14
Hysterical (Histrionic) Personalities
Psychoanalysis began with the effort to understand hysterical conditions and has returned to that problem regularly since the 1880s, when Freud first tackled it. Inspired by the work of the French psychiatrists Charcot, Janet, and Bernheim, who were investigating hysterical afflictions via hypnosis, Freud first began asking the kinds of questions that gave psychoanalytic theory its shape: How can someone know and not know at the same time? What accounts for forgetting important experiences? Does the body express what the mind cannot fathom? What would explain such sensational symptoms as full epileptic-like seizures in a person without epilepsy? Or blindness in someone optically normal? Or paralysis when nothing is wrong with the nerves?
At the time, hysterically ill women were being thrown out of physicians’ offices as malingerers. Whatever Freud’s mistakes about female psychology or sexual trauma, it is to his credit that he took these women seriously and paid them the respect of trying to understand their particular suffering. By doing so, he believed he would begin comprehending processes that operate in the emotionally healthy as well as in the emotionally disabled. Although this chapter is not about the dramatic disturbances that were in Freud’s day subsumed under the rubric of hysterical neurosis (conversion, amnesia, inexplicable attacks of anxiety, and other disparate phenomena), I review some psychoanalytic history relevant to those conditions in the service of eventually focusing on the personality structure that often accompanies them.
Hysterical (or, as per later editions of the DSM, histrionic) character is common in people without frequent or striking hysterical symptoms. As with obsessive–compulsive individuals who lack obsessions and compulsions but who operate on the same principles that produce them, there are many of us who have never had hysterical outbreaks but whose subjective experience is colored by the dynamics that create them. Although this type of personality is seen more in women, hysterically organized men are not uncommon. In fact, Freud (e.g., 1897) regarded himself—with good reason—as somewhat hysterical. One of his earliest publications (1886) was on hysteria in a man. Analytically oriented therapists are accustomed to thinking of individuals with hysterical personalities as in the neurotic range, since their defenses have been considered more mature, but many people have hysterical psychologies organized at the borderline and psychotic levels.
Elizabeth Zetzel (1968) noted some time ago (in an article that begins with the nursery rhyme that observes “When she was good she was very, very good, but when she was bad she was horrid”) the great distance between healthier and more deeply impaired individuals in this group. Confusingly, post-1980 DSMs have reconceptualized histrionic personality disorder toward the pathological end of the hysterical continuum, indistinguishable from “Zetzel type 3 and 4” personalities and Kernberg’s (1975, 1984) “infantile personality.” Kernberg and others have used the term “hysterical” for higher-functioning patients and “hysteroid” or “histrionic” or “pseudohysterical infantile” to refer to those in the borderline and psychotic ranges.
In the language of more recent research on personality and personality disorder, people with hysterical tendencies who are securely attached may be seen as having a histrionic style (but not disorder) or hysterical personality. Researchers studying psychopathology and attachment (e.g., Ouimette, Klein, Anderson, Riso, & Lizardi, 1994) have noted an anxious–resistant attachment style in histrionic people who meet DSM criteria for histrionic personality disorder. Hysterically oriented people with histories of significant early trauma, for whom the infantile object of safety was also the source of fear, show a disorganized attachment style characterized by subjective helplessness and compulsive caregiving rather than hostility and aggression (Lyons-Ruth, 2001).
The phenomenon of hysterical psychosis, which may overlap with the extreme version of the disorganized, posttraumatic attachment style, has been known since antiquity (Veith, 1965, 1977), noted across cultures (Linton, 1956), and supported by earlier research (Hirsch & Hollender, 1969; Hollender & Hirsch, 1964; Langness, 1967; Richman & White, 1970). Its absence from the DSM has arguably impoverished our approach to assessment and contributed to the overdiagnosis of schizophrenia when a trauma-related, hysteroid process should have been considered.
People with hysterical personalities have high anxiety, high intensity, and high reactivity, especially interpersonally. They are warm, energetic, and intuitive “people people,” attracted to situations of personal drama and risk. They may be so addicted to excitement that they go from crisis to crisis. Because of their anxiety level and the conflicts they suffer, their own emotionality may look superficial, artificial, and exaggerated to others, and their feelings may shift rapidly (“hysterical lability of affect”). The great actress Sarah Bernhardt (Gottlieb, 2010) seems to have had many hysterical features, as did the fictional Scarlett O’Hara. People with hysterical characters may like high-visibility professions, such as acting, performing, preaching, teaching, and politics.
DRIVE, AFFECT, AND TEMPERAMENT IN HYSTERIA
Many have suggested that hysterically organized people are by temperament intense, hypersensitive, and sociophilic. The kind of baby who kicks and screams when frustrated but shrieks with glee when entertained may well have the constitutional template for hysteria. Freud (e.g., 1931) suggested that powerful appetites may be characteristic of people who become hysterical, that they crave oral supplies, love, attention, and erotic closeness. Blatt and Levy (2003) have reviewed extensive empirical data attesting to their tilt in the anaclitic direction. They seek stimulation but get overwhelmed by too much of it, and they have trouble processing distressing experiences. They may have the sensitivity of the schizoid person, to whom they often have an affinity (McWilliams, 2006), but they move toward people rather than away from them.
