Psychology as we know it would not exist today without Bertha Pappenheim, patient zero of psychoanalysis, yet the contours of her experience are often excluded from the narrative written about her. In the pages of Sigmund Freud and Josef Breuer’s Studies in Hysteria (1895), she remains an enigma, suffering in profound ways from the disease then labeled hysteria while helping develop the method she named “the talking cure.” Just a few decades after her case history was written, her affliction faded from Freud’s interest and, soon after, disappeared from history. But where did hysteria, and those who suffered like Pappenheim, go?
Gabriel Brownstein’s remarkable new book, The Secret Mind of Bertha Pappenheim: The Woman Who Invented Freud’s Talking Cure, restores Pappenheim to the center of her story and situates her within her historical context. Brownstein invites us to consider her life before and after she entered treatment with Breuer. Pappenheim, Freud’s “Anna O,” would go on to become one of the most influential and important feminists in the German-speaking world. The Secret Mind of Bertha Pappenheim invites us to consider her illness and treatment in light of contemporary neurological thinking about what was once termed “hysteria,” “hysterical conversion,” and “conversion disorder.” In the current DSM, conversion disorder is now synonymous with “functional neurological symptom disorder,” or as the doctors who treat it call it, FND. The new scientific attitude has compelled Brownstein to reconsider the old literature. Brownstein, professor of English at St. John’s University and the author of The Open Heart Club, among other works, weaves a sensitive tale of pains both old and modern in tracing the complicated legacy of hysteria through its most famous patient while paying memory to the legacy of his father, who first set him upon the path of examining Freud’s work.
It was my pleasure to speak with Gabriel Brownstein to learn about what had first led him to Bertha Pappenheim, how her story helped him navigate an incredibly difficult season of his own life, and what he hopes readers learn about the experience of those with FND.
Jonathan Foiles (JF): As someone who teaches psychoanalysis, one of the things can be really hard is that so much of the history seems to be just white men. In fact, it’s more complicated, which is one of the reasons I really loved your book: you discuss the issue of class, and that the rise of psychoanalysis corresponds to the rise of modern antisemitism.
Still, Freud’s own work casts only a few glances at Bertha Pappenheim’s story, which your book really gives a chance to breathe. For those who haven’t encountered her before, Pappenheim was a patient of Freud’s colleague Josef Breuer whom he diagnosed and treated for hysteria in the early 1890s. The case was later written up in their jointly authored Studies in Hysteria (1895) and became the source of much of Freud’s early theorizing and, with that, the history of psychoanalysis as a whole.
You write in the book about how this project guided you through some really difficult times in your life. So, what was it like to have Pappenheim as a companion through that?
Gabriel Brownstein (GB): I started the book because of my dad. My dad was a little bit obsessed with Bertha Pappenheim, and he had written an essay about her and Breuer sometime in the 1990s. I had dinner with him right before he died and he gave me this essay. He said it was his masterpiece.
So I really started this book for very personal reasons, to figure out what my dad was interested in.
At first, Pappenheim was very obscure to me. The facts of her life seemed irreconcilable. Here was this helpless young woman, “Anna O,” in Studies in Hysteria, who grows up to be this powerhouse, world-trotting writer, organizer, and social worker, fighting the sex trade. It was impossible to square one with the other. The way Breuer writes about her in Studies in Hysteria, it’s almost impossible to imagine an actual person. He says she lived in “perfect health” after his treatment of her, but the facts are that she spent the decade after treatment addicted to morphine and chloral hydrate, in and out of sanitariums. When she was an adult, running homes for young women in trouble, she—so the story goes—never let any of those women in her care see a psychoanalyst, and she never spoke publicly about her relation with Freud or Breuer. In the psychoanalytic commentary around the case, she’s always presented as a mystery, a puzzle to be solved. There are many answers that are proposed in the psychoanalytic literature. I found these tremendously unsatisfying.
I read some compelling sources. There’s an amazing book by Marion Kaplan about the Jüdischer Frauenbund, the organization that Pappenheim ran. There’s an interesting but flawed biography of Pappenheim that came out around the year 2000, and there’s a very good literary biography of Pappenheim by Elizabeth Loentz. Still, Pappenheim remained very hard to see. It wasn’t always that she was a companion, so much as she was someone that I was trying to see.
