The article on which this lecture is based¹ opens with a quotation from Tom Bottomore, who recalls the need to distinguish between the development of a discipline and the work carried out along the borders between different disciplines. It is this latter work that I have attempted, not in order to promote a difficult integration, but because this work on the borders can foster mutual understanding and produce a fruitful exchange, instead of reciprocal disqualification.

Introduction

To begin with, it seems necessary to differentiate cases from the explanatory constructions that are elaborated about them. Cases are cases. I consider that Dora is not a case of hysteria: she is a case². I have chosen a Freudian case for its prototypical value.

Even if one accepts the debatable incommensurability of paradigms, this cannot prevent us from analysing explanatory results and comparing them, exploring the possibility of articulating them and making them complementary.

This has implications not only in the field of psychology, but throughout the human world, particularly in the domain of ethics, of politics and of human conflict in general. Problems, too, are cases.

If the case remains glued to the explanatory construction (EC), the case is the EC: such has been the fate of this one, which became “Dora, a case of hysteria”. That is precisely what I am attempting to question, by showing that we have here one case and two ECs (there could be more):

Dora case:

• Freudian EC;
• systemic / relational EC.

If we take the trouble to analyse the case, we can distinguish between its phenomenology and the explanatory constructions brought to bear on it, and we shall thereby make a contribution to professional knowledge.

The difficulty that arises is that this work is arduous (it cannot be otherwise), because the phenomenology of the case comes glued to the explanatory constructions and to the language employed, interpenetrated with them, and of course marked by the subjectivity of whoever undertakes it.

But professional and scientific development commits us to doing this work. What arises here, when intrapsychic and relational phenomena are compared, is the question of who bears the greater or lesser responsibility for the fact of falling ill³. We shall therefore have to avoid the temptation of the “much easier” option (simpler, or simplified), which consists in taking sides and carrying on with the chosen EC, always sustained by a certain number of undiscussed, though debatable, presuppositions.

In this sense, I propose a “praxis of the interdisciplinary” (in the verbal mode, as action), inasmuch as this practice can give us tools towards a better, richer and more complex understanding of the phenomenon, that is, of the case.

When I wrote the article, I had not read the works of R. Rorty. I subsequently noted my convergences with him, for he says strong things, such as this: “we must ask ourselves whether the concept of truth should not be replaced by the concept of conversation”.

Fundamental difficulties of comparative work

• the abandonment of certainties (which are so necessary to praxis);
• the effort required to tolerate anxiety and to rebuild new certainties;
• tolerating the criticism and the attacks of the dogmatic;
• tolerating the threat weighing on identity and on belonging, both of which are sustained and conditioned by our perspective on the case.

Working with the case

In order to be able to operate, I have distinguished in the text the narrative of the case, the general hypotheses and the hypotheses about the case, with the intention of differentiating, as I have already said, the study material from the explanatory principles employed to understand that material.

I then attempt, from a relational perspective, an alternative view of the case, taking the aforementioned narrative as a basis.

I then move on to comparative reflections on the different theorisations, and on their possible articulations and correspondences.

Finally, I relate these to the field of clinical possibilities and of clinical effectiveness.

The narrative of the case

The place of Dora’s father (DF) in her present family, and Dora’s place in relation to him

The dominant person was the father, a great industrialist. It was he, Freud writes, who provided the “framework” around which the patient’s infantile and pathological history was built. The daughter was attached to him with a particular tenderness, a tenderness further increased by the illnesses from which the father had suffered ever since she was small.

Freud’s relationship with Dora’s father

At a certain point the father consults Freud, who applies to him an anti-luetic cure crowned with success; and it is by reason of this happy precedent that, four years later, he places Dora under his psychotherapeutic treatment.

The father’s family of origin, and the place Dora occupies in it

Freud met a sister of the father’s, afflicted with a severe psychoneurosis and unhappy in her marriage; she dies following a marasmus. An elder brother of the father’s was, for his part, a hypochondriacal bachelor. Dora had always placed her sympathies on the side of the paternal family and, after falling ill, saw her model in the aunt I have just mentioned.