Others have speculated (e.g., D. W. Allen, 1977) that people with hysterical tendencies are more dependent constitutionally on right-hemisphere brain functioning (Galin, 1974; Wasserman & Stefanatos, 2000), in contrast to obsessively inclined individuals, who may be left-brain dominant. Before fMRI studies, one basis for this speculation was the careful work of D. Shapiro (1965) on the hysterical cognitive style. Hysterically organized people differ strikingly from more obsessional ones in the quality of their mental operations; specifically, they are impressionistic, global, and imaginal. Some highly intelligent people with hysterical personality organization are remarkably creative; their integration of affective and sensory apperception with more linear, logical approaches to understanding produces a rich integration of intellectual and artistic sensibility.
Developmentally, Freud (1925b, 1932) and many later analysts (e.g., Halleck, 1967; Hollender, 1971; Marmor, 1953) suggested a dual fixation in hysteria, at oral and oedipal issues. An oversimplified account of this formulation follows: A sensitive and hungry little girl needs particularly responsive maternal care in infancy. She becomes disappointed with her mother, who fails to make her feel adequately safe, sated, and prized. As she approaches the oedipal phase, she achieves separation from the mother by devaluing her. She turns her intense love toward Father, a most exciting object, especially because her unmet oral needs combine with later genital concerns to magnify oedipal dynamics. But how can she make a normal resolution of the oedipal conflict by identifying with and competing with her mother? She still needs her, and she has also devalued her.
This dilemma traps her at the oedipal level. As a result of her fixation, she continues to see males as strong and exciting, and females, herself included, as weak and insignificant. Because she regards power as inherently a male attribute, she looks up to men, but she also—unconsciously, for the most part—hates and envies them. She tries to increase her sense of adequacy and self-esteem by attaching to males, yet she also subtly punishes them for their assumed superiority. She uses her sexuality, the one kind of power she feels her gender affords, along with idealization and “feminine wiles”—the strategies of the subjectively weak—in order to access male strength. Because she uses sex defensively rather than expressively, and because she fears men and their abuses of power, she does not fully enjoy sexual intimacy with them and may suffer physical equivalents of fear and rejection, such as sexual pain or anesthesia, lack of full responsiveness, or failure of orgasm.
Freud’s stress on penis envy as a universal female problem arose from his work with hysterically structured women. When he discovered that his patients symbolized male power in their dreams, fantasies, and symptoms with phallic images, he speculated that during their early years these women had learned to equate powerlessness—their own and that of their mothers—with penislessness. In a patriarchal and increasingly complex urban culture where traditional feminine virtues carried little prestige, such a conclusion was probably easy for many young girls to draw. Freud (1932) stated:
The castration complex of girls is ... started by the sight of the genitals of the other sex. They at once notice the difference and, it must be admitted, its significance too. They feel seriously wronged, often declare that they want to “have something like it too,” and fall victim to “envy for the penis,” which will leave ineradicable traces on their development and the formation of their character. (p. 125; emphasis added)
This quotation suggests that despite his reputation in some intellectual quarters, Freud appreciated the negative consequences of patriarchy. In his life he encouraged women toward professional achievement and intellectual equality. He also hoped that by interpreting their penis envy he would foster his patients’ realization that men are not in fact superior—that a belief to that effect betrays an infantile fantasy that can be examined and discarded. Blame for the fact that ideas about penis envy were used by some mid-century American therapists in the service of trying to keep women safely in an “appropriate” domestic sphere cannot justly be laid at Freud’s door. (See Young-Bruehl, 1990, for a thoughtful commentary on Freud’s complex views about women.)
In the affective realm, hysterical individuals are notable for their high level of anxiety and their vulnerability to both shame and guilt. Often conceptualized as having “shallow affect,” they actually struggle with intense affect that terrifies them, against which they erect distinctive defenses. I say more about this in the context of the histrionic person’s sense of self.
DEFENSIVE AND ADAPTIVE PROCESSES IN HYSTERIA
People with hysterical personalities use repression, sexualization, and regression. They act out in counterphobic ways, usually related to preoccupations with the fantasied power and danger of the opposite sex. They also use dissociative defenses, about which I say more in the next chapter.
Freud regarded repression as the cardinal mental process in hysteria. Amnesia was a phenomenon of such fascination for him that it led to a whole theory about the structure of the mind and about how we can “forget” things that at some inaccessible level we also “know.” Freud’s first constructions of repression as an active force rather than an accidental lapse derived from his work with people who under hypnosis recalled and relived childhood traumas, often incestuous ones, and then lost their hysterical symptoms. In his earliest therapeutic attempts, first with hypnosis and then with nonhypnotic suggestion, he put all his energies into undoing repression, inviting his patients to relax and exhorting them to let their minds be open to recollection. He observed that when traumatic memories returned with their original emotional power, a process he labeled “abreaction,” hysterical disabilities would disappear.
Repressed memory and its associated affects became central objects of early psychoanalytic study, and lifting repression came to be seen as a key therapeutic task. Before long, however, Freud became convinced that some of the “memories” recovered by hysterical patients were actually fantasies, and his interest shifted from amnesia for trauma to the repression of wishes, fears, infantile theories, and painful affects. He saw Victorian myths about the asexual nature of females as particularly inimical to psychological health, and he felt that women raised to repress their erotic strivings were at risk of hysteria because so compelling a biological force could only be deflected, not quelled. He began to see some maladies as conversions of impulse into bodily symptoms. A woman who, for instance, had been reared to regard sexual self-stimulation as depraved might lose feeling and movement in the hand with which she would be tempted to masturbate. This phenomenon, known as “glove paralysis” or “glove anesthesia” because only the hand was affected (which cannot be of neurological origin because nerve damage that paralyzes the hand would also paralyze the arm), was not uncommon in Freud’s time, and it begged for an explanation.