She was indomitable, remarkably powerful, constantly a fighter. She’s fascinating.
I came to her story and the story of “Anna O” as a well-trained English major. I believed hysteria was a misogynist myth, a way of warehousing women. I had no idea, starting out, that right now at the most important medical research centers in the country—the NIH, Mayo Clinic, Massachusetts General, Yale, Stanford—there are doctors studying this thing they call FND, and which they argue, in the medical literature, corresponds in many ways to the 19th-century diagnosis of hysteria. When I started reading about FND I was flabbergasted.
The hysterical woman is always seen as absolutely voiceless, powerless, but here’s this person who was diagnosed as hysterical who was anything but.
JF: What vision of Freud did you bring to the project? There’s that wonderfully evocative image in the book of your father burning the standard edition of his works at his house in Vermont.
GB: My dad was obsessed with Freud. A lot of people of his age, of his generation, were obsessed with Freud. But by the time I was a teenager, my father was absolutely hostile to Freud and he talked about it a lot. Out of nowhere, you’d be driving with him and he’d just start yelling about Freud.
I really became interested in the part of Freud that we don’t know much about, Freud before he became Freud. The first third of his life. There’s some really good writing about it, but, like the Pappenheim material, it’s all very shrouded in mystery.
I began to think of Freud as an immigrant kid, as I began to think a lot about Vienna and a lot about Jews coming to Vienna as immigrants. I thought about his poverty, his relation to the German language as an immigrant in whose house they probably spoke Yiddish. A boy from the wrong side of the Danube.
The more I read, the more I imagined Freud as a certain type that I know very well. My mom’s parents were from Poland, I knew a whole generation of intellectuals around my mom who were kids of Jewish immigrants. I went to the Bronx High School of Science, and the kids I went to school with there were largely Asian immigrants, many of them very ambitious.
Freud struck me as a certain kind of really determined, intellectual child of immigrants, who believed he was going to dominate the world by learning something really obscure. And, in fact, Freud did start in a marginal place, and he did conquer the world.
JF: The later Freud can be so confident that it can be hard to grasp the times when he wasn’t. And, of course, he famously burned a lot of early letters and writings; so it takes an even more active reconstruction to figure out what those times might be like before he was, as Auden said, “no more a person now but a whole climate of opinion.”
I found it really fascinating in listening to Pappenheim that you end up investigating Functional Neurological Disorder. I’m wondering what led you to that, because, as a reader and as someone who knows a bit about her case, it feels like a good fit. Still, I’m guessing that’s not a connection a lot of people would make.
GB: I don’t want to diagnose her. I hope the book is clear. It seems like a possible misreading: Brownstein is diagnosing Pappenheim. But she’s dead and I’m not a doctor.
There is an almost endless list of writers who proposed diagnoses for her. This recurrent assumption that Breuer was wrong and another diagnosis must be put forward. In her life, there are these two stories that don’t quite fit together. One story is Breuer and Freud’s story of the young woman who has hysteria. And then there’s the highly competent, highly mobile, highly verbal woman who is this endless creative force. Those two stories don’t really fit together.
Many of the ways proposed to connect these two stories are, to my mind, glib. One way is the Freudian misogynist readings of her life: In this version, her feminism is a symptom of her hysteria—she didn’t like men. Then in the 1980s, there are theorists who propose that the hysteria of the 1880s and ’90s was a form of proto-feminist rebellion. Neither seems like a full explanation to me, a satisfying description of an actual person’s life.
Then I found the new neurological thinking about the medical condition that used to be called “hysteria,” or “hysterical conversion” or “conversion disorder”—writing, which again, doesn’t solve the mystery of Pappenheim’s illness, but helped me imagine her, by imagining her illness as something real, something that’s not necessarily mythic.
Mark Hallett, who is the chief brain researcher at the NIH, really sounded the alarm about medical neglect of the problem in 2006, in a paper that declared that functional disorders and the denial of their actuality as a neurological condition represented a crisis for neurology. (In that essay, Hallett uses the term “psychogenic movement disorders”; he now uses the term “FND.” The terms we use to describe this problem shift constantly.) About the same time, in Britain, the Lancet published a survey and concluded that functional problems were the second most common reason for outpatient neurology visits. Dr. David Perez, the neurologist, psychiatrist, and neuroscientist who runs the busy FND unit at Mass General, will refer directly back to 19th-century neurologists, like Jean-Martin Charcot, who argued that hysteria was caused by “dynamic lesions” in the brain. For Perez, Charcot’s idea of “dynamic lesions” is a prescient way of describing FND. And Charcot, for young Freud, was the great authority on hysteria.
