Paul McHugh on Hysteria

It may be hard to believe, but despite my best efforts there are still some people who have not had enough therapy.

I was reminded of this by an excellent article about hysteria by the eminent psychiatrist, Dr. Paul McHugh, former chairman of the Psychiatry Department at Johns Hopkins. Link here.

Modern psychotherapy began with Freud's work on hysteria. Freud posited that hysterics suffer because they have forgotten a trauma, and thus, that they can be healed by remembering.

To which McHugh replies: "It is remarkable (even breathtaking), to realize that, despite all the changes in theory and practice that Freudian psychoanalysis underwent in the following decades, this basic idea-- heal by remembering-- has never been questioned. It remains today the fundamental concept behind the multiple-personality-disorder and recovered memory crazes."

Once an idea becomes dogma by being wrapped in myth it can live on for a long time, even if it is clinically ineffective.

But why does this treatment fail? McHugh's work offers an explanation.

McHugh begins by explaining that hysteria is mimicry. Hysterics adopt patterns of behavior that look like illness, and that they believe make them ill. They may be mimicking neurological disorders, like fugues and seizures, or they may be mimicking psychological disorders, like multiple personalities.

Hysterics are not consciously faking it. They believe that they are ill. McHugh calls it "a vivid form of self deception."

Hysteria, then, is learned behavior designed to attract the attention of authority figures like physicians or pastors. It develops over time as the hysteric tries on new symptoms and sees whether they attract sufficient attention and concern.

Most hysterics are young women. The authority figures whose attention and care they seek are most often male. It is, as Freud discovered, a game of seduction.

Why do they do it. Most often, McHugh suggests, they are demoralized from failure. Rather than admit that they have failed, they decide that they are ill, that they are not in their right minds. In this way they do not have to take responsibility for their mistakes.

Hysteria is living theatre. Hysterics are notably histrionic. That means, as McHugh shows, that they require an audience that sits quietly and attentively in the dark. A good listener, one who accepts the hysteric's complaints as legal tender, sustains the condition.

In his article McHugh offers several examples of groups of women developing the same set of hysterical symptoms. The witches of Salem and the hysterics in Charcot's clinic all manifested the same problems. And yet, once the controlling authority figures stopped colluding in their production the symptoms largely went away.

Since hysteria is theatre, once the lights go on and the audience leaves, the hysteric is more amenable to reason.

McHugh's most salient point concerns hysterical mimicry. For Freud hysterics were suffering from forgotten traumas, thus from personal experiences that they were refusing to allow into consciousness. Their symptoms were expressions of something intensely intimate that could not be told in a story.

The solution, to many therapists, is to allow patients to recall their repressed memories or to reconstruct their past, and then, to express their unconscious feelings.

Now we can see why it did not work. If hysteria is mimicry and if several hysterics develop the same symptoms, it makes no sense to say that each of them is expressing something intimate and personal.

When Freud tried to tell his hysterical patients that they were expressing forgotten traumas they often reacted with disdain and indifference. They were right to do so. Freud was analyzing the role, not the person.

If the symptoms do not express something hidden deep within the individual psyche, a therapist's efforts to plumb the depths of said psyche cannot possibly resolve the problem.

A therapist's solicitous attention, his quiet, imperturbable listening, and his ability to be drawn into the performance, to take it on its own terms... that is exactly what an audience offers a dramatic performance. Not only will this never cure; it can only aggravate the condition.

Therapy does not cure hysteria because, to the extent that it follows the Freudian template, it is the problem, not the solution.