The very different appraisal Freud makes of Dora’s mother

It contrasts with the one he makes of the father. Freud states that he did not meet the mother. From the communications of the father and of the young girl, he had formed the idea of a woman of little culture, not very intelligent, and suffering from a “housewife’s psychosis”.

Dora’s position towards her mother and her brother

The relationship between mother and daughter was most unfriendly: Dora took no notice of her and had withdrawn from her influence. The brother, for his part, sought to keep out of the family quarrels; when he found himself obliged to take sides, he did so on the mother’s side.

The father’s role in the request for consultation, and the facts that motivated it

It was following Dora’s suicide threat that the father decided she should be placed under Freud’s treatment. She came to his consulting room moved only, Freud notes, by the father’s authoritative word.

The complex web of relationships with the K. couple and Dora’s successive positions towards them

Frau K. had taken care of Dora’s father during his long illness. Herr K., for his part, had always shown himself most amiable towards Dora: he went out walking with her, gave her small presents, without anyone having found anything reprehensible in it. Dora looked after the two children of the K. couple; she served them as a mother. Father and daughter travelled to join Herr and Frau K., who spent the summer beside one of the Alpine lakes.

One day, Dora told her mother, so that she in turn should pass it on to the father, that Herr K. had dared to make her a proposal of love.

The father, Freud reports, has no doubt that this event is the cause of Dora’s malaise, of her irritability and of her suicidal ideas. She asks him to break off his relations with Herr K., and above all with Frau K., whom she had previously revered. But he declares that he cannot do so, for seven reasons which he enumerates:

• 1. he takes Dora’s account of that man’s immoral audacity to be a fantasy of his daughter’s;
• 2. a sincere friendship binds him to that lady and he does not want to cause her such grief;
• 3. the poor woman is very unhappy with her husband;
• 4. a husband of whom, moreover, he does not have a very high opinion;
• 5. she herself has suffered a great deal with her nerves and has only him for support;
• 6. given his state of health, he need not assure Freud that nothing illicit lies behind this relationship: they are two poor beings who console each other as best they can, in friendly sympathy;
• 7. and Freud knows very well, he adds, that he does not find that with his own wife.

Dora, for her part, declares herself unshakeable in her hatred of the K.s. Her latest attack came after a conversation in which she had once again addressed the same demand to her father. He concludes his account to Freud with a sentence that will decide everything: “Please try now to bring her to better ways.”

For Dora there was no doubt: her father had entered into a vulgar love affair with that young and beautiful woman. The dealings with the K.s had begun before the father’s serious illness; but they had only become intimate when, in the course of that illness, the young Frau K. had officially set herself up as his nurse, while the mother kept away from the sick man’s bed.

Finally, when Dora was in a bad mood, one idea imposed itself upon her: that of having been handed over to Herr K. as the price of the tolerance he showed towards her father’s relations with Frau K.; and behind her tenderness for the father one could glimpse the fury that such a use of her person provoked in her.

The general hypotheses

These too are Freud’s, and I summarise them here in the order in which the text proposes them.

Pathogenic is that psychical material, or that mental impulse, which, by virtue of the aversion aroused by its content, has been blocked out of consciousness and repressed.

What the patient’s relatives report almost always offers a very distorted picture of the course of the illness.

We must pay as much attention to the purely human and social conditions of patients as to somatic data and pathological symptoms.

Above all, our interest will be directed towards the family relationships of patients – and this not only because of the hereditary antecedents that must be sought, but because of other links as well, as we shall see.

The state of illness is without any doubt the work of a design: pathological states are generally addressed to a particular person, so that they disappear when that person moves away.

Finally, Freud recalls having set out elsewhere how early the sexual attraction between parents and children comes into play, and having shown that the fable of Oedipus should probably be understood as the literary elaboration of what is typical in these bonds. This early inclination of the daughter for the father and of the son for the mother, of which a clear trace is in all likelihood to be found in every human being, can only be supposed to be more intense, from the very beginning, “in children constitutionally destined for neurosis, precociously matured and starved of love”.