I cannot tell you how shocking this was to me. It’s very challenging for people like me who were taught that hysteria doesn’t exist. The neurologists will no longer use the word “hysteria” to describe a medical condition. That’s pejorative. An epithet. No longer usable. But they will say: If you think the old symptoms of hysteria no longer exist, you’ve never been to my clinic.
Hallet, Perez, and others describe a study of a continuous history of a continuous set of psychoneurological problems: the seizures, the loss of limb use, the loss of voice, the movement of symptoms from part of the body to part to the body, all of these things without an obvious physiological correlate. Symptoms in the body that emerge from problems in the brain. I should say that the terms are not interchangeable. The new terminology comes with increasingly precise diagnostic criteria—you can’t say that everyone diagnosed with “hysteria” had FND.
About two-thirds of the diagnosed patients with FND are women, and this has led some people in the field to argue—kind of turning 20th-century feminist arguments on their head—that the reason neurologists had in the past ignored and denied this problem was precisely because it was a condition suffered primarily by women. If I were going to recommend one neurology article to interested people in the humanities, it would be “Fuctional neurological disorder is a feminist issue.” It’s co-authored by something like 40 women doctors, researchers, and therapists from leading medical centers all over the world.
I’m not saying that FND is the answer to the mystery of Anna O. I’m saying that it is the way contemporary neurology conceives of the problem Freud and Breuer discussed in Studies, and that it gives us a new lens through which to look at this medical mystery central to the history of psychoanalysis.
JF: One of the reasons why something like FND, or hysteria, is so uncomfortable for people is just how much of ordinary experience does not have a physical cause, but is in our minds. Even with something that we know works on an organic level, like antidepressants, we have found that whether or not a patient believes they will work plays a large role in the subjective experience of whether or not they alleviate someone’s symptoms. I’ve certainly seen patients who have tried 10 different medications and are for various reasons invested in none of them working; if you care that much about them not working, chances are they’re not going to.
It’s something about our often very rational society: We’re uncomfortable with these things that seem to threaten the centrality of rationality to what we think it means to be human.
GB: Functional Neurological Disorder challenges many of our basic presumptions about health and illness, about mind and body and autonomy, and because of that, it is really scary.
But the fact is that patients without epilepsy go into seizures. Patients whose legs are physiologically fine can lose the power to walk. And brain scans from the early 2000s indicated that these patients’ brains looked different than the brains of people who were just pretending to be ill.
These patients had been dismissed for decades. I talked with Dr. Kathrin LaFaver, a neurologist who trained at Mayo and the NIH and who ran FND clinics at Northwestern and at Louisville, and she told me how shocking it was for her, at first, to see patients who had been confined to wheelchairs learn, with treatment, how to walk. These doctors are outraged by the idea that “hysteria isn’t real”—the idea that their patients don’t suffer a “real” illness. And when I met them, and met their patients, I began to think, I better listen to these people.
To lose control of your body is a terrifying thought. One of the basic stories we tell ourselves is I am in control of my body; if I am healthy, I will be able to move my hands; I will not fall into a seizure unless I have epilepsy. We need to believe that to get through our day.
You can see a continuous story even in our attempts to name the disorder over the last 150 years. We start with hysteria, which becomes hysterical conversion, and then conversion disorder. In the most recent DSM, FND and conversion disorder are synonymous. And “functional” is an old term. It’s an older term than Charcot or Freud. So we have been going around in circles trying to name this thing.
How weird is that: That large numbers of people have been falling into this continuously and that for most of the second half of the 20th century, there were no doctors to treat these people? We decided it wasn’t “real.”
Today, the Mayo Clinic encourages patients and doctors to think of FND as an ordinary illness, something on the order of a migraine headache. I encountered a number of very intelligent, careful, humane, eminent doctors, who say, Oh yeah, it happens all the time. I see it all the time, and anyone who tells you it doesn’t happen has never been to a neurology outpatient clinic.
