The ‘Dora’ case

Dora was analysed by Freud for 3 months in the autumn of 1900. Aged 18, she was brought by her father to Freud with a series of mental and physical symptoms – depression and difficulty socialising, along with a nervous cough, a loss of voice, migraines and difficulty breathing. Significantly, her father had himself been treated some years ago by Freud for syphilis, and then for some years he had suffered various other illnesses. Dora's previously idealised view of her father had turned hostile, and her relationship with her mother was full of conflict. While sifting through reports of emotional upsets and suicidal behaviour, Freud noticed the family's concurrent relationship with a young couple, Herr and Frau K, pre-dating the onset of Dora's symptoms. Here Freud began to develop his theory of the formation of Dora's hysterical symptoms. The first was a ‘reversal of affect’, where sexual excitement was turned into disgust, and the second ‘displacement of sensation’, where a stimulus felt in one part of the body, and felt to be unacceptable, was repressed and relegated to another, unrelated area. Freud described the hysterical symptom as resulting from a path taken by the psychic conflict into the body: a somatic compliance. Two dreams that emerged in treatment were analysed following what was by now an established dream interpretation technique.^{Reference Freud and Strachey4} They revealed a conflict and repressed desires: Dora's adolescent preoccupation with and terror of sexual intimacy, resulting in repression of her sexual feelings, as well as her unconscious desire for revenge against her beloved father, who was felt to have betrayed her. The idea of the hysterical symptom being the outcome of an irresolvable sexual conflict was thus clearly shown through a case-history format. Dora's fantasies of being of central importance in the family drama, followed by bitter disappointments, made hysteria her ‘solution’ to the internal dilemma. Freud wrote ‘incapacity for meeting a real erotic demand is one of the most essential features of a neurosis. Neurotics are dominated by the opposition between reality and phantasy’.^{Reference Freud and Strachey1}

Among Freud's five case histories, Dora's stands out as probably the most discussed and critiqued by his successors.^{Reference Bernheimer and Kahane5} Blass writes ‘Through Dora's analysis Freud gradually passes from the seduction theory to a theory of neurosis that centres on intrapsychically originating moral conflict and on the early childhood events that make it pathogenic’.^{Reference Blass6}

There were, however, several clinical discoveries which Freud considered later, looking back on the work: Dora's underlying homoerotic conflicts, her transference to Freud, the countertransference, the brevity of the treatment. Freud's Oedipal theory was yet to be fully developed.^{Reference Blass6} Conversion came to be understood as the body becoming the stage on which an unacceptable conflict in the psyche gets staged or represented, and this mechanism was viewed as radically different from that of hypochondria and severe psychosomatic illnesses. A detailed exposition of these ideas in contemporary psychoanalysis is beyond the scope of this paper but interested readers are encouraged to read further.^{Reference Bronstein7}

Dora's mother: the background

Freud suggested that ‘a daughter takes her mother's love story as her model’. Dora's mother had met her future husband, a man much older than her and sexually experienced, at 17 and then waited 2 years to marry him. As a mature woman and mother, she was now exacting, preoccupied with looking after material household things and seemingly indifferent to Dora's emotional needs. She also seemed strangely cut off from evidence of her husband's infidelity, offering disinterested explanations in response to the anxious questioning of her precocious daughter. Dora was anxious about her father's relationship with Frau K, a younger, married woman and a family friend:

There was clearly an unhappy, heavily disguised family drama in the backdrop of Dora's hysterical presentation. Her suicidally depressed father and rather cut-off mother seemed to have relied on Frau K to act as an intermediary in their relationship. Freud correctly gauged Dora's scorn at her mother's naivety in taking the father's account of his relations with Frau K at face value. Dora presented with hysterical symptoms alongside her conscious contempt of both her parents for their tendency to self-deception and lies.

Freud noted at the start how Dora's father told him ‘you know I get nothing out of my own wife’ as a justification for his involvement with Frau K: a loaded sentiment ironically echoed by Herr K in describing his wife when he made sexual advances towards Dora. This acted as a trigger for Dora's hysterical symptoms. The subtext seemed that this was a world where men were justified in seeking their sexual pleasures freely and at some risk, as long as they kept up appearances to save face while married. Freud deftly linked these confusing observations in young Dora's mind, giving them a voice: ‘How dare the man make an assumption about me?’. A passing reference to her mother being in Herr K's confidence, hearing bitter complaints about Frau K's relations with Dora's father, made one wonder about her complicity in Dora's predicament.

What might be the mysterious illness that plagued Dora's mother all this while? Freud wrote:

He noted that if the conditions were not suitable for a hysterical symptom, as was possibly the case with Dora's mother, one found instead a psychical symptom. She was caught up in a mindless trap of domesticity, posing a severe problem to her family:

The lack of insight or understanding of the other and the repetitive acts which made it impossible for others to enjoy their comforts: all these seemed to be significant. Here I thought Freud was marking a lack of receptivity; instead, there seemed a marked tendency to repulse others, to keep them away from her person while keeping up a façade of housewifely devotion. This could be a projection into the other of a desperate need to get in, while thwarting this and erecting a psychic barrier. For example, Dora's father stated that he got ‘nothing out of’ his wife as a hint of a lack of sexual relations; this may be rephrased as ‘I cannot get into her’. This was also Dora's experience of an unavailable mother. Instead, her mother transformed the house, and her body, into a whirlwind of activity that did not allow for entry or habitation.

