Review: Suzanne O'Sullivan, It's All in Your Head

This is another book picked up by chance in Waterstone's and a most unusual one too. It's quite easy to find books which narrate the case histories of patients seen by private psychotherapists (Stephen Grosz's The Examined Life is a recent example, reviewed on this site 3 February 2014) or, in the case of Adam Phillips, by a former NHS child psychologist. But this book is by a consultant neurologist with a special interest in epilepsy who in the course of her work (both NHS and, I assume, private) encounters patients whose symptoms have no identifiable organic base and are thus, sooner or later, classified as psychological in origin.

The symptoms are major and disabling - seizures, convulsions, paralysis, blindness. They are symptoms which have led to ambulances being called, A and E working flat out, consultants being telephoned, provisional diagnoses and medication being prescribed - and to no avail. 

For the most part, they are symptoms which if not organically caused, would once have been assigned to the category of hysteria. Dr O'Sullivan devotes some pages to the history of hysteria within modern clinical medicine, starting with Charcot and Janet and continuing to Breuer and Freud. But - perhaps on editorial advice - she gives no bibliographic references at all, not even a Further Reading list. This is a pity since part of the interest of this book lies in the fact that it is written from the perspective of a neurologist with an orthodox medical training and wide experience of conventional clinical practice in Ireland and the UK. It thus gives an unusual insight into what hospital neurologists nowadays know and think about psychosomatic or psychogenic disorders.

But the book uses case histories rather than theoretical argument or research review to guide our understanding. One of the first things to strike me about these case histories was the prominent position of the patient's parents, partners and other carers. Of course, if you are confined to a wheelchair you are going to have carers. But the carers are often present in the kinds of unhelpful way which R D Laing and A Esterson flagged up many years ago now in Sanity, Madness and the Family: the carers present themselves as authoritative in regard to the medical history and current feelings of the patient. They also have strong views on what will count as an acceptable diagnosis. O'Sullivan does not really engage with the facts she extensively reports and the patient is always referred as an individual to a psychiatrist and never everyone involved to family or marital therapy.

She frequently makes the point that the psychogenic illnesses she encounters are found in people who often have no conscious awareness of being anxious, depressed or stressed and who indeed often enough proclaim themselves happy and worry-free. You could say, this is why they have ended up in A and E rather than in the armchair of a private psychotherapist. At one point she remarks, "Perhaps those who deny stress do so because they do not feel stress, having converted it to something else" (p 243) - that "something else" being a somatic symptom. But this is not an incidental "Perhaps" feature. It seems to be the heart of the matter - the patients she is seeing suffer from conversion disorders in which the body expresses (in a terrifying manner) what the conscious mind, the tongue cannot.

This is a very interesting, quite brave book. It is consistently humane, even towards the occasional malingerer who makes it all the way to the neurologist's telemetry suite - in the final chapter, there is a charming, warm portrait of just such a person. We know a lot about the world of those who can be articulate on the analyst's couch, much less about those whose body takes the brunt of their illness.

Review: Stephen Grosz, The Examined Life

Stephen Grosz begins this book by telling us that for twenty five years he has worked as a psychoanalyst, spending more than 50,000 hours with patients. I calculated:  that's 2000 hours a year which implies 40 hours a week, 50 weeks of the year. He's working too hard.

He has lots of stories to tell and each of the thirty plus short chapters is a well-crafted vignette of encounters with patients, mostly in private practice in London and making use of the traditional Freudian couch. The text is double spaced which means you turn pages quickly and finish in a few hours.

All the stories are readable and some - especially those which deal with serious illness and dying - are moving.

I think that broadly Freudian psychoanalytic theory is the best of the bunch, despite attempts by some of its adherents to make of it a cult (their own) rather than the theoretical basis of a regime of treatment. Many of the criticisms are misguided. In particular, critics fail to realise that all theories are undetermined by data - another theory will always fit the same data - which does not mean that theories are useless or that none are better than others. The weak point in Freudianism is not the theory but whether a curative therapeutic practice can be founded on it - on that, there is reason to doubt.

One of the most challenging stories in the book (pp 158 - 165) concerns a young boy (seen in a public health service context) who eventually puts it to the analyst that his brain doesn't work - not like other people's - and says that it's sad. And all the analyst can do is agree, "Yes, it is really, really sad" (page 165)

For me, the strong point in Freudianism has always been the theory of dreams and the possibility which arises from that of using them diagnostically and therapeutically. So illiterate have we become that some people think that Freud's dream theory is a theory of dream symbols when it starts out, quite explicitly,  to demolish the dream symbol approach and replace it with one which argues that meaning is created in a context - and that the key context for a dream is the events of the recent past (in the strictest theory, the previous day). So you do not look up a Symbol in a Dream Book which tells you what it Stands For - no, you lead your patient back to the recent past and link the Unicorn in the dream to some event,some conversation, some book recently read and work from that link.

As you read Grosz's vignettes, you see him constantly probing for a context not only for dreams but for all symptoms and odd behaviours. Only when you find their context do they begin to yield up their meaning. In particular, he looks for a context where something otherwise bizarre makes sense as a way of achieving satisfaction or avoiding a feared outcome or as indirect acknowledgment of something known but not acknowledged.