It was symptoms like glove paralysis that inspired Freud to conceive of hysterical ailments as achieving a primary gain in resolving a conflict between a wish (e.g., to masturbate) and a prohibition (against masturbating), and also secondary gains in the form of concern from others. The secondary gains compensated the afflicted person for the loss of sexual satisfaction by the resulting nonerotic attention to the person’s body and its disability. With the development of the structural theory, this dynamic was seen as a conflict between the id and the superego. Freud felt that such a solution is highly unstable, since sexual energy is blocked up rather than expressed or sublimated, and he was inclined to interpret any outbreaks of sexualized interest as “the return of the repressed.” Repression can be a useful defense, but it is a brittle and unreliable one when directed against normal impulses that will continue to exert a pressure for discharge. Freud’s original formulation about the high degree of anxiety for which hysterical people are noted was that they were converting dammed-up sexual energy into diffuse nervousness (see Chapter 2).
I am dwelling on this formulation about hysterical symptoms because a comparable process can be inferred at a characterological level. People who repress erotic strivings and conflicts that seem dangerous or unacceptable tend to feel both sexually frustrated and vaguely anxious. Their normal wishes for closeness and love may become amplified, as if energized by unsatisfied sexual longing. They may be highly seductive (the return of the repressed) but unaware of the implied sexual invitation in their behavior. In fact, they are often shocked when their actions are construed as initiating a sexual connection. Moreover, if they proceed with such an encounter (as they sometimes do, both to placate the frightening sexualizing object and to assuage their guilt over the effects of their behavior), they generally do not enjoy it erotically.
In addition to these interacting processes of repression and sexualization, people with hysterical personalities may use regression. When insecure, fearful of rejection, or faced with a challenge that stimulates unconscious fear, they may become helpless and childlike in an attempt to fend off trouble by disarming potential rejecters and abusers. Like anyone in a state of high anxiety (cf. the “Stockholm syndrome” or the “Patty Hearst phenomenon,” terms for situations in which captive people become trusting toward their abductors or persecutors), people with hysterical tendencies may be quite suggestible. In the high-functioning range they can be charming when operating regressively; in the borderline and psychotic ranges histrionic clients may become physically ill, clingily dependent, whiny and demanding, or addicted to crisis. The regressive aspect of hysterical dynamics was once so common in some female subcultures that playing dumb, giggling girlishly, and gushing over big, strong men were seen as normal. The 19th-century equivalent was the swoon.
Acting out in hysterical people is often counterphobic: They approach what they unconsciously fear. Behaving seductively when they dread sex is only one example; they may also exhibit themselves when they are unconsciously ashamed of their bodies, make themselves the center of attention when they are feeling inferior to others, throw themselves into acts of bravery and heroism when they are unconsciously frightened of aggression, and provoke authorities when they are intimidated by their power. The depiction of histrionic personality disorder in DSM-IV (American Psychiatric Association, 1994) emphasizes the acting-out aspects of hysterical character to the exclusion of other equally important features. While counterphobic enactments are clearly the most striking of the purely behavioral phenomena associated with hysteria—and they are certainly the ones that get people’s attention—the meaning of these behaviors is also important to the diagnosis. The most pressing internal characteristic of the hysterical style is anxiety.
Because hysterically structured people have a surfeit of unconscious anxiety, guilt, and shame, and because they may be temperamentally intense and subject to overstimulation, they are easily overwhelmed. Experiences that are manageable for others may be traumatic to hysterical people. Consequently, they may use dissociative mechanisms to reduce the amount of affectively charged information that they must deal with all at once. Examples include the phenomenon that 19th-century French psychiatrists labeled la belle indifférence, a strange minimization of the gravity of a situation or symptom; fausse reconnaissance, the conviction of remembering something that did not happen; pseudologia fantastica, the tendency to tell patent untruths while seeming, at least during the telling, to believe them; fugue states; body memories of traumatic events not recalled cognitively; dissociated behaviors such as binge eating or hysterical rages, and so forth. There is considerable overlap between hysterical and dissociative personality structures; many contemporary writers view histrionic psychology as a version of dissociative psychology.
One of my patients, a highly successful professional woman in her 60s who had devoted a large portion of her career to educating people about safe sex, found herself during a conference going to bed with a man to whom she was not particularly attracted (“He wanted it, and somehow that felt like the final word”). It did not occur to her to ask him to use a condom. She dissociated both her capacity to say no and her awareness of the negative consequences of unprotected sex. The sources of her dissociation included a seductive, narcissistic father and unremitting childhood messages to the effect that the needs of the other person always come first.
RELATIONAL PATTERNS IN HYSTERICAL PSYCHOLOGY
In the backgrounds of heterosexual people of a hysterical bent, one often finds events and attitudes that assigned differential power and value to the different sexes. Common hysterogenic situations include families in which a little girl is painfully aware that one or both parents greatly favor her brother(s), or where she senses she was supposed to have been a boy. (Sometimes she is accurate; sometimes she erroneously deduces this theory from data such as her being the third of three daughters.) Or a young girl may notice that her father and the male members of the family have much more power than her mother, herself, and her sisters.
When positive attention is given to this child, it involves superficial, external attributes, such as her appearance, or nonthreatening, infantile ones such as her innocence and niceness. When negative attention is given to her brothers, their putative inadequacies are equated with femininity (“You throw like a girl!” or “You’re not acting like someone who wears the pants in the family”). As she gets older and matures physically, she notices that her father pulls away from her and seems uncomfortable with her developing sexuality. She feels deeply rejected on the basis of her gender, yet she senses that femininity has a strange power over men (Celani, 1976; Chodoff, 1978, 1982).
