately from Colitis ana Migraine

Thanks to her artistic talent, Wilhelmina is able to afford us a particularly vivid insight into the course of developments in her analysis. At the outset of her analytic therapy this patient was thirty-two years old. The earliest signs of her illness had shown, themselves shortly after she entered school. Throughout her school life, she was plagued before every examination with severe diarrhea. As she developed, the inevitably increasing demands on her self-reliance were matched by an increasingly refractory dysfunction of the bowel. Shortly after puberty the diarrheic episodes began to assume, on occasion, the character of a true mucous colitis. At about the same time an unequivocal allergy to chocolate and to chives was established. The merest trace of either of these sub­stances sufficed to precipitate a mucous diarrhea so excessive as to utterly incapacitate the patient for days and even weeks on end. In the years preceding the analysis, the patient had become reduced to a pitiful wreck of a human being. Not only was she completely in­capacitated for any sort of work, but her very life was in jeopardy. There were times when the mucous and bloody diarrhea was so unremitting as to keep her practically permanently on the bedpan day and night for up to a week at a time. No diet or medication had the slightest effect. A major surgical intervention was out of the question, because of the hazardous general condition of the patient.

In the ensuing five years of analysis, it became ever more apparent what a devastating influence the mother had wielded upon the patient's development. The mother was so overpowering with re­spect to this rather sensitive, delicate child as to virtually rob her of her power to breathe on her own. In addition she was incredibly

Translated by Elsa Lehman, M.D.

147

148 Daseinsanalytic Re-evaluation of Psychoanalytic Doctrine of Neuroses

prudish. She made, for instance, a most frightful issue of the patient's first menstrual period. Having carefully evaded even a \oken effort at enlightening her daughter on sexual matters, she then proceeded to employ the most elaborate precautions to pre­clude any possibility of the father or the brother catching an inkling of this menstrual occurrence. And then, a few months later, when a first innocent love letter was discovered, the most rigorous inquisition ensued. The mother persisted in an unrelenting torment of the most indelicate questioning until she had attained her object of finding out whether anything so dire as a kiss had already oc­curred. From then on, whenever she was anywhere near her mother, the patient felt miserably unhappy and indescribably tense. Every­thing that had anything to do with her mother became the object of her special and increasing hatred. In effect, the only reason she attended high school was to evade the various domestic tasks her mother imposed upon her. In the occupational field this protest against the prevailing domestic proclivities of her mother expressed itself in tentative efforts to absorb herself in studies of the history of art. Moreover, in conspicuous contrast to this "pious" and puri­tanical mother, the patient developed an uncompromising atheism.

The first complaints the patient made to the analyst concerned snakes and worms, which appeared in writhing masses the moment she closed her eyes. Extraordinarily enough, it had never occurred to her to mention these snakes to any of the more than two dozen doctors who had so far treated her. And yet these were exceedingly distressing apparitions, terrifying and loathesome to her. Further­more, if she happened to see a picture of a snake, or to encounter an actual worm in the garden, her fright amounted to sheer terror. Eventually even the sight of the serpentine shape of a telephone cord plunged her into shuddering horror. The analyst asked her to put her snakes and worms into form on paper. He received a paint­ing which is reproduced in black and white in Figure 1. (Illustrations appear after p. 152.)

The picture represents a swarming tangle of snakes or worms, somewhere in the open, suspended, as it were, in space, but occupy­ing the full expanse of the picture. When the patient was encouraged to look a little more closely, the worms and snakes took on the most monstrous and menacing shapes (see Figure 2).

This sort of grotesque caricature intensified her fear immeasur­ably, and with it the diarrhea worsened to an alarming extent. But

Дата добавления: 2015-06-04