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Conversion Disorder: The Human Body is the Best Picture of the Soul

Jamieson Webster writes like a combination of an Exocet missile and a feline feather tease. Webster has previously published on The Life and Death of Psychoanalysis (2012) and with Simon Critchley on Hamlet (Stay Illusion! The Hamlet Doctrine (2014)). Her latest contribution is Conversion Disorder: Listening to the Body in Psychoanalysis (Columbia University Press, 2019, 303 pp. ($33)).

Between Jacques Lacan, Giorgio Agamben, and Michel Foucault, Conversion Disorder is

Cover Art: Conversion Disorder

Cover Art: Conversion Disorder

a challenging read, though the effort will be rewarding for many.  The audience for this book is largely academics engaged by the some version of psychoanalysis, drawing mainly on Lacan and Freud. Much is to be admired in this courageous work, but since this is not a softball review, I have some criticisms, too. Webster has given us a brilliant work, though a deeply flawed one.

After such a significant effort, I am going to have some fun with this one.

Webster exemplifies a kind of postmodern writing that assumes one has read everything and therefore context is not required. Ideas streak through the text like ciphers from the Oracle of Delphi, whereas the statements are just ideas of university graduate level complexity being quoted out of context. Summaries are sometimes provided at the end of arguments, resulting in a benefit to those who decide to read the text backwards. Nothing wrong with that as such, but the approach does seem to be limited to intellectual haunts in Southern Manhattan, The New School For Social Research, the academic suburbs of London, and comparative literature seminars at the more prestigious universities.

With any book on psychoanalysis, the recommendation is to read the Appendix and endnotes first. They are the equivalent of a literary slip of the tongue, a symptomatic action, a parapraxis, revealing the subtext. Reading the book backwards works well in this case.

Webster recognizes that her relationship with her own body is troubled – the work is acknowledged as an attempt at self-help. It takes courage to make oneself vulnerable by this manner of self-disclosure: Diets, Pilates, yoga, purges, mega-purges, and more purges. Within the realm of the fundamental unity of mind and body, psyche and soma, this self-treatment triggers a full-blown appendicitis in the author. Literally. What happened? A powerful demonstration of the inseparability of, yet tension between, psyche and soma?

The final three words of the book (p. 272) assert that the conversion disorder in question is “my conversion disorder” – i.e., Webster’s. The microcosm is the macrocosm. “Conversion” is writ large. Very  large. Many other conversions and conversion disorders are engaged along the way.

Webster asserts that her work has aspects of a memoire, and the reader does eventually get to meet the parents (who had their own struggles to survive) in the last ten pages of the book. However, I was disappointed in that I got no sense of the “good parts” of the memoire – what the author had to survive or how she ended up becoming a psychoanalyst, which is surely a courageous project, and not an undertaking for the faint of heart.

Webster repeatedly calls out psychoanalysis as an “impossible” profession, notwithstanding the paradox that she credibly claims to  practice it. Here Webster walks the semi-sacred ground mapped out by Janet Malcolm in a book of the same name (Psychoanalysis: The Impossible Profession, Alfred Knopf, 1977/1981). Webster might usefully have invoked Janet Malcolm and whether her (Webster’s) contribution is a debunking in the same or a different sense than Malcolm’s.  How about a footnote? This is the sort of thing I would have expected the editor (Wendy Lochner) to catch, but editing is not what it used to be.

Another editorial pet peeve: The words “abjection” and “abject” are used as if they are clear to the reader. Context? Julia Kristeva is not in the references, though she is the one who gave “abjection” currency and a certain popularity. It is not otherwise defined. A criteria: If you do not already know what it means or are prepared to live with this uncertainty of not knowing, then this text is not for you. Once again I would have hoped that the editor would have intervened with guidance: “Please define one’s terms.” Once again, editing is not what is used to be.

Meanwhile, on how psychosomatic physical symptoms – migraines, lower back pain, headaches, which are notoriously difficult to diagnose – get “hijacked” by the emotions and become the source of substantial psychic suffering, there are more recent treatments, including Webster’s, but there is quite simply no better one than Arthur Kleinman’s The Illness Narratives (1988). An engagement with Kleinman will decisively change one’s listening – as, of course, will reading Lacan or being hit in the head with a rolled up newspaper – but Kleinman will also deepen one’s empathy, humanity, and toleration of uncertainty, which the former will not do.

Webster engages with biopolitics (key term: biopolitics) and the institutional dynamics around psychoanalysis. On the professional issues confronting psychoanalysis – and there are many self-inflicted wounds here – Kate Schechter’s The Illusion of a Future (2010) deserves honorable mention and more – and Schechter provides a far superior treatment of psychoanalytic gossip than Webster – very juicy indeed and funny in a satirical sort of way – albeit in the context of the Chicago Institute for Psychoanalysis. While Webster talks a lot about “courage” and she demonstrates much, noticeably absent is any trace of speaking truth to institutional power that might ruffle any feathers in the local establishment. Courage indeed.

