Notes from My Logbook as Supervisor in a Psychiatric Outpatient Clinic in an Israeli Hospital

Editorial

“A wonderful fact to reflect upon, that every human creature is constituted to be that profound secret and mystery to every other.” - Charles Dickens, A Tale of Two Cities [1].

The most important insight in my profession is the belief that every new day you will make a new discovery.

Urgent call from the ER

Woman in her fifties whose complaint is that she cannot walk is seemingly suffering from a paralysis of her legs. She is barely able to take a step or two without help. This happened suddenly and without warning, at the end of the day, when she left for home after spending the morning at a psychiatric outpatient facility. An intensive care unit brought her to the ER.

Immediately various tests were run, and no physiological problem was found. Afterwards, when the ER staff learned that S. was a psychiatric outpatient, they contacted the psychiatry department to find out what had happened.

That day, S, spent the morning, as usual, in therapy to maintain and reinforce anti-depressant and anti-anxiety therapy. The department provides medical follow-up. Individual psychotherapy and participation in various group therapies.

S..an religious woman, belongs to an Ultra Orthodox community, had been undergoing a family and business crisis for an extended period, a subject that is emerging and is often discussed in the psychodynamic psychotherapy which she receives in the department. S. has created a good relationship with the therapist; she trusts her and shares with her many events in her life. From the beginning of the therapeutic process, a “rape story” is mentioned from time to time, fleetingly and without any details. As the therapist evinces more interest, S. tends to be evasive. This situation has repeated itself several times throughout the therapy process. After giving it some thought, we decided not to press her, only to note the various contexts in which the story appears and to comment, because the therapist realizes that there is a “story” here that is not really in the open, and apparently it is emotionally charged.

That morning, S. was in a state of anxiety, because her son was about to marry a girl from a prominent and wealthy family. As the matter became more serious and real and the date of the wedding drew near, she was flooded more intensely by anxiety. In the conversation that day, the rape story came up again. The therapist, who was trying to trace the roots of S.’s anxiety, asked for details of the story. S. described the incident very confusedly, and claimed that she does not remember exactly what happened. During the session, S. complained that she did not feel well, and the story aroused various strange feelings in her. She stated that she thinks that since that incident, her guilt feelings have returned to her; these feelings have accompanied her throughout the years and she does not know why. Gradually, and with difficulty in patching together the details, the therapist understood that S. was afraid to tell exactly what had happened, because if she told, she feared that it would put a blot on the family.

According to Halakha (Jewish law), a married woman who had intimate relations with another man of her own will is prohibited to remain with her husband and he is obligated to divorce her - unless he does not know about it. It was evident that in the story of S., the ‘rape’ was the result of deliberate seduction on her part with the expectation that it would happen. Upon revealing her secret, S. felt very bad and expressed concern that perhaps her children were unworthy and not acceptable under Jewish law, although, in halakhic terms, she had already clarified the matter and was told it was all right. Still, as the wedding date approached, she was overwhelmed by anxiety.

The therapist reflected her difficulty and her courage in speaking out; she shared S.’s feelings, and was accepting and containing. S. added that another difficulty was the longing and yearning that she felt for that man, who had been sensitive to her.

The therapist shared her distress, and the conversation continued on to her current distress.

Toward the end of the conversation, S. complained about a sexual urge that she felt when she remembered that ‘rapist’, which is one of the reasons that kept her from telling about it. The session ended with S. feeling that she had been heard and understood and a promise by the therapist to continue the talk the next day. Until the call came from the emergency room.

Conversion

We thought that conversion, or by its Freudian name, ‘hysterical conversion’, had disappeared from the lexicon of psychotherapists.

Our world is very advanced; civilization has inculcated beliefs of freedom, liberation, openness, candid talk about any subject in the media, social networks, and wherever possible. The institution of religion is becoming softer, pluralistic, and flexible, changing its personal and idiosyncratic character, or it is simply disappearing because of being outdated and incompatible.

In populations where life is still conducted according to laws, commandments, and prohibitions, there are still such phenomena of hysteria that characterize closed community life with a more stringent milieu and stricter rules.

S belongs to an ultra-Orthodox religious community; the type of this closed community is less exposed to the media and the unconstrained discourse on intimate topics that characterizes the world today. In the modern world today, betrayal or deviation from norms are not subjects for discussion because there is a strong emphasis on personal liberty, individualism, pluralism, and alternative life styles. In an ultra-Orthodox religious community, secrecy regarding deviations is part of an almost existential mechanism that is necessary to preserve the good name of the individual and of the family. This is especially so when it comes to issues that could impugn the honesty, propriety, and integrity of the family.

Similar reservations and conventions are found in any community that is closed or self-contained. Therefore, I posit that similar phenomena can occur in such communities. This is an interesting topic for further investigation.

When Freud was studying under the neurologist Charcot, he realized that paralysis was not a degeneration of parts of the brain, as Charcot thought but could not prove, but rather, a result of psychological factors. Freud later called these ‘provoking agents’, or ‘triggers’.

Freud (1894) [2,3] describes hysterical symptoms appearing as the result of trauma, which is an emotional or physical injury, in a way that elicits strong emotional responses that the self cannot process and digest. Then the ego exercises defense mechanisms and pushes those feelings from the conscious to the unconscious. When the defense mechanism is strong enough, the emotion associated with the idea builds up, but because it is repressed without an outlet, it finds its way to escape through contact with a sensitive physical element, and breaks out in the form of a physical symptom.

At the end of the nineteenth century, Freud saw the onset of a symptom and its central role as a hysterical conversion. Later, he distinguished between the central importance of the symptom and the centrality of anxiety, and differentiated between hysterical conversion and hysterical anxiety. In the case study of Anna O (1895/2005) [4], Freud describes various types of hysterical conversion, such as strabismus, partial paralysis in various organs, loss of appetite to the point of ceasing to eat, muscle contractions, etc. as expressions of the suppressed libido and conversion symptom.

Freud in Inhibitions, Symptoms and Anxiety (1926) stated that hysterical conversion is a mechanism to relieve psychological distress. Thus, the conversion symptom, in contrast to the symptoms of other neuroses, is accompanied by peace of mind. The physical symptom is ‘transferred’ to the body, leaving behind the emotional suffering.

On the conversion symptom expressed in walking, Freud writes that walking is a symbolic replacement of overloading, or trampling, the body of ‘Mother Earth’. According to Freud’s explanation, walking is an unconscious symbol of sexual contact (Freud, 1926/2003) [5].

The case described here left the departmental staff surprised and marveling that Freud’s theory would be demonstrated so clearly, and it prompted them to read and understand more about such mental processes.

While writing up this case, I recalled an incident of a few years ago. One day I received a terrified phone call from a bride who was about to be married that evening; when she got up in the morning, she discovered in panic that she couldn’t move her hand. A quick medical examination revealed that it was mental distress and anxiety about what awaited her that evening. Hysterical conversion, in an interesting choice of location - the hand…..

The complexity of the psyche is so idiosyncratic, mysterious and subtle, that even though we supposedly have knowledge of a thing, much of it is an illusion. Because what is hidden is still greater than what is revealed.

References

1. Dickens C. A tale of two cities. Penguin Classics, Reprint. 1859.
2. Freud S. The Neuropsychosis of Defense. SE. 1894; 3: 41-61.
3. Freud S. The Etiology of Hysteria. SE. 1896; 3: 187-222.
4. Freud S, Breuer J. Studies in hysteria. M Kraus Heb trans. Safad: Sefarim Publishers. 2005.
5. Freud S. Inhibitions, symptoms and anxiety. Y Or Heb. trans. 2003.