The Secret Mind of Bertha Pappenheim

On Sunday, somewhat against my will, I did get out of the house, and here is a picture of a waterfall to prove it.

Book report: The Secret Mind of Bertha Pappenheim: The Woman Who Invented Freud's Talking Cure, by Gabriel Brownstein

I decided on Saturday that I was going to stay in bed and read this book all the way through, and I did. Indulgent, for sure, but also encouraging to know that my internet-addled brain and increasingly aged eyes are still capable of such a thing.

One might surmise from the title of this book that it is the story of Bertha Pappenheim, the "hysteric" called "Anna O." in Sigmund Freud and Josef Breuer's Studies on Hysteria who was the first patient to participate in what is now known as psychoanalysis. Breuer treated her many psychosomatic symptoms using something she herself named the "talking cure"--just like that, in English, because one of her symptoms was that she would periodically lose the ability to speak or understand her native German--and that she experienced an immediate and full recovery. The story of this miracle cure turns out, like so many others, to be at best embellished: Breuer did treat Pappenheim and did listen to her stories, but he did not cure her. What eventually did help, apparently, was getting the f*ck out of Dodge--in this case Vienna--and starting a new life in Frankfurt, where she became a passionate campaigner for the education of poor Jewish girls and founded the Jewish Women's Association. More, though, no one knows for sure: all of the relevant documents have since been lost or destroyed.

So the "secret mind" of the title does in fact remain a secret, and the the book is less a biography of Pappenheim than a meditation on Freud and Pappenheim as contemporaries in Victorian-era Vienna. Only three years apart in age, both passionate, both brilliant, both drug-addicted: one is a striving young doctor in search of the insight that will make him rich and famous; the other is imprisoned and thwarted by her social station and a long and ever-changing list of ailments. Brownstein says that it's impossible to retrospectively re-diagnose Pappenheim, but about half his book is about the contemporary experience of people with functional neurological disorder (FND): the clear implication is that FND has inherited the baton of hysteria, the "wandering womb" described at least as far back as the second century AD by Aretaeus of Cappadocia, "...like an animal within an animal."

If the womb wandered into the eyes, so the classical story went, the patient went blind. If it went to the legs, the legs spun out of control. Paralysis. Paresis. Unusual walking patterns. If the womb sidled up toward the mouth, it caused globus hystericus, the feeling of a lump in the throat, a common functional symptom that at its most severe can interfere with speaking and swallowing. 

So. With this as our starting point it's no wonder we still have some way to go in understanding how and why women so often suffer. I suppose Freud did move the ball forward with his theories of the unconscious mind. But my ill-informed but generally negative opinion of him was not improved by this book. Did you know that during his most productive years as a doctor, he had an intimate intellectual, emotional, and sexual relationship with one Wilhelm Fliess? Trigger warning: this is JUST GROSS.

Fliess saw an anatomical parallel between the structure of the sinuses and the structure of the vagina and the womb. He believed that all kinds of neurotic illnesses, especially in women, were caused by something that he called the “nasal reflex neurosis.” Fliess’s first course of treatment for any psychosexual problem was cocaine applied to the nostrils; the second, electrically shocking the nose; and the third, surgery: the removal of the patient’s turbinate bones, the nasal conchae, the long, thin, curved bones that flare from the middle of the face into the breathing passages. The “bad practice” of masturbation, Fliess wrote, could “only be finally cured through an operation of the nose.” He believed that menstrual pains were caused by masturbation. 

"The bromance, the eccentricity, and the misogyny of it all can distract us from the[ir] correspondence’s profundity," says Brownstein. Which first, would this really be considered a "bromance"? and second, maybe we *should* get distracted by the misogyny of it all? Brownstein largely dismisses feminist interpretations of Pappenheim's illness as speculation, but also mentions several times that Pappenheim herself had no time for psychotherapy. 

I can’t escape a feeling that I have through much of the Studies: that the patients are more important to the doctors than the doctors are to the patients. This is especially true for Bertha Pappenheim—Anna O. meant the world to Freud, the first ship in his armada, but for Pappenheim, Freud was the husband of an old friend, the colleague of a doctor who had tried and failed to help her. Freud was someone whose wise theories—if they interested her—she found appalling and unworkable in her business of saving young women’s lives. 

