October 20th, 2011
Case and Treatment
Anna O. (A Case History)
Anna O. was the pseudonym of a patient who was treated by Joseph Breuer for paralysis on the right side of her body, severe cough, and problems affecting her vision, hearing, and speech. Anna O. was also suffering from hallucinations and loss of consciousness which was eventually diagnosed as hysteria as its causes. Freud believed that her illness was a result of the grief felt over her father's debilitating illness that eventually led to his death. Breuer observed that while she experienced a change of personality that was accompanied by confusion, she would mutter words or phrases to herself. She had two completely separate states of consciousness which alternated and in the course of her illness became more diverse. In the one state she was miserable and anxious but comparatively normal, but in the other state she had hallucinations and became aggressive and violent.
Breuer began the therapy without a clear method or theoretical basis. The treatment of Anna’s symptoms ranged from feeding her when she rejected food to dosages of chloral when she was agitated. One of Breuer’s initial therapy approaches was led by the observation that the patient calmed down and her speech disorder improved whenever she was asked to tell stories that had emerged from her daydreams. Breuer encouraged her to relay these stories by using such prompts as a first sentence. At times Anna could only express herself in English, but usually understood the German spoken around her.
Breuer’s final therapy approach entailed asking Anna under light hypnosis about the occasions and circumstances under which a particular symptom had occurred. Later Breuer asked Anna to systematically recant these episodes in reverse chronological order. When Anna got to the first episode and thus to the "cause", the symptoms appeared in an intensified form and then disappeared. The therapy came to a conclusion when they had worked their way back to a "black snake" hallucination which Anna experienced one night when she was at her father's sickbed.
Aspect of Psychoanalytic Theory highlighted
Anna O’s treatment is regarded by Freud as marking the beginning of psychoanalysis. During her treatment Free Association was created and utilized after Anna decided at the suggestion of Breuer to end her hypnosis sessions and merely talk to Breuer in which she said anything that came into her mind. She referred to this method of communication "chimney sweeping", and this served as the beginning of free association. In free association, patients are invited to relate whatever comes into their minds during the analytic session, and not to censor their thoughts. This technique is intended to help the patient learn more about what he or she thinks and feels, in an atmosphere of non-judgmental curiosity and acceptance. Psychoanalysis assumes that people are often conflicted between their need to learn about themselves, and their conscious or unconscious fears of and defenses against change and self-exposure. The goal of free association is not to uncover specific answers or memories, but to prompt a passage of co-discovery which can enhance the patient's integration of thought, feeling, action, and one’s self.
Anna's case also shed light for the first time on the phenomenon called Transference, where the patient's feelings toward a significant figure in his/her life are redirected onto the therapist. By transference, Anna imagined that she was pregnant with Breuer’s baby where she experienced nausea and all the symptoms associated with pregnancy. Transference is an occurrence in psychoanalysis characterized by an unconscious redirection of feelings from one person to another. Transference is thought to be a reflection in the present of a relationship that was important in a person's childhood, the redirection of feelings and desires and especially of those unconsciously retained from childhood toward a new object, and a reproduction of emotions relating to repressed experiences, especially of childhood, and the substitution of another person for the original object of the repressed impulses.
Evaluation of Case from Today's Perspective
Anna O’s case study will now be critically evaluated through the lens of three neo Freudian psychoanalysts and the new directions they have taken Freud’s original theory and psychoanalysis. Harry Stack Sullivan laid the groundwork for understanding the individual based on the network of relationships in which he or she is enmeshed. He developed a theory based on interpersonal relationshipswhere cultural forces are largely responsible for mental illnesses. Sullivan believed that one must pay attention to the interactional, not the intrapsychic or the internal psyche of the individual. From this perspective Anna O’s childhood would have been analyzed to evaluate her past relationships with others, primarily family members. The analyst would have taken note of how Anna coped with perceived rejection from loved ones and the strategies she developed to limit anxiety. This strategy is utilizing Sullivan’s developed Self System, which is a configuration of personality traits developed in childhood by the patient and reinforced by positive affirmation through loved ones or close relationships.