My complaint? There is something fake about “I don’t want to be a psychoanalyst” – if one does not, okay, then stop and do something else – practice CBT, DBT, ACT, primal scream therapy (joke!) or take up water colors. At no point does the two ton elephant in the living room get noted – the dirty little secret: most of the psychoanalytic “patients” are behavioral health professionals (graduate students in psychology or psychiatric residents) aspiring to be enrolled in the pyramid. Nothing wrong with that. These good folks need help too. And it is a shame that psychoanalysis has fallen on such hard times as it can get results that no other intervention seems able to produce. But what does one have to do to get a piece of the action – a piece of the objet (petit) a? If one has doubts about the viability of psychoanalysis, this text will do little to dispel them.

Therefore, get ready for – biopolitics!? Webster follows Giorgio Agamben, who, in turn, follows Foucault off the biopolitical cliff into the abyss of – what? The objet (petit) a– we are now speaking French – which, according to Lacan, is not to be translated, the unattainable object, the part object (penis, breast, foot) – perhaps the Kantian thing in itself. Another cipher = x,  that which is being converted in somatoform disorder?

If one wants to bring biopolitics into the vicinity of hysteria, then ditch the Agamben. Take a look at Arthur Miller’s The Crucible, which is a re-telling of the Salem Witch Trials using a lens from the 1950 McCarthy Hearings on House Un-American Activities. Politics and hysteria are front and center. Once the authorities agree to admit spectral evidence – not unlike fake news or alternative facts – including the hysterical utterances of over wrought pubertal girls, then the audience of The Crucible knows things are not going to go well for the adults. If one is going to make a deal with the devil, be sure to read the fine print. The pact with the devil results in a commotion – a literal witch-hunt – and a slaughter of innocents. The emotional anguish and suffering is wide spread and the audience is vicariously traumatized.

Webster has considerable “skin in the game.” Webster is suffering, too, though admittedly not to the degree of John Proctor (protagonist of The Crucible). Webster is engaging with conversion because she has a contribution to make in disentangling the complexities of the phenomena. What really  interests her is how the [counter]transference of hysterical symptoms occurs from patient to analyst (e.g., p. 74). Webster is Exhibit A – and proud of it.

Webster tells the reader as much: “Who would want to make themselves the vessel for so many others in this way? To have them repeat their pain and unlived life in your flesh?” [P. 54.] This is her “day job.” Once again, there is nothing wrong but there is something missing – empathy.

The lack of well-regulated empathy leads to compassion fatigue, burn out, and empathic distress. Apparently it also leads to an appendicitis. Her own appendicitis (see the Appendix) is not a hysterical pregnancy, but then again her patient is confronted with one of those – and see Freud’s comments on Negation. (When the patient says “now that is not my mother,” then strike though the not: not. Who do you think it is?)

The word “empathy” plays no explicit role in the text, though I suggest empathy’s breakdown is the underlying mechanism is many examples of conversion. I am not saying Webster has too much empathy. I am not saying Webster lacks empathy. I am saying: expanding empathy is hard work. Webster is no natural empath, as near as I can see from here, but a committed professional – and a celebrity academic. She is on the path of bearing witness and self-disclosure, but something is off the rails. Webster suffers from a breakdown of empathy specifically in the regulation of empathic receptivity.

Webster “picks up” the patient’s somatization – whether it is mirror neurons, neuropeptides, the adrenal pituitary axis or simple muscle mimicry (which is not so simple). The emotional receptivity breaks down into an individual form of emotional contagion so the therapist suffers too. The educated guess is that, being all-too-human, some unprocessed sex and aggression lurks near by, but mostly unprocessed narcissism, a term conspicuous by its absence.

People seeking dynamic psychotherapy (and its extreme form in psychoanalysis) are suffering. Sometimes after much work and effort and self-overcoming these same people become therapists. All well and good. The process is daunting and not to be made light of. However, Webster is so overwhelmingly taken with the significance of the process that no room remains available to enjoy a lighter moment. In addition to expanded capacity to love and work, Heinz Kohut (dismissed by Webster in the closing pages) pointed out how a successful psychoanalysis of the self may expect to transform frozen narcissism into expanded humor, empathy, and even wisdom. Here the narcissism is ultimately untransformed – and unconverted?

Webster quotes the Diagnostic and Statistical Manual of Mental Disorders, Version 5 (2013), the deeply flawed but consensus-forming, boundary defining “bible” of the behavioral health world. Webster “gets it” that something essential is missing. “Hysteria” in the narrow sense of a signification (representation/symbolization) of an underlying sexual or aggressive content was removed from the manual several editions ago. Yet hysteria in the narrow sense lives on in Webster’s practice, in her transference, and (here is the courageous part) especially in her counter-transference.

In the DSM itself, mental and emotional disorders are described at the level of behavior and constellations of symptoms. It is a check list manifesto (with apologies to Atul Gawande) that enables the therapist (or prescribing psychiatrist) to map symptoms to treatments without having to unmask, go “under the hood,” or seek for hidden causes = x. Ideal for those prescribing psychotropic medications.