It has often been observed (e.g., Easser & Lesser, 1965; Herman, 1981; Slipp, 1977) that the fathers of histrionic women were both frightening and seductive. Men may easily underestimate how intimidating they are to their young female children; male bodies, faces, and voices are harsher than those of either little girls or mothers, and they take some getting used to. A father who is angry seems particularly formidable, perhaps especially to a sensitive female child. If a man engages in tantrums, harsh criticism, erratic behavior, or sexual violation, he may be terrifying. A doting father who also intimidates his little girl creates a kind of approach–avoidance conflict; he is an exciting but feared object. If he seems to dominate his wife, as in a patriarchal family, the effect is magnified. His daughter will learn that people of her own gender are less valued, especially once the days of delectable girlhood are gone, and that people of her father’s gender must be approached with calculation. Mueller and Aniskiewitz (1986) emphasize the combination of maternal inadequacy and paternal narcissism in the etiology of hysterical personality:
Whether the mother is resigned to a weak, ineffectual role or is threatened by the child and reacts competitively, the basic issue remains one of not having achieved a mature mutuality. . . . Similarly, whether the father’s adequacy conflicts are expressed through a brittle, pseudomasculine exterior or directly in warm, sexual, or collusive ways with the daughter, he . . . reveals his own immaturity. . . . Despite variations in the manifest traits of the fathers, the common latent personality trends reflect a phallic–oedipal orientation. The fathers are self-centered and possessive, and view relationships as extensions of themselves. (pp. 15–17)
Thus, a frequent source of hysterical personality structure is the sense that one’s sexual identity is problematic. Some little boys reared in matriarchies where their masculinity is denigrated (e.g., with scornful contrasts to hypothetical “real” men) develop in a hysterical direction, despite the advantages the larger culture has traditionally conferred on males. There is an identifiable subgroup of gay men who meet DSM-IV criteria for histrionic personality, about whom such family dynamics have been reported (e.g., Friedman, 1988). The greater frequency of hysteria in females seems to me to be explicable by two facts: (1) men have more power than women in the larger culture, and no child fails to notice this; and (2) men do less of the primary care for infants, and their relative absence makes them more exciting, idealizable, and “other” than women.
The outcome of an upbringing that magnifies simplistic gender stereotypes (men are powerful but narcissistic and dangerous; women are soft and warm but weak and helpless) is for a woman thus reared to seek security and self-esteem from attaching herself to males she sees as particularly powerful. She may use her sexuality to do this and then find she has no satisfactory sexual response to physical involvement with such a person. She may also, because his power scares her, seek to evoke the more tender side of a male partner and then unconsciously devalue him for being less of a man (i.e., soft, feminine, weak). Some hysterically organized people, male as well as female, thus go through repetitive cycles of gender-specific overvaluation and devaluation, where power is sexualized but sexual satisfaction is curiously absent or ephemeral.
THE HYSTERICAL SELF
The hysterical sense of self is that of a small, fearful, defective child coping as well as can be expected in a world dominated by powerful and alien others. Although people with hysterical personalities may come across as controlling and manipulative, their subjective state of mind is quite the opposite. Manipulations carried out by individuals with hysterical structure are, in marked contrast to the maneuvering of psychopathic people, secondary to their quest for safety and acceptance. Their orchestration of others involves efforts to achieve an island of security in a frightening world, to stabilize self-esteem, to master frightening possibilities by initiating them, to express unconscious hostility, or some combination of these motives (Bollas, 1999). They do not seek pleasure from “getting over on” others.
For example, one of my patients, a graduate student in theater arts, a young woman who had grown up with a loving but capriciously explosive father, used to become infatuated with one after another man in authority and would knock herself out to be the favorite student of each. She would approach all her male teachers and coaches with subtle flattery and an attitude of awestruck discipleship, a demeanor she rationalized as going with the territory of being an acting student at the mercy of arbitrary men. Her seductiveness was hard for some of her mentors to ignore. When she began getting signals that they were attracted to her, she reacted with excitement (at feeling powerful and valued), exhilaration (at feeling attractive and desired), fear (of their translating their attraction into sexual demands), and guilt (for exerting her will over them and winning their forbidden erotic interest). Her manipulativeness was limited to men, and men in authority at that, and although powerfully driven, it was full of conflict.
Self-esteem in histrionic people is often dependent on their repetitively achieving the sense that they have as much status and power as the people they fear (those of the other gender or, in the case of hysterically structured gay individuals, those of their own gender who are seen as powerful). Attachment to an idealized object—especially being seen with one—may create a kind of “derived” self-esteem (Ferenczi, 1913): “This powerful person is part of me.” The psychology of groupies who idealize artists or politicians has this feel. Sexual acting out may be fueled by the unconscious fantasy that to be penetrated by a powerful man is somehow to capture his strength.
Another way hysterically structured people attain self-esteem is through rescue operations. Via reversal, they may care for their internal frightened child by helping children at risk. Or they may handle their fear of authorities counterphobically and set out to change or heal present-day substitutes for a frightening–exciting childhood object. The phenomenon of sweet, warm, loving females falling in love with predatory, destructive males in the hope of “saving” them is bewildering but familiar to many parents, teachers, and friends of hysterical young women.