The therapist will analyze the security operations developed in childhood by the patient to avoid anxiety and threats to self-esteem. These learned behaviors would have defined how Anna interacted with people around her which Sullivan called parataxical integrations and which would have transcended into adulthood. Sullivan noted that such action-reaction combinations can become rigid and dominate an adult's thinking pattern, limiting its actions and reactions toward the world as the adult sees it and not as it really is. The death of her father is perhaps the trigger that caused Anna to develop the symptoms she did and as a result would have caused her great anxiety by taking away an important interpersonal relationship that has been used since childhood to shape her personality.
The resulting inaccuracies in judgment created by the patient Sullivan termed parataxic distortion, which is when other persons are perceived or evaluated based on the patterns of one’s previous experiences, which is similar to Freud's concept of transference. In line with Sullivan’s theory Anna’s developed infatuation with Breuer would have been confusion or a distortion created by one of Anna’s relationships from her childhood. Perhaps the relationship with her father due to the fact that most of her symptoms escalated after the death of her father. Sullivan’s overall theory would have attributed much of Anna’s symptoms to coping behavior she adopted as a child which would have been shaped by the cultural upbringing that was utilized by people she interacted with, primarily her parents. These behaviors would have become distorted as she became an adult and would have caused her anxiety and emotional distress laying the groundwork for her physical manifestations.
Erik Erikson was a Neo-Freudian who developed stages of psychosocial development that are marked by a conflict, for which successful resolution will result in a favorable outcome. Erikson's research suggests that each individual must learn how to hold both extremes of each specific life-stage challenge in tension with one another, not rejecting one end of the tension or the other. Only when both extremes in a life-stage challenge are understood and accepted can the optimal virtue for that stage surface. Anna’s case would have been evaluated by an analyst following the Eriksonian perspective as her stunted psychological development caused by her inability to complete one of the psychosocial stages. Due to this incompletion Anna would have developed psychological trauma’s that would have progressively gotten worse as she grew older. This could have accounted for Anna’s development of physical illnesses that had no biological causes but seemingly psychological ones. Having Anna revisit her past through free association, the analyst can pinpoint and determine at which stage her psychological growth was stunted and begin to work towards resolution.
Karen Horney looked at emotional disturbance differently than other psychoanalysts and perhaps would have had the greatest insight into Anna O’s condition. Horney believed neurosis to be a continuous process with these disturbances commonly occurring periodically in one's lifetime. This greatly resembles Anna’s condition in that it progressed at different intensities at different stages in her life and resurfaced even after Breuer thought he had cured her. This was in contrast to the opinions of her contemporaries who believed neurosis was a negative malfunction of the mind in response to external stimuli like negative experiences during one’s childhood and adolescence. Horney believed influences during childhood had a significant impact brought on by an emphasis on parental indifference towards the child.
She also believed that a child's perception of events, as opposed to the parent's intentions, is the key to understanding a person's neurosis in that it had a negative impact on the child’s mental state. In this perspective the analyst would have probed into Anna’s childhood to see if there were traumatic events that the patient would have perceived as harmful and that have then pushed them towards utilizing coping strategies. Horney developed ten needs that are utilized as coping strategies for an emotionally disturbed person. The need for affection and approval, which would have been Anna’s need from her father, could have been unmet causing her afflictions. The need for a partner was also unmet due to her lack of love and experience of it. These two needs in Honey’s theory classify an individual moving towards people. Needs three and four are uncategoristic of Anna because she didn’t display behaviors which suggested the need for power or the need to exploit others. The need for social recognition, personal admiration, and personal achievement could have been unmet by Anna O due to the culture she lived in that viewed women in a desired role which was mostly home tending and fragile. The need for self sufficiency and independence, perfection, and autonomy could have been unmet by Anna due to her integration into her family that restricted her movements and had her close to her family for the most part, as well as the times she lived in, and due to her young age.
Through this perspective the analyst would have viewed the patients early childhood experiences as fostering damaging emotional mind states that were brought on by either the lack of need fulfillment or the overindulgence of certain needs to compensate for anxiety provoking events. Anna’s physical manifestations would have stemmed from these negative early childhood perceptions which would have caused varying levels of neurosis throughout later stages in Anna’s life. Finally Horney would have viewed Anna’s day dreaming as Anna’s distortion between her actual life and her idealized life through the process of alienation. Horney’s work may be the best to shed light on female psychology, like Anna’s case, and the dynamic and unique perspectives and experiences that only women perceive that can lead to emotional disturbance and its possible physical manifestations.