The PANY Bulletin

Psychoanalytic Association of New York
Volume 41, #3 Fall 2003

Book Review
Family Romance, Family Secrets: Case Notes from an American Psychoanalysis, 1912
by Elizabeth Lunbeck
and Bennett Simon
reviewed by Janice Lieberman, Ph. D.

"IN THE NAME OF FREUD"
This collaborative effort on the part of a psychoanalyst (Bennett Simon) and an historian (Elizabeth Lunbeck) is a most felicitous piece of applied psychoanalysis. They chronicle the treatment of a difficult five-year case begun in 1912 and inform us about the ideas mental health practitioners held then as well as the social milieu of that era. They demonstrate how Freud's technical recommendations were revised and re-interpreted in America from the very beginning.

We are accustomed to critiquing Freud's cases and note that his patients were usually "European" and therefore "different" from ours. We focus on early psychoanalysis in Vienna, London, and Budapest and tend to forget that it was conducted here in America on both an in-patient and out-patient basis. There were American "hysterics" not unlike those treated by Breuer and Freud. (Our contemporary version may very well be those suffering from anorexia). Freud's lectures at Clark University in 1909 stimulated the beginnings of psychoanalysis here. This book is about the work of Louville Eugene Emerson, a psychologist and a member of the Boston Psychoanalytic Society, with his patient Rachel C. Emerson saw 220 patients between 1911 and 1917! His treatment of the 22 year old Rachel C., who for six months had had several (hysterical) convulsions, could not hold food or water without vomiting and fell quite often, breaking her hands in these falls, is chronicled and commented upon.

The authors examined typed and hand-written notes for most of the 292 sessions, some at a frequency of 5 times/week. Emerson, who had many publications, wrote his case up and was much criticized by his colleagues. The introduction, extremely clear and well-written, provides the reader with the historical context of psychoanalytic treatment, how it was learned and how it was practiced in its fledgling form. Expectations then were for quick cures. They note:
"It[the book] offers the opportunity to examine, at the level of day-to-day practice, how Freud was interpreted at a distance, and to track the oscillations of hopefulness and despair, exhilaration and frustration experienced by one enthusiastic proponent of his new technique" (p. 8)

Emerson was his own man, however, and took an ethical and moral stance (like his mentor, Putnam) and objected to Freud's neutrality and amorality. He used only some of Freud's technical recommendations. For example, he disobeyed Freud and took notes during the sessions. When writing up this case for publication he cordoned off some of the more sexually explicit sexual material. The authors are particularly interested in the vicissitudes of the recording process itself and in tracking inconsistencies in the different reports. Like detectives they continually comment on the distortions of accounts of what went on between patient and analyst. The book reads like a mystery story with the plot ever-thickening!

Lunbeck and Simon present three different phases of this complicated treatment in sections, each preceded by a summary and commentary. This on the one hand helps the reader to search for the themes they focus upon. On the other hand, this prevents the reader from independently forming his or her own hypotheses about what the material is about. I recommend the reader to look at the case material before reading their comments, no matter how chaotic it may seem, to think about the material and then compare impressions with the authors' views.

Emerson first saw his patient at Massachusetts General Hospital on an outpatient basis and then hospitalized her after 17 sessions. She was in and out of the hospital. As memories emerged some of her symptoms disappeared, but more and more alarming symptoms would occur, e.g. paralysis of her legs, fogginess, confusion, dissociation. Rachel C. at first reported having been assaulted by a stranger in the woods when she was nine; then she remembered being raped by a neighbor at age 13; this was followed by remembering (or admitting) repeated incest with her brother. She mourned a lover, then after many sessions, confessed that he had raped her. Throughout all of this Emerson sought to change her negative and yet uninformed attitudes about sex. Like Freud with Dora, he tried to show her what her role was in all of this. He had powerful countertransference reactions to her getting worse rather than better and being so very difficult to treat. He used much pushing and exhortation, putting his hands over her eyes to get her to visualize, which drove her to threaten suicide. Every memory retrieved, however painful and traumatic, was seen as a step forward. (Today, analysts focus more on the relationship with the patient than memory retrieval). At the beginning of treatment, he reported that: "Last night she dreamed she was in the hospital and that I was trying to make her tell something she wouldn't and couldn't tell.." (p. 47)

While Rachel C. was in the hospital, the other doctors and the nurses (whose notes are also included) participated in examining her and in trying to undo her paralysis. For example, they would pry open her closed hand with a wedge while putting pins in her and put their fingernails under hers. She was given hydrotherapy and Emerson himself prescribed massage administered by three persons. He followed Ferenczi's recommendations at times and called the genitals by their obscene names. One doctor, critical of Emerson's technique, regarded Rachel C. as suffering more from lack of sexual intercourse than from thinking about what had happened to her. Emerson could not moderate his disappointment in his patient's "not trying". He saw the negative transference only as interference, not to be understood. The authors note: "Whereas Freud, in 1912, saw transference largely as resistance, Emerson saw it as a weapon to be used against resistance" (p. 35) Emerson wrote: "Always it is the vision of the mother that is standing between her and the knowledge she is seeking" (p.36). He was unable to see the mother as an object choice. Her mother's death a few years prior to her entering psychoanalysis was given little import.

By the end of the book we learn that the patient, who was hospitalized three times due to the worsening of her symptoms, (for example, she began to bite herself and cut herself to relieve bodily tensions) reported having had sex with her brother since she was a child (with her mother's knowledge) and having been masturbated by her father since she was 7. Finally she reported having had intercourse with her father at age 13. Her family forbade her to have sex with men outside the family but it was permissible inside the family. Released from the hospital she had an affair with a married man and was treated for TB and back and neck problems in a hospital in North Dakota. After so many years of psychoanalytic treatment with Emerson, she attributed her feeling better to osteopathic treatment!
Reading all of this I had difficulty distinguishing her dreams from her memories or her fantasies and wondered about the veracity of her reports. Many of the doctors at the hospital thought Rachel C. to be a liar. I wondered when reading this case whether she was perversely providing Emerson an ever-increasingly number of the salacious memories he so insisted were the key to her cure. The problem may have been in part due to Emerson's note-taking. He recorded her dreams but did not seem to ask for her associations or give many interpretations. It may be that he did not write them down. Rachel C.'s dreams provide excellent material for those who are interested in the manifest dream and have the contemporary tools with which to interpret them. Emerson noted one dream that particularly seems to reflect the Pandora's box this treatment had become:
"Dreamed I gave her an ordinary string with a lot of knots in it which I told her she was to untie. As she did so the string grew heavier and heavier until it became a rope ... she had me tied up in the rope" (p.222)

In the Afterword the authors raise the issue of Rachel C's analysability and the questionable diagnosis of hysteria. Today the sadomasochistic quality of the interaction between patient and analyst would be understood and addressed. Emerson never mentioned the Oedipus complex even though his contemporaries were using the term. Emerson was a psychologist and was never officially acknowledged as a psychoanalyst. They present two ways of understanding him: 1) as a pioneer; and 2) as rigid and fixated on recovering repressed trauma.
I personally found this book to be a fascinating read and one that could be assigned to candidates. The case is compelling and one gets a realistic view of what went on in mental health in Boston at that time. It seems that Dora had an even sicker American cousin.