The hypotheses about the case

Freud concludes that the thoughts repressed in this case – and which gave rise to the symptoms – are Dora’s impossible infatuations: that with the father, that with Herr K., and that with Frau K., which she cannot manage to communicate to him. Several passages of the text are very clear on this point.

Dora’s conduct, he writes, went far beyond the sphere proper to a daughter: she felt and acted rather like a jealous wife, as one would have expected of the mother. With her demand “either she or I”, with the scenes she made and the suicide threat she let it be understood she might carry out, she was manifestly occupying the mother’s place.

The many illnesses the father contracted, he goes on, could only increase Dora’s tenderness towards him; in these situations it also happened that the father would accept from her alone the small services his care required. Proud of her precocious intelligence, he had made her his confidante while she was still a child. When Frau K. appeared, it was Dora, and not her mother, who found herself supplanted in more than one position.

The conclusion then imposes itself on Freud: Dora felt inclined towards her father to a greater degree than she knew or was willing to admit, for she was in love with him.

He then comes to think that what was stifled was the love for Herr K., and that the young girl had taken up and reinforced her old inclination for the father so as to have to notice nothing, in her consciousness, of that first adolescent love which had become painful.

But, he finally adds, behind the train of thought that made her occupy herself with her father’s relationship with Frau K. there was in fact concealed a jealous impulse whose object was that woman: that is, an impulse that could only rest on an inclination towards the same sex.

Relational perspective

The Freudian text abounds in elements – I have underlined some of them – that make it possible to display the case from this perspective. The first thing that strikes one, in this sense, is that the reason for consultation is not Dora’s but Dora’s father’s.

Now, why, and to what end, does the father consult? We may suppose that Dora’s parents were unable to build the conjugal and co-parental alliance necessary to meet the needs of adult life, both sexual and those of bringing up the children, which gave rise to intergenerational coalitions and, consequently, to difficulties in the filial bonds. These conjugal disagreements obviously also open the way to the appearance of third parties, such as Frau K.

We have no information about what prevented this conjugal and co-parental alliance. Perhaps that specific infection of the father’s, of which Freud speaks, came in between: affective and sexual distance protected the wife from this illness, which, clinically, would warrant a positive connotation. There are also elements suggesting that both of them must have had difficulty separating from their families of origin.

Freud moreover states, in the text of the case history, that “the usual sexual attraction had drawn father and daughter closer together on the one side, and mother and son on the other”.

From a relational perspective, the absence of this affective and sexual bond between the spouses opens up, as I have just said, the space for the seduction of the children in order to cover these lacks. Once installed, these relationships feed themselves, constituting a coalition against the other spouse, who in turn rejects this child because the child is the ally of the other.

Thus the parent and the child find themselves caught in an intense bond, without clear boundaries, with the confusion that ensues. The child ceases to occupy their natural place, that of being-raised, in order to occupy the place of a pseudo-spouse of the parent, if it may be so named. There is here an alteration of the distances that are functional to the growth of the family and of the children, and, in sum, to exogamy.

It is these bonds that stimulate the incestuous or promiscuous desires that would not otherwise have developed, and that are the product of this psycho-relational “overcrowding”. There is a clear correspondence between distance and erotic tension. Spatial overcrowding, occasioned by material deprivation, likewise gives rise to situations of incest, promiscuity, delinquency and so on.

Starting from the Freudian narrative of the case, one can visualise from the outset the father–Dora coalition, with Dora’s over-involvement in that bond.

This coalition does not take place between peers. A coalition between peers, in which each is supposed to have the same degree of autonomy, does not necessarily over-involve one in the affairs of the other. A coalition between an adult and a child, on the other hand, necessarily sub-jugates the child – note the difference with con-jugates –, the child having less capacity to keep at a distance affairs that do not belong to them. The symptom is the means at the child’s disposal for creating that distance.