Freud then considered the role of heredity in hysteria, and gave Dora's mother a place in this constellation:

The role of neurosyphilis

One might speculate on another possibility that lent credence to Freud's observations of Dora's neurosis: her mother's ‘psychosis’ and the peculiar circumstances of a sexual (parental) couple of that time. Dora's mother had already contracted syphilis from her partner early in the marriage, like many middle-class women who seemed to have little choice other than to suffer the illness and seek treatment, risking shame and humiliation. Freud, in describing the significance of the male parents’ syphilis in their children's illnesses, is mysteriously silent on the mother's predicament:

The age of Freud was also the age of syphilis, as pointed out by Ropper & Burrell,^{Reference Harrington8,Reference Ropper and Burrell9} while psychoanalysis grew into a body of work fuelled by Freud's emphasis on patients’ fantasies around sex. In a patient's psychic elaboration of phantasy, the patient's real experience was crucial as the shameful and terrifying spectre of syphilis hung over every sexual encounter like ‘the sword of Damocles’. By the late-19th century, neurologists acknowledged that syphilis was, in its pathological manifestations, the ‘great imitator’ of maladies.

Freud commented on Dora's father's luetic condition before marriage, as well as his successful involvement in treating the latter's troubling vascular and neurological syphilitic symptoms 4 years before Dora arrived as Freud's patient. But in fact, prior to the first use of penicillin against syphilis in 1943, it is well-known that mercury compounds had a prominent position in the medical practice despite a tremendous toxicity and a questionable efficiency.

Freud, with his background in neurology before his pioneering work in psychoanalysis, would have keenly observed syphilis's twofold impact: the neurological manifestation of syphilis, a ‘general paresis of the insane’, which galvanised biological psychiatry while the psychological impact gave impetus to the study of hysteria.^{Reference Harrington8} Ironically, it was in Germany in 1905 that the discovery of the spiral-shaped bacterium now known as Treponema pallidum was made by zoologist Fritz Schaudinn and dermatologist Erich Hoffmann; this changed the understanding of syphilis and general paresis of the insane.

But the aspect of the family drama often got minimised: the terrible social and psychological impact of syphilis on the sexual relations of couples, an experience of unconscious threat, neglect and violence. Most significantly, a legitimate place for the mother's state of mind and for her sense of an interiority was lacking.

Freud speculated on a possible early transmission of Dora's father's syphilitic infection to his wife, as well as the possibility that he was later cured of his condition. But what of Dora's mother, who continued to cohabit with a man who may or may not have been cured of syphilis, may have been suffering tertiary syphilitic complications and whose further infidelity was betrayed by gonorrhoea? We do not know; Freud was never able to meet her, nor discuss what influence her situation might have had on Dora. We also do not know when the mother's venereal symptoms began or whether they were fully treated and cured; however, we can speculate on an experience of sex being fraught with danger. A phantasy of sex as destructive may have turned into reality, a fact that was perhaps not lost on Dora.^{Reference Ramas, Bernheimer and Kahane10}

Syphilis was widespread enough to give rise to a special form of hypochondria known as syphilis imaginaria, or the development of imaginary symptoms of syphilis.^{Reference Veith11} Physicians also reported syphilophobia, or the exaggerated fear of the disease, and hydrargyrophobia, or the fear of mercury, which was one of the main medical treatments.^{Reference Harsin12}

It is also difficult to know whether a ‘vertical’ transmission of syphilis from mothers to babies as congenital syphilis, causing still-births and miscarriages, was a possibility in Dora's mother's case before the birth of Dora and her brothers.

By the time Dora was brought by her father to see Freud, the parental couple had ostensibly ceased sexual relations – perhaps even as early as when she was 6 years old and her father contracted tuberculosis. Dora suggested to Freud at one point that her father was impotent. She hinted also of her knowledge of sexual activities involving other parts of the body if genital sex was inadvisable. Freud's elaboration of Dora's sexual fantasies, linking them to her hysterical symptoms, is at once a phenomenological enquiry into the individual psyche and a description of the social and family structures in 19th-century Vienna. And so he noted Dora's complaints against her father as a ‘wearisome monotony’ with an ‘incessant repetition’, at the knowledge of her father's extramarital affair. The sexual betrayal of the mother by the father thus seemed to have been experienced as something unbearable by Dora, and led to her behaving like a jealous wife, while her mother stayed silent.

If the ‘housewife's psychosis’ was a disturbed relationship with reality, Dora's mother's behaviour signalled an internal disturbance that could not be articulated. Taking up the syphilitic vector as a projected experience perhaps of ‘care-lessness’ originating in the father's apparent indifference allowed another way of looking at Dora's mother's frantic avoidance of contact. Freud had already suggested the possibility that shame and humiliation, a sense of being contaminated, gave rise to a reaction formation that drove Dora's mother's incessant cleaning. The sense of being ‘dirty’ seemed to be linked to the mother's venereal infection, the white vaginal discharge and abdominal pains which needed medical treatment. But the sense of neglect and damage felt to be inflicted by the other in this way was perhaps projected into Dora by her parents. In later emphasising the significance of Frau K in Dora's fantasies, Dora's conscious alienation from her mother and alliance with her father seemed to mask, at a deeper level, an unconscious longing for an unavailable mother and rivalry with a father who pursued his own needs at a heavy cost to the family:

If Dora was perhaps forced to stand on the sidelines while her mother lavished attention on material things, she eventually found herself in a similar position while her father found substitutes for her mother. Freud's final observations of Dora's father as ‘never entirely straightforward’ and Dora's dropping out of analysis seemed to confirm this and has since been used (sometimes unfairly) as a way of underlining Freud's own contentious, academic motives in this unsatisfactorily brief yet trail-blazing treatment.