The Secret Mind was motivated by Brownstein's father, himself a psychotherapist. 

Freud, hero of my dad's youth, was the villain of his later years. Mulling relentlessly in his long retirement, my dad despaired over the value of psychotherapy, talk therapy, his primary avocation and livelihood. His eyes would tear up, and he'd ask awful questions. Had it ever helped anyone? He was tough to console. 

The day before he dies, the elder Brownstein hands his son an envelope containing "my masterpiece": a paper on "Josef Breuer and Psychoanalysis." But the paper mysteriously disappears. Curious what his father had turned up, Brownstein starts researching the topic and the resulting writing project (this book) grounds him first through his father's death and then through the even more terrifying experience of his wife's terminal illness. When the paper finally resurfaces, it turns out that his father argued "that Breuer's technique is or should be the ideal in psychoanalysis: two minds meeting, the doctor giving the patient room for play and self-discovery." By this time, Brownstein has come to see Breuer and his work in a positive but more nuanced light:

As contemporary neurologists have it, we should not assume that Pappenheim’s symptoms were any kind of symbolic storytelling, nor should we dismiss them as some kind of performance suggested by her doctors or the world around her. She was not necessarily trying to say or do anything—consciously or unconsciously. She was in a “hell hole,” as Oliver Sacks describes it, a place from which she could not speak but nonetheless needed to be heard. Breuer sat by her side and listened to her. This was not a talking cure in the way that Freud would later have it, and it was not the kind of partnering that happens in Massachusetts General, where David Perez joins his patients in considering the best understanding we have of the function and malfunction of the brain. What Breuer offered in 1881 was preliminary to all that—a human face, a chunk of time, and someone who would listen, all of it offered as medicine. 

..."medicine" that, helpful as it may have been, did not ultimately cure his patient, and probably got him into hot water with his wife. 

Today, people--still mostly women, lest we take our eye off the misogyny ball--continue to suffer from symptoms for which their doctors can't find a cause, and continue to find themselves disbelieved and dismissed by large swathes of the medical establishment (and taken advantage of by others). A few years ago I read another book on this subject in which men entered the psychosomatic mix after World War I with shell shock (now PTSD), but Brownstein leaves them out, tracing the majority-female lineage of this illness from the "wandering womb" through hysteria, hysterical conversion, conversion disorder, and functional neurological symptom disorder (FNSD) to today's FND. Do these patients have an undetected or as-yet-undiscovered disease? are they suffering from the aftereffects of trauma? surfacing repressed memories? acting out unconscious desires? (I'd add: playing a role in a dysfunctional family system? and/or a systematically oppressive society?) Brownstein finds that for a given person, it could be any of these things. Or none of them. The FND specialists who do successfully help the patients he interviews distinguish themselves by taking their clients seriously--but also, it seems, by projecting confidence. I can empathize with a patient who feels insulted and discouraged after a(nother) doctor tells her that her debilitating symptoms are "just anxiety" and that she should maybe take a yoga class--but then seen and cared for by the expert (maybe not coincidentally in a famous medical center, behind a 6-month waiting list) who tells her that she has FND and needs to learn to retrain her brain with breathing exercises. *And* I can understand how a third party (the insurance company) might struggle to see the difference between these two treatments... 

Brownstein concludes that our minds and our social contracts are far more fragile than we would like to believe. 

I have tried to get as close to Pappenheim as I could, to represent her in all her dynamism and not to reduce her to a cartoon. But her story remains a secret. The various attempts at interpretation and reinterpretation of the “Anna O.” case show us how we have tried and failed to know the actual woman. The centuries of argument about FND...show us how we have tried and failed to know the human mind.

I don't know that we've "failed" so much as tried (and tried and tried) and found that our theories will always be incomplete and that there is always more to learn, particularly from the voices we've never considered authoritative. And: artificial intelligence doesn't come up in this book but I wonder whether, as we learn more about how large language models work (and don't), we will become more sympathetic to our own hallucinations?