We may also allow ourselves to suppose that Freud himself is included in the father’s coalitions: against Dora’s mother first, against Dora afterwards. This provides elements for continuing the construction of the story in the following way.

The father–Dora coalition was established from Dora’s earliest years, until, for reasons we shall see, that coalition became destabilised. It is then that Dora becomes angry with her father and intensifies her symptoms. And it is this that drives the father, and not Dora, to consult.

• The father–Dora coalition is destabilised when Frau K. appears as a substitute for Dora.
• The father–Frau K. coalition replaces the father–Dora coalition.
• It becomes necessary to give Dora something in exchange, in order to restore the balance.
• That something is, in the first place, Herr K.
• This fails, owing to Dora’s refusal.
• Dora’s symptoms arise.
• The father turns to Freud – “Please try now to bring her to better ways” – in order to restore the balance that will allow him to pursue his relationship with Frau K. unhindered, by neutralising Dora’s protest.

This construction differs from the psychoanalytic reading, which attributes Dora’s symptomatology to the infatuations arising within her psyche.

As long as the father–Dora coalition against the mother was working – offset by the latter’s coalition with the son –, the family system was stable. When Frau K. appears, the father betrays Dora, who surely identifies at that point with her mother, betrayed before her. Both are victims of the same man, from which a new coalition may arise: Dora’s mother–Dora.

Dora strongly destabilises the system (and the father), for, besides standing in the way of her father’s relationship with Frau K. – which is clearly expressed in the text as an explicit demand of Dora’s –, these behaviours must have forced undesired rapprochements between the two parents, in order to attend to the problem daughter.

What is happening to Dora in this development? She appears as a child subjected – over-involved – to the tensions proper to the conflicts of her parents and of other adults.

Dora finds herself deprived of the world of people her own age, of which almost nothing appears in the narrative. The little that is mentioned of it is the “young engineer whom Dora had met…”, who then seems to turn into a significant relationship in the context of Dora’s growth and cure, according to the information available within the limits of this case history.

In this context, it is then understandable that the fantasies and desires – heterosexual and homosexual – that people commonly develop with their peers in adolescence, Dora should have with people who, without being peers, function in this story as her peers. Thus appear the infatuations with the father, with Herr K. and with Frau K.

Dora’s infatuations surely existed, but they are the intrapsychic correlate of the relational dynamic in which she is immersed.

I use the word correlate in its double sense: equivalent, and alternative account proper to each of the disciplines.

Why does the analysis with Freud cure Dora?

Because it allows her to perceive from the outside a situation in which, one might say, she could only be. And it is this that allows her to get out of it.

The relationship with Freud cures Dora because, although it does begin by answering the paternal need to be able to pursue his relationship with Frau K. unhindered⁵, Freud offers Dora a relationship that is in fact an articulation between the father’s needs and Dora’s: at the same time as it satisfies the father’s reason for consultation, it feeds Dora with elements that allow her to come out of the triangulation, to grow and to become autonomous. Dora’s growth and individuation were hindered. In the relationship with her parents, she loses her personal possibilities. In the relationship with Freud, on the contrary, she recovers her individuality. He and Dora occupy themselves with Dora – the opposite of what happens to her with her parents.

Some conclusions

I have attempted to make a contribution by analysing and comparing different theoretical models, as well as different clinical approaches, individual or family, proposing a way of articulating them. It must be stressed how necessary it is to attend to the importance of the differentiations occasioned by the passage of time in the family evolutionary process, which give rise to conflicts and to changes.

In sum, the different approaches developed here refer to “two” patients. What is Dora: a young girl inhabited by incestuous or homosexual infatuations, repressed and unconscious, which promote her repeated participation in painful situations? Or else a young girl included in several overlapping triangulations⁶, the weak point of a complex and dysfunctional system? Can we articulate these two views? As I have already suggested, one way of doing so is to hold that certain manifestations of subjectivity are the intrapsychic correlate of certain relational structures.