In the dream imagery of hysterical men and women one often finds symbols that represent possession of a secret uterus or penis, respectively. Hysterically organized women tend to see any power they have in their natural aggressiveness as representing their “masculine” side rather than as integrated with their gender identity. The inability to feel power in womanhood gives them an insoluble and self-perpetuating problem. As one of my clients put it, “When I feel strong, I feel like a man, not a strong woman.” This kind of thinking—that maleness equates with activity and femaleness with passivity, and that an assertive woman is thus exercising her “masculine” side, or a tender man his “femininity”—was rife throughout the late 19th century and assumed in numerous psychoanalytic theories (e.g., Jung’s [1954] archetypes of the animus and anima). Contemporary psychoanalytic gender theory (e.g., Dyess & Dean, 2000) challenges this essentialistic, reductive thinking, but in the unconscious, such images may retain great psychic force.
The perception that one’s erotic objects, as a class, have the power can lead to depressive reactions to aging in people with hysterical personality structure. Because heterosexual women with hysterical dynamics feel that the only potency in femaleness is sexual attractiveness, they may be overinvested in how they look and subject to a greater-than-average dread of aging. Gay men who struggle with unconscious hysterical beliefs that they are insignificant and weak when not desired by the powerful may suffer similarly. The tragicomic quality of the older hysterical woman was captured in the character of Blanche duBois in A Streetcar Named Desire. The pain of the aging gay man is striking in the character of Gustav von Ashenbach in Thomas Mann’s Death in Venice. Any hysterically inclined client needs to be encouraged to develop other areas besides attractiveness in which self-esteem may be sought and realized.
The tendency toward vanity and seductiveness in histrionic people, although constituting a narcissistic defense in that these attitudes function to achieve and maintain self-esteem, differs from behaviorally similar processes in individuals whose basic personality is narcissistic. Hysterically structured people are not internally empty and indifferent; they charm people not because they crave any attention that fills a void but because they fear intrusion, exploitation, and rejection. When these anxieties are not aroused, they are genuinely warm and caring. In healthier hysterical people, the loving aspects of the personality are conspicuously in conflict with the defensive and sometimes destructive ones. The aspiring actress I described previously was painfully and guiltily aware of her complex effect on the men she worked so hard to beguile, and despite being able to dissociate the feeling most of the time, she felt guilt toward their wives.
The attention-seeking behavior of histrionic people has the unconscious meaning of attaining reassurance that they are acceptable—in particular that their gendered body is appreciated, in contrast to their childhood experiences. Hysterically organized individuals tend to feel unconsciously castrated; by showing off their bodies they may be converting a passive sense of physical inferiority into an active feeling of power in physicality. Their exhibitionism is thus counterdepressive.
Similar considerations illuminate the “shallow affect” associated with hysteria. It is true that when histrionic people express feelings, there is often a dramatized, inauthentic, exaggerated quality to what they say. This does not mean that they do not “really” have the emotions to which they are giving voice. Their superficiality and apparent playacting derive from their having extreme anxiety over what will happen if they have the temerity to express themselves to someone they see as powerful. Having been infantilized and devalued, they do not anticipate respectful attention to their feelings. They magnify them to get past their anxiety and convince themselves and others of their right to self-expression; simultaneously, by conveying that they are not really serious, they preserve their option to retract or minimize what they are saying if it should turn out that this is another unsafe place to express oneself. Announcements such as “I was SOOOO furious!”, accompanied by theatrically rolling eyes, invite others to see the emotion as not really there or as trivial. It is there, but it is drenched in conflict.
Bromberg (1996, p. 223) makes the quip, attributing an earlier version of it to R. D. Laing (1962, p. 34), that a hysteric “is someone who goes through life pretending to be who he really is.” Behind the wit here, there is a deeply empathic sensibility, in which the dilemma of the hysterical person is framed as the “tragic inability to convince others of the authenticity of his or her own subjective experience” (p. 224). In a therapeutic atmosphere of scrupulous respect, the histrionic person will eventually feel sufficiently heard to become able to describe anger and other feelings in a credible, direct way, and to augment a reactive, impressionistic style with a proactive, analytic one.
TRANSFERENCE AND COUNTERTRANSFERENCE
WITH HYSTERICAL PATIENTS
Transference was originally discovered with clients whose complaints were in the hysterical realm, and it is no accident that it became so visible there. Freud’s whole conception of hysteria revolved around the observation that what is not consciously remembered remains active in the unconscious realm, finding expression in symptoms, enactments, and reexperiences of early scenarios. The present is misunderstood as containing the perceived dangers and insults of the past, partly because the hysterical person is too anxious to let contradictory information in.
In addition to these factors, histrionic people are strongly object related and emotionally expressive. They are more likely than other individuals to talk about their reactions to people in general and to the therapist in particular. Given the dynamics described above, the reader can probably see how the combination of a heterosexual female hysterical patient and a male therapist would immediately evoke the client’s central conflicts. Freud (1925a) was initially quite exasperated to find that while he was trying to put himself across to his histrionic patients as a benevolent physician, they insisted on seeing him as a provocative male presence, with whom they would suffer, struggle, and sometimes fall in love.
Because hysterical personality is a psychology in which gender-related issues may dominate the patient’s way of seeing the world, the nature of the initial transferences may differ as a function of the sex of both client and therapist. With male practitioners, heterosexual female clients with hysterical dynamics may be excited, intimidated, and defensively seductive. With female therapists, they are often subtly hostile and competitive. With both, they may seem somewhat childlike. The transferences of male hysterical patients will vary depending on whether their internal cosmology assigns greater power to maternal or paternal figures. Most hysterical clients are cooperative and appreciative of the therapist’s interest, but borderline and psychotic-level hysteroid people are difficult to treat because they act out so destructively and feel so menaced by the treatment relationship (Lazare, 1971).