While Webster is a strong advocate for a close reading of Freud, this is precisely the area in which she is significantly at risk. The hazard of  Jacque Lacan’s guidance of “getting back to Freud” is that what Lacan really means is “replacing Freud with Lacan.”

In a separate interview, the Webster notes: “When I read him [Lacan], it changes the way I listen.” Of course it does. So does being beaten about the head with a rolled up newspaper (once the ears stop ringing).

My concern? I believe that it is possible for one to read too much Lacan or Foucault – like sniffing too much glue – it does make one high, but after a certain point the consequences are irreversible. [See Webster’s interview with Cassandra Seltman (01/05/2019 https://blog.lareviewofbooks.org/interviews/cost-alone-cassandra-seltman-interviews-jamieson-webster/ )].

For Webster, “conversion” is not restricted to the somatization of psychic or emotional conflict into physical systems that present in a human body. “Conversation” also refers to religious transformation as might have interested William James or Giorgio Agamben or any radical discontinuity in experience that profoundly shifts the experience of the subject in a lasting and sustainable way. So it’s all fair game and whatever comes up, comes up. Quite a lot comes up.

“Conversion” is writ large, as noted, but I suspect most readers will require more guidance than is provided by Webster. For example, a person is under extreme stress. The person develops irritable bowel syndrome, lower back pain, or migraine headaches. That is direct somatization – conversion of the stress into a physical symptom (pain) – depending on whether one has a weak head, intestine, or lower back – depending on whether one has a disposition or microscopic, subclinical injury that is exacerbated by the stress.

Next comes extreme stress resulting in hypochondriasis – now called “illness anxiety” – where the person is not in pain but is literally worried sick, for example, believing the sebaceous cyst in his neck is incurable cancer or the headache means an inoperable brain tumor.

The third form (which is the one Freud engaged with most insightfully) is exemplified as the conversion disorder takes on an unmistakable symbolic expression. The patient’s

Jean Martin Charcot working with a hysterical patient

Jean Martin Charcot (one of Freud’s mentors) working with a hysterical patient

hand is neurasthenic – loses feeling and the patient is unable to control it. The paralysis ends at the wrist, which confirms that the paralysis does not map to standard neural anatomy. The patient’s leg is paralyzed, but in such a way that his paralysis does not map to standard neural anatomy. The patient is asked to free associate and her reflections go in the direction of her shame and conflict over masturbation – with the hand in question.

In a different example, Freud’s patient Frau Emma von N is accused by her late husband’s relatives of poisoning him (an accusation that is fake and self-serving). Emma develops a persisting burning on her face – on her cheek – as if she had been slapped!? Insulted? Trigeminal neuropathy? Freud after all was a neurologist. (Note this is Freud’s example, not Webster’s.) She talks about it with Freud, and it gets better.

For Freud when libido (desire) is directly transformed into bodily symptoms, the result is an “actual neurosis” (better translated as a “contemporary neurosis,” but, in any case, a technical term) – the body directly translates the psychic suffering as physical symptoms – paralysis, cramps, in extreme cases symptoms like epilepsy – except there is no anatomic lesion.

In some cases, these symptoms are painful; in other cases they are just disruptive of daily life – as when the patient loses consciousness. However, for Freud, when libido (desire) is unable to be directly expressed in bodily symptoms due to repression, then the desire (libido) gets expressed in bodily symptoms that enact sexual  representations. Desire finds a way to become articulate, symbolizing forth what it has to express by means of bodily signifiers (i.e., symptoms).

For instance, the patient is conflicted over marrying her brother-in-law (once again Freud’s example, not Webster’s), the husband of her late sister (who has just died). The patient is free to remarry and (a crucial condition) such a thought is abhorrent to the patient. It has no where else to go to be expressed than to be translated into a bodily symbol.

Although I believe Webster gives examples of this third kind, to the best of my knowledge (and I have read every word), no where does she make the point that the symbolism expresses sexual or aggressive or a conflict-inspiring violations of conventional community standards – which is precisely what has fallen out of the latest editions of the DSM.

By the way, Ludwig Wittgenstein, who was a tortured soul for reasons completely unrelated to conversion disorder, wrote: “The human body is the best picture of the human soul” (Philosophical Investigations, 1950, tr E. Anscombe, p. 178e).

Perhaps it is so obvious to Webster that it does not require mentioning; yet unless one is steeped in these matters, this loss in the DSM is of the essence. In short, if one is looking for a book on conversion disorders that does for them what the late Oliver Sacks did for migraines, Tourette’s syndrome, music, or diverse anomalous neurological disorders (a high bar indeed!) that work has yet to be written.

References

American Psychiatric Association. 2013. Diagnostic and Statistical Manual of Mental Disorders. DSM-5, Fifth Edition. Arlington, VA: American Psychiatric Association.

© Lou Agosta, PhD and the Chicago Empathy Project

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