It is legitimate for us to ask ourselves as well: to whom does responsibility fall for the fact of falling ill? and how far, and to whom, may the responsibility for the cure be extended? Or, more plainly: what is the illness? Certain behaviours of Dora’s – fainting fits, suicide threats? Or the fact of using a daughter in the service of her father’s sexual entanglements?

It is also worth asking oneself, in Foucault’s manner, whether that sentence of Dora’s father to Freud, “Please try now to bring her to better ways”, is not worthy of a “daddy-State” seeking to “commit” (to Freud’s consulting room) a “mad-girl” who disturbs the order with her “follies” (fainting fits, suicide threats and so on), and who has become an obstacle to an established order – the father’s – at the same time as she is the product of a disorder. That is why the father requests the consultation: to give the appearance of a “cure” to what looks rather like a design of domination.

We may also put questions to ourselves such as these: was there a cure of Dora? Did Dora really change? Of what magnitude and of what quality were the cure or the change? And others, more specific: why did Dora remain more satisfied with the analysis than Freud himself? Why did he cure Dora when he declares that he committed errors and omissions? Why did Dora recover although she had abandoned the psychoanalytic treatment?

I believe I have already given some answers to these questions above. They may be summarised by stressing that Freud offered Dora, a young girl starved of love, what she needed: someone to take care of her and to offer her an adult and containing context in which to listen to and understand her pains and her demands. I use here once again that Freudian expression, starved of love, applied to Dora, but this time as an articulation between the two theories: by resignifying Dora’s “hunger for love” as the subjective correlate of the affective deprivations suffered at the hands of her immature parents.

A digression: rereading Oedipus relationally

On this subject, I allow myself a digression. If we wish to go further in the project of rereading Freudian psychoanalytic theory relationally, let us leave Dora for a moment and occupy ourselves with Oedipus. Let us take, for example, the last of Freud’s general hypotheses cited in this work, the one that refers to the Oedipus complex, which Laplanche and Pontalis (1971)⁷ summarise as follows: “An organised set of loving and hostile desires that the child experiences towards its parents. In its so-called positive form, the complex appears as in the story of Oedipus Rex: a desire for the death of the rival, who is the figure of the same sex, and a sexual desire for the figure of the opposite sex.”

We can review these formulations in a relational manner, by asking ourselves whether this attribution of desires, infatuations and jealousies is enough to explain the behaviours that derive from them – putting Laius to death and marrying Jocasta –, inasmuch as neither of them was⁸, for Oedipus, father and mother, given that from his earliest days he had been abandoned by them – at least by the father – and that he meets them again, many years later, as persons foreign to his family, made up of Polybus and his own. That, it seems to me, is what the mythological story of Oedipus recounts. He does not kill his father, but a stranger who crosses his path and with whom he disputes the right of way; and he does not marry his mother, but a foreign woman, a queen who chooses him for a triumph that saves the city.

At most we can see these actions of Oedipus as an unconscious biblical retribution towards those who, when he was a baby, abandon him in a forest so that wild beasts should put him to death, because an informant – the Oracle – predicts that he will kill his father. This looks like a self-fulfilling prophecy. We should therefore explore the relationship of the Oedipus complex thus construed with the complex situations that arise when parents do not assume their biological, family, social and ethical responsibilities, as is the case with Dora’s parents. Within the psychoanalytic field itself, authors such as Winnicott and Kohut take up these concerns.

The transference, and the family’s

Let us return to Dora. We see that, further on in the case history, Freud shows a difficulty with her when he writes that he was taken by surprise by the transference and that she took revenge on him as she would have taken revenge on Herr K., by abandoning him.

We could reformulate this transference as a behaviour of Dora’s towards a Freud whom she does not forgive for occupying, structurally, a place that he does not manage – or does not have the time – to leave: the place of the person who, with a genuine similarity to Herr K., had received from the father the mission of preventing Dora’s interferences in his relationship with Frau K.