Even high-functioning hysterical clients, however, can have transferences of such intensity that they feel almost psychotic. Hot transferences are unnerving to both therapist and client. They can be addressed effectively by tactful investigation and by scrupulous observance of professional boundaries. Therapists who are secure in their role will find such reactions, as Freud did, not an obstacle to treatment but rather the means through which it heals, as clients learn to tolerate their complexly determined desire in a safe environment. When histrionic patients are too afraid to admit to such passionate responses in the presence of the therapist, they may act out with objects who are transparent substitutes. A supervisee of mine named James began seeing a hysterical young woman whose father had alternated between traumatic intrusiveness and rejection; she had sequential affairs with men named Jim, Jamie, and Jay within the first several months of her treatment.
Occasionally the transference of a person with hysterical dynamics becomes painfully intense before he or she has sufficient trust in the therapist to bear that intensity. Especially in the early months, histrionic clients may flee treatment, sometimes with rationalizations and sometimes with awareness that it is the strength of their attraction, or fear, or hatred—and the anxiety that it evokes—that is driving them away. Even though the frightening reactions may coexist with warm feelings, they can be too upsetting to tolerate. I have worked with several women who became so upset by the hostility and devaluation they found themselves feeling in my presence that they could not keep coming to me. Similarly, several of my male colleagues have been fired by histrionic clients who became too obsessed with winning their therapist’s love to benefit from therapy. In these cases, especially if the transference is somewhat ego alien, a change of therapists to someone who seems less like the original overstimulating or devalued object may work out well.
Countertransference with hysterical clients may include both defensive distancing and infantilization. The therapeutic dyad in which these potentials are most problematic is that of the male therapist, especially if his personality is at all narcissistic, and the female client. It can be hard to attend respectfully to what feels like pseudoaffect in histrionic clients; the self-dramatizing quality of these anxious patients invites ridicule. Most hysterically organized people are highly sensitive to interpersonal cues, however, and an attitude of patronizing amusement will be very injurious to them, even if they manage to keep the therapist’s disrespect out of their awareness.
Before it was politically incorrect to talk openly and ego-syntonically about one’s misogyny, it was common to hear (male) psychiatric residents condoling with each other man-to-man about their exasperating histrionic patients. “I’ve got this wacko hysteric—she bursts into tears every time I frown. And today she comes in with a skirt that barely reaches her thighs!” Female professionals within range of such conversations would exchange pained expressions and give silent thanks—or prayers—that they were not in treatment with someone who could talk like this about a person he hoped to help. One still hears this kind of conversation about borderline patients, and given that the DSM depiction of BPD emphasizes hysteroid features, the power of this devaluing countertransference remains impressive. It is arguable, in fact, that even though “hysteria” has disappeared as a disease entity, we have seen the return of the repressed in the contemporary concept of BPD (Bollas, 1999).
Related to this more condescending and hostile reaction is the temptation to treat the histrionic woman like a little girl. As a major weapon in the hysterical arsenal, regression is to be expected. Still, it is surprising how many clinicians accept the hysterical invitation to act out omnipotence. The appeal of playing “Big Daddy” to a helpless, grateful young thing is evidently quite strong. I have known otherwise disciplined practitioners who, when treating a hysterically organized woman, could not contain their impulse to give her reassurance, consolation, advice, or praise, despite the fact that the subtext in all these messages is that she is too weak to figure things out on her own, or to develop the capacity to give herself her own reassurance or comfort. Because regression in most histrionic people is defensive—that is, it protects them from fear and guilt that accompany adult responsibility—it should not be confused with genuine helplessness. Being afraid and being incompetent are not the same thing. The problem with being too indulgent and commiserative with a hysterical person, even if that stance lacks any hostile condescension, is that the client’s diminished self-concept will be reinforced. An attitude of parental solicitude is as much of an insult as one of scorn for the patient’s “manipulativeness.”
Finally, I should mention countertransference temptations to respond to seductiveness in hysterical clients. As has been repeatedly demonstrated in studies of the sexual abuse of clients (see Celenza, 2007; Gabbard & Lester, 2002; Gutheil & Brodsky, 2008; Pope, Tabachnick, & Keith-Spiegel, 1987), this is a greater danger to male than to female therapists. Women treating hysterical patients, even highly seductive males, are protected by internalized social conventions that make the dyad of dependent male–authoritative female harder to erotize. Cultural acceptance of the phenomenon of the older or more powerful man’s attraction to the younger or more needy woman, in contrast, which has psychodynamic roots in male fears of female engulfment that are assuaged by this paradigm, leaves men much more vulnerable to sexual temptation in their therapeutic role.
The implications of theory and the lessons of practice emphatically confirm that sexual acting out with patients has disastrous effects (Celenza, 2007; Gabbard & Lester, 2002; Gutheil & Brodsky, 2008; Pope, 1987; Smith, 1984). What hysterical clients need, as opposed to what they may feel they need when their core conflicts are activated in treatment, is the experience of having and giving voice to powerful desires that are not exploited by the object of those desires. Trying and failing to seduce someone is profoundly transformative to histrionic people, because—often for the first time in their lives—they learn that someone they depend on will put their welfare above the opportunity to use them, and that the direct exertion of their autonomy is more effective than defensive, sexualized distortions of it.