That was shocking to me. It’s very challenging to people like me who grew up in the humanities, where we were taught that “hysteria” didn’t exist.
Pappenheim’s recovery happens when she is in a community of people who give her opportunities. She becomes a social worker and a writer because she has an opportunity and an audience. A community in which she fits.
JF: Your book really reminded me of the start of my career, when I was working in the outpatient psychiatry department of a safety net hospital. We would do intakes for new patients, and you would occasionally see patients coming in—who, in retrospect, probably had something like FND—reporting a constellation of unexplainable symptoms. So they would get referred to the hospital, because their doctor either (charitably) didn’t know what to do with them anymore or (maybe less charitably) got fed up with them.
I remember those were some of the most difficult interviews. Because I knew they were there because the doctor thought they were essentially making it all up. Yet, at the same time, I wanted to be present with someone in the midst of that and also to try to get them what they need, given finite resources and limited understanding. It’s an incredibly difficult place for anybody to be in as a patient.
GB: It’s awful! Imagine you are one of these patients. From 1950 to 2000, the neurological consensus was that you were crazy or faking. Get this patient out of my neurology ward! And with the fading out of Freudian psychoanalysis, there was very little psychiatrists could do to address these conditions: there’s no pill that will make the blind see, the lame walk. And in recent years, for patients, the psychoanalytic argument—that deep down, they wanted to have seizures, to be in wheelchairs, to lose their ability to speak—this was not an argument patients could accept. And it’s an implication encoded in the phrase “conversion disorder,” the idea that subconscious feelings are converted into physical symptoms.
The FND doctors whom I talked to—people like Perez and LaFaver—do not claim to have all the answers. But they do take these patients, and their patients’ complaints, very seriously. The name, FND, is a way to take the patients seriously, to remove from the condition centuries of misogyny and stigma.
Patients who have seen these doctors, over and over again, said to me, “The doctor listened to me.” “The doctor talked to me like they would to any other patient.” And this, in and of itself, is enormously helpful. And it reminds me of the Pappenheim-Breuer relationship.
It’s an amazing achievement, Breuer and Pappenheim’s decision to sit down and just talk to each other, the idea of the talking cure, which, you have got to remember, is her phrase. It’s just incredibly humane on Breuer’s part. It was not the way you dealt with patients who had symptoms like Pappenheim’s. Meanwhile, Freud—who always asked the deepest and most important questions—saw what Breuer and Pappenheim had done, and he did not let go of it.
It’s interesting for me to think of that in terms of contemporary FND patients and doctors. Now, there’s a very different talking cure happening. If you tell a patient they have a brain-body disorder, rather than saying they have a psychosomatic problem, you allow the patient in. If you say to the patient, “this isn’t real,” or, “you’re doing this for some reason you can’t admit,” then it’s very hard for a patient to work with that.
You need to give the patient what one neurology paper I read described as “a narrative with healing power.” The FND diagnosis allows a patient to think, I can retrain my brain, I can get control of this tremor, these seizures, this inability to talk, this paralysis. It doesn’t work for everybody, but a lot of people have significant improvement in these treatments.
JF: In some sense, that’s the premise of therapy in general: that by talking through something, and thinking through something, you can change how your brain works. If you don’t have that, what do you have?
GB: I don’t know that Pappenheim had FND, but I included the stories of doctors and patients because it helped me see her condition as real. I wanted the reader to see that this thing just happens to people. She maybe had an ordinary illness. This has not been the dominant view in writing about her or hysteria.
JF: There is also something very modern in Pappenheim’s case. What she was given to treat her actually made her sicker. To me, the resonances with the opioid epidemic seemed really clear: the suffering that she was under was, in part, because of the massive amounts of drugs that she was placed on.
GB: It’s terrible to think that a brilliant, well-meaning doctor could do that to a patient, could prescribe drugs on which she became dependent. I do think Breuer was a brilliant and well-meaning doctor, but under his care, Pappenheim became hooked on these drugs, chloral hydrate and morphine.
One of the most common functional symptoms is pain. I imagine that over the decades a lot of people have been treated for these kinds of symptoms with painkillers. And I imagine the effects aren’t always good.
JF: It seems like the therapy of choice for FND is cognitive behavioral therapy. What do you make of the switch from a more psychoanalytic approach to that?