This alerts us to the fact that in clinical work we must be attentive not only to the patient’s transference – and first of all: who is our patient? – but also to the one the patient’s family operates upon us. Or, in the language of family therapy: who carries out the designation of the “patient”, and who, in the family group, assigns us – and conditions for us – the place and the task of therapists?

And afterwards? Change and maintenance of change

Finally, what do we know of the Dora who came after her analysis with Freud? Despite the strong indications in favour of her cure, twenty years later she presents herself to Felix Deutsch as a woman in failure, with serious organic and psychical symptoms, severe sexual and marital disturbances, a poor relationship with her son, and so on.

This is not surprising, for we have direct or indirect experience of cases in which the patient, or the patients, although they have carried through a successful treatment (as regards the attainment of the objectives initially established) and set in motion processes of growth and differentiation, come back for consultation, after a longer or shorter time, with similar problems. This indicates that we must differentiate change from the maintenance of change. It also tells us that if a family such as Dora’s were to present itself today for a necessarily brief family therapy, that therapy would in all likelihood have to be completed afterwards by a more prolonged individual therapy for Dora.

In sum, what do Freudian psychoanalysis and the systemic-relational approaches have, among other things, in common? Schematically, one may say that both propose a new context for the symptoms: for the former, it is the unconscious psyche; for the latter, family and relational dynamics. Both of these new contexts have the enormous virtue of allowing therapists to include themselves and to operate, and to construct a meaning for the apparent non-sense of the symptoms. In other words: nothing less than creating the condition of possibility for whoever needs it and asks for it to be able to receive help from outside.

Final comment: how would I treat Dora today?

It seemed important to me to add to this work a reflection answering a question formulated during the presentation: how would I treat Dora today, or how would I approach today a “Dora” who came for consultation? For my part, it seemed pertinent to derive another question from it: in what way do all these reflections carried out around Dora enrich clinical practice?

I shall attempt to answer these questions as a whole, thinking of the consultation of a patient similar to the one in question, whom I shall call “Dora”, and whom I imagine presenting herself with her family for consultation with comparable problems, but adapted to the new forms of our own time.

If that were to happen, I would from the outset pay particular attention to who is requesting the consultation, and this would influence the approach to be proposed. If it were “Dora” herself who consulted, I would embark on an individual therapy, completed by a few complementary family interviews, in order to explore the importance of the family dynamic in the daughter’s suffering. These interviews would be more or less numerous according to that importance.

In the individual sessions, I would seek to promote in “Dora”, by means of different interventions drawn from my clinical experience and from the various theoretical conceptualisations I handle, changes in her self and in her behaviours, so that she might move away from the triangulations that affect her and that do not let her grow. I would stimulate “Dora’s” extra-familial life.

In the sessions with the members of “Dora’s” family – surely some in her presence, others not –, I would undertake different interventions aimed at putting the adults back in charge of their own problems, thereby avoiding the use of the daughter to plug or to avoid the underlying conflicts. If the opening up of these conflicts were to destabilise the parental couple and the couple asked for more attention, I would offer them further interviews or would indicate a couple therapy for them, referring them to a colleague with whom I could maintain an exchange likely to enrich both therapies.

If it were the father who consulted, I would propose a few exploratory family interviews in order to understand the problem; they would surely have a flexible format, with full family interviews – “Dora” present –, others with the couple, others individual with each of them, with the aim of forming an idea of where it is necessary – and possible – to focus the therapeutic action. The question would surely move towards conducting couple interviews with the parents and referring “Dora” to an individual therapy with a colleague, on the same terms as those indicated above.

Whatever the format of each of the alternatives mentioned, I would attend both to the family dynamic and to the characteristics of the subjectivity of each of its members, and to the interactions between these two orders of manifestation, seeking to promote a healthy related individuation, such as H. Stierlin (1997)⁹ proposes, a master coming from the psychoanalytic field who approaches the systemic movement and who posits the need to articulate individuation and belonging.