THERAPEUTIC IMPLICATIONS OF THE DIAGNOSIS
OF HYSTERICAL PERSONALITY
Standard psychoanalytic treatment was invented for people with hysterical personality structure, and it is still the treatment of choice with healthier clients in this group. By standard treatment, I mean that the therapist is relatively quiet and nondirective, addresses process more than content, deals with defenses rather than what is being defended against, and limits interpretation mostly to addressing resistances as they appear in the transference. As David Allen (1977) notes:
Hysterical patients make contact immediately, and it is a reparative contact they seek. . . . For the beginning therapist, such patients give the clearest and most accessible evidence of transference. . . . The crux of the treatment of the hysterical personality is the transference. If we give wrong interpretations, we can correct them in the light of later information. If we miss opportunities to interpret, they will occur again and again. But if we mishandle the transference, the treatment is in trouble. Mishandling of the transference or failing to establish a therapeutic alliance is almost the only vital mistake, and it is exceedingly difficult to repair. (p. 291)
One must first develop rapport and spell out the responsibilities of both parties to the therapy contract—a swift and easy process with higher-functioning hysterical clients because of their basic relatedness. Then, by a nonintrusive but warm demeanor, along with a judicious avoidance of self-disclosure, the therapist allows the transference to flourish. Once the patient’s issues surface in the treatment relationship, the therapist can tactfully address feelings, fantasies, frustrations, wishes, and fears as they appear directly in the consulting room. It is critical that the therapist allow the hysterical client to come to his or her own understandings. A rush to interpret will only intimidate someone with hysterical sensibilities, reminding the patient once again of the superior power and insight of others. Comments with any trace of the attitude “I know you better than you know yourself” may, in the imagery that often dominates the internal representational world of the hysterical person, feel castrating or penetrating to the client. Raising gentle questions, remarking casually when the patient seems stuck, and continually bringing him or her back to what is being felt, and how that is understood, comprise the main features of effective technique.
With neurotic-level hysterical people, the therapist may have the experience of sitting back and watching the patient make him- or herself well. It is important to rein in one’s narcissistic needs to be valued for making a contribution; the best contribution one can make to a histrionic person is confidence in the client’s capacity to figure things out and make responsible adult decisions. One should attend not only to the elicitation of feelings but to the integration of thinking and feeling. D. W. Allen (1977) observes:
An essential part of craftsmanship in therapy is to communicate within the cognitive style of the patient with full respect for the patient’s feelings and values. The hysterical thinking style is not inferior as far as it goes, but the hysterical style needs the complementary advantages of detailed, linear “left-hemisphere thinking” as well. In a sense, the hysteric does need to learn how to think and what to connect in thinking, just as the obsessive compulsive needs to learn how to feel and what to connect in feeling. (p. 324)
More disturbed hysterical clients require much more active and educative work. In the first interview, besides tolerating and naming their crippling anxiety, one should predict any temptations that may imperil the treatment. For example: “I know that right now you are determined to work these problems out in therapy. But we can see that in your life so far when your anxiety has gotten too high, you have escaped into an exciting love affair [or gotten sick, or gone into a rage and left—whatever is the pattern]. That is likely to happen here, too. Do you think you can stick with our work over the long haul?”
Lower-functioning hysterical clients should be told to expect powerful and negative reactions to the therapist and urged to come in and talk about them. In general, approaches that apply to borderline patients across the typological spectrum are useful with more disturbed hysterical people, with special attention to their transference reactions.
DIFFERENTIAL DIAGNOSIS
The main conditions with which hysterical personality organization can be confused, on the basis of its surface characteristics, are psychopathy and narcissism. In addition, some imprecision exists, as it did in Freud’s day, between the diagnoses of hysterical and dissociative psychology. Finally, also as in the time of Freud and earlier, individuals with undiagnosed physiological conditions may be misunderstood as having a hysterical personality disorder.
Hysterical versus Psychopathic Personality
Many writers, over many decades (e.g., Chodoff, 1982; Cloninger & Guze, 1970; Kraepelin, 1915; Lilienfield, Van Valkenburg, Larntz & Akiskal, 1986; Meloy, 1988; Rosanoff, 1938; Vaillant, 1975), have noted connections between psychopathy and hysteria. Anecdotal evidence suggests that there is an affinity between the two psychologies; specifically, some histrionic women, especially in the borderline range, are attracted to psychopathic men. Meloy (1988) mentions the familiar phenomenon of the convicted murderer who gets inundated with letters from female sympathizers looking to come to his defense and/or to become his lover.
Qualities seen as hysterical in women are often construed as psychopathic in men. A study by Richard Warner (1978), in which a fictional case vignette was given to mental health professionals, found that identical descriptions of sensational, flirtatious, excitable behavior attributed to either a man or a woman yielded assessments of antisocial or hysterical personality, respectively, depending on the gender of the patient portrayed. Warner concluded that hysteria and psychopathy are essentially the same. And yet every experienced clinician has seen at least a few women who were unquestionably psychopathic rather than hysterical characterologically, even if they had some hysterical symptoms, and a few men who were clearly histrionic and not antisocial. If these categories were just gendered versions of the same psychology, that would not be so. (Also, Warner’s vignettes featured behaviors that make differential diagnosis difficult.) A more reasonable view of his findings is that because of the greater frequency of psychopathy in men and of hysteria in women, most of his diagnosticians engaged in the research task with an explanatory “set” that was not sufficiently counteracted to change their expectancies.