GB: There’s a lot of different kinds of approaches. If you go to the Mayo Clinic, you get a one-week outpatient training, and then you are sent home to work on it. If you go to Mass General, you get a wide variety of kinds of treatments. One of the things a lot of the doctors kept repeating to me was, there’s no one-size-fits-all treatment for FND.
I do wonder how well we understand functional symptoms at this point—these shifting disabilities that seem not to come from injury to the physical body. There are people who have suffered terrible childhood traumas who carry these things, and doctors will prescribe talk therapy in terms of working through those traumas. The assumption that someone who has a functional symptom has suffered a childhood trauma is being questioned a lot; it’s not a one-to-one correspondence. Patients who have both anxiety disorders and functional symptoms are treated as if these are comorbid conditions, not causal—in other words, you prescribe drugs for anxiety or depression, but you don’t automatically assume that the anxiety causes the tremor or the seizure. The doctors say: Don’t jump to any quick conclusion, in a given patient, about the causes or meaning of FND.
Jon Stone is the doctor in Scotland who really starts taking these FND patients seriously, in the early 2000s. When I interviewed him, he said his thought at the start about his patients was, Why are they being so mean to these people? Neurologists could be quite cruel to these patients, dismissive of them, even ridiculing them.
But yes, FND treatment centers do tend to put an emphasis on cognitive behavioral therapy, often in tandem with physical or occupational therapy. They’re trying multiple cross-disciplinary therapies. Perez is both a psychiatrist and a neurologist and he works on the gap between those disciplines. Bridging the gap is the phrase he likes to use.
JF: And that’s as old as Freud too, the whole debate of psychiatry versus neurology.
GB: There are many interesting problems here. No one claims anything has been solved, and as with any complicated story, we’re left with as many questions as answers. For example, neurologists don’t really have a term for libido. I’m not a sexual reductivist but I wonder: Really, we’re gonna take sex out of the equation entirely? Right now, if you have functional GI disorders you go to a gastroenterologist, and if you have functional movement disorders in your hand, like a tremor, you go to a neurologist. But we do not believe the problem resides either in the hand or in the digestive track. The doctors exploring this problem are very smart people, really humane people, working on a very, very hard problem, a problem that challenges the basic structures of their disciplines.
If we take their point of view on the problem, we can tell patient stories—for me, Pappenheim’s story—in a more humane way. She becomes less of a mystery to be solved and more of an ordinary, complex person.
JF: You really help patients experiencing FND share their stories. Is there something they want people without FND to know about their condition?
GB: That it’s ordinary. I read a paper in a neurology journal detailing story after story of patients being treated incredibly badly. If you have seizures but you don’t have epilepsy and you go to the hospital, there’s a very good chance you’re going to be sent home without any help. They’re going to say to you, it’s all in your head. Or even: You’re faking.
The Freudian idea that they intend to perform their symptoms for the secondary gain of their doctors’ attention can feel very cruel. In the Dora case, Freud describes Dora’s stutter as the result of a repressed desire to perform oral sex on her father. How terrible if you’re the person who comes to the doctor with a stutter and they think, Oh, I know what you want to do. Can you imagine if you came in with a knee injury and somebody said that?
What the FND doctors and patients would want to say is: Could we please set aside the stigma of this? One of the things I wanted to do in telling Pappenheim’s story was to say, look at this miraculous person who suffered, if not the same then a very similar condition, and look how powerful she was. The hysterical woman is always seen as absolutely voiceless, powerless, but here’s this person who was diagnosed as hysterical who was anything but.
JF: I’m glad you brought up the Dora case, because that was on my mind too. It is such a shock to go from reading Studies in Hysteria with Breuer and Pappenheim obviously but other cases in there too that have a similar sensitivity and an aliveness to them that you capture, and then to go from that and just a few years later, the Dora cases happens in 1900 and is finally published in 1905, to something like Dora where Freud does almost anything but listen to her. In the Dora study, a chronicle of his treatment of a young woman named Ida Bauer, Freud continually tries to convince her that on an unconscious level she wants to have a sexual relationship with her father’s friend who, as we would say today, sexually harasses her despite her protestations. It is just a remarkable switch, almost vertigo inducing.