Confusion of hysteria with psychopathy is likelier toward the more disturbed end of the hysterical continuum. In the borderline and psychotic ranges, many people have aspects of both psychologies. But a determination of which dynamic predominates is valuable to the formation of an alliance and to the ultimate success of therapy. Hysterical individuals are intensely anaclitic, conflicted, and frightened, and a therapeutic relationship with them depends on the clinician’s appreciation of their fear. Psychopathic people equate fear with weakness, resonate to self-definition themes over anaclitic onces, and disdain therapists who mirror their trepidation. Hysterical and antisocial people both behave dramatically, but the defensive theatricality of the histrionic person is absent in psychopathy. Demonstrating one’s power as a therapist will engage a psychopathic person positively yet will intimidate or infantilize a hysterical client.
Hysterical versus Narcissistic Personality
As I have noted, hysterical people use narcissistic defenses. Both hysterical and narcissistic individuals have basic self-esteem defects, deep shame, and compensatory needs for attention and reassurance; both idealize and devalue. But the sources of these similarities differ. First, for the hysterical person, self-esteem problems are usually related to gender identification or to particular conflicts, while with narcissistic people they are diffuse. Second, people who are hysterically organized are basically warm and caring; their exploitive qualities arise only when their core dilemmas and fears are activated. Third, hysterical people idealize and devalue in specific, often gender-related ways; their idealization frequently has its origins in counterphobia (“This wonderful man would not hurt me”), and their devaluation has a reactive, aggressive quality. In contrast, narcissistic people habitually rank all others in terms of better and worse, without the press of powerful, object-directed affects. Kernberg (1982) has commented on how a hysterical and a narcissistic woman may both have unsatisfactory intimate relationships, but the former tends to pick bad objects whom she has counterphobically idealized, while the latter picks adequate objects whom she then devalues.
Implications of this differential for treatment are substantial, though too complex to cover except with the overall observation that basically hysterical people do well with traditional analytic treatment, whereas narcissistic ones need therapeutic efforts adapted to the primacy of their efforts to maintain self-cohesion and a positively valued self-concept.
Hysterical versus Dissociative Conditions
Hysterical and dissociative psychologies are closely related and are viewed by many contemporary scholars as variations on the same traumatic theme. Because it is more common for a dissociative person to be presumed to be hysterical than vice versa, I discuss the distinctions between these two conditions, and the metapsychological problems of classification related to dissociative dynamics, in the next chapter.
Hysterical versus Physiological Conditions
Although it is much less common now than in the heyday of American pop Freudianism to attribute any baffling physical symptom to unconscious conflict, a final word should be said about not overlooking the possibility of physical origins of mysterious ailments. Symptoms of some systemic illnesses—multiple sclerosis, for example—are frequently assumed to be of hysterical origin, as are many “female complaints” that frustrate physicians. In England in the 1990s there was an outbreak of what was widely diagnosed as “gardener’s hysteria” in members of a group of horticulturists who had visited the United States; eventually it was discovered that they had gathered examples of American fall foliage on the trip, including a lot of brilliantly red poison ivy. More consequentially, George Gershwin probably would have lived well beyond 38 if his therapist had not interpreted the symptoms of his brain tumor as psychogenic rather than organic.
Because histrionic people regress when they are anxious, and have off-putting, self-dramatizing ways of expressing their complaints, a physical illness in a person with hysterical tendencies is in jeopardy of not being thoroughly investigated. It is more than simply medically prudent to pursue the possibility of an organic problem in a histrionic person; it also sends a therapeutic message to a scared human being whose basic dignity has not always been respected.
SUMMARY
I have described hysterical personality in the context of evolving psychoanalytic conceptualizations that include aspects of drive (intense and affectionate basic temperament, with oral and oedipal struggles aggravated by gender-related disappointments), ego (impressionistic cognitive style; defenses of repression, sexualization, regression, acting out, dissociation), object relations (inadequate parenting that includes narcissistic and seductive messages, replicated in later relationships dominated by the repetition compulsion), and self (self-image as small, defective, and endangered, and self-esteem burdened by conflicts over sexualized expressions of power).
I described transference and countertransference experiences as including strong, competitive, and erotized reactions, depending on the sexual orientation and gender of client and therapist, as well as regressive trends that invite contempt or infantilization rather than respect. I addressed the value of working through erotic transferences and stressed the destructiveness of therapist sexualization. I recommended a treatment style characterized by the careful maintenance of professional boundaries, a warm and empathic attitude, and an economy of interpretation guided by traditional psychoanalytic technique. I contrasted hysterical character with psychopathic, narcissistic, and dissociative personality, and offered a final caveat about investigating possible physiological causes of presumptively hysterical symptoms.
SUGGESTIONS FOR FURTHER READING
For a sympathetic understanding of hysterical personality, I am partial to Mardi Horowitz’s (1991) edited volume and also to the work of Mueller and Aniskiewitz (1986), whose tone lacks the condescension so common in male therapists’ writing on hysteria. D. Shapiro’s (1965) essay on the hysterical cognitive style is thorough and still timely.
For readers interested in hysterical neurosis as the emblematic mental illness of the late 19th century (perhaps comparable to depression in our current era), Scull’s (2009) mordant “biography” of hysteria is fascinating. Veith’s (1965) history from ancient to modern times is illuminating and entertaining. For those who enjoy thoughtful and passionate feminist scholarship I recommend Juliet Mitchell’s (2001) plea that we resume attending to hysteria (contra to those who have regarded it as a constructed and bygone cultural phenomenon) and Storms in Her Head by Muriel Dimen and Adrienne Harris (2001). Bromberg’s chapter on “Hysteria, Dissociation, and Cure” in Standing in the Spaces (1996) is a gracefully written, incisive commentary on Freudian and post-Freudian formulations, that foregrounds the relational context of healing for people with hysterical issues.