GB: Right, Freud kind of calcifies, over time, into this very ideological position. And that was in part—in the early 20th century—how patients with so-called “hysterical” symptoms were moved from neurology to psychiatry. Then around 1950 Eliot Slater, a British neurologist, says that hysteria does not exist: and that becomes encoded in the way we talk about the illness. That it’s not real. It’s not an actual illness.
Then, in 1990, in 2000, in American hospitals there was very little psychoanalysis or psychoanalytic thinking. That meant that patients who suffered these things were shunted off and away, and had no recourse. People stopped listening to the patients. “Therapeutic nihilism” is the phrase that one of the FND doctors I read used.
I am continuously struck by the humanity of these new FND doctors, their willingness to listen to people who were not being listened to. I’m impressed by how well these doctors have managed to keep their distance from any rigid ideology. That was very striking to me.
Which brings it all back to what seemed to make the biggest difference for Pappenheim in her life. The shift in her life, from sick to healthy, happens when she moves away from Vienna, when she moves with her mother and begins to meet her mother’s relatives in Frankfurt: intellectually, politically active women who go to the same synagogue she does.
The theorists’ idea that the shift happened because of something totally internal to Pappenheim—for the Freudians, her hatred of men; or for 1980s feminists, her willingness to fight the patriarchy—seems inaccurate to me. She may very well have hated men, and she did want to fight the patriarchy. I’m not denying either of those things. But her recovery happens when she is in a community of people who give her opportunities. She becomes a social worker and a writer because she has an opportunity and an audience. A community in which she fits.
JF: Which is what we all ultimately need for our mental health. Certainly there have been various experiments—mostly small and not to scale necessarily—of having people with various forms of mental suffering live in a more regular, communal setting, and the outcomes are just astounding.
If we had more political will or even just personal compassion toward people who suffer in ways that are unknown to us, that would be less rare.
GB: That’s what she tried to do in her house in Neu-Isenburg in Frankfurt. She built a house for young women who had no opportunities, had no home: immigrants, people from communities ravaged by pogroms, people who were very likely to go into sex work because throughout history that is what poor, powerless, dispossessed women are forced into. She believed that if she fed them breakfast, and taught them songs, and taught them to type and to have skills, they would have better lives.
She was wonderfully pragmatic in her work to help these girls and young women. Not theoretical, not Freudian. That’s why my father loved her. She was so central to inventing what would become psychoanalysis, and she really wanted nothing to do with it at all.
JF: Has coming to know her in that way helped you understand that facet of your father?
GB: My father really liked to fight. He had a lot of different jobs, but one of the things he did was he worked at a family clinic at Harlem Hospital Center, and that was very, very difficult work. It was the age of crack, the age of AIDS, and he was the white guy. It was very fraught.
And as he got older, his whiteness became seen as more problematic. It was hard. He really liked the idea of free association, and he was really antidogmatic. The Breuer-Pappenheim relationship struck him as a beautiful one. I don’t know how interested he was in Pappenheim the social worker, Pappenheim the activist.
Ernest Jones says that she’s the one who brought the idea of catharsis to psychoanalysis, and there’s this idea that Jacob Bernays—Martha Freud’s grandfather—wrote an important essay on Aristotle and catharsis, and that essay may have led to Pappenheim thinking about catharsis. This was something my father was really interested in. But that’s a complicated intellectual history on which I don’t really feel I can speak with tremendous authority.
JF: Is there anything else you’d like people to know about the book?
GB: Late in his life, in the 1920s after Breuer was dead, Freud claimed to remember a story Breuer told, a story about a hysterical pregnancy that Anna O. suffered at the end of her treatment. One thing that struck me is there’s no way that Freud wasn’t thinking about the actual, mature, powerful Bertha Pappenheim when he claimed to be struck by that supposed recollection. She was in Vienna on and off throughout the ’20s. She was a public figure. She was his wife’s old friend. He just had to be thinking about her the whole time.
And that that changes the way I think about how these stories get written. Because the story that he made up late in life becomes the official history: One thing that recurs in most books about Freud and Pappenheim is that she has this hysterical pregnancy. Meanwhile, her actual history vanishes, the accomplishments of her actual life fade away.
All these stories get laid on top of her life by Freud by others. I wanted to dig through those stories, and I wanted to try to find her. 
Featured image courtesy of Gabriel Brownstein.