When Dora came to see me for a second analysis

Orstein, P. H. (2005). When “Dora” came to see me for a second analysis. Psychoanalytic
Inquiry, 25 (1).

Paul H. Ornstein, MD, author, is Professor Emeritus of Psychiatry and Psychoanalysis,

University of Cincinnati College of Medicine; Training and Supervising Analyst, Cincinnati
Psychoanalytic Institute.; 60 Longwood Avenue, #509 Brookline, MA 02446

In this essay, I imagine what Dora's second analysis would have been like had she come to see
me many years after her first analysis with Freud. To contextualize Dora's “second” experience
(aided by my knowledge of Freud's analysis and his ideas about the nature of Dora's problems),
I picture what she would have presented to me and how my understanding of her selfobject
transference would have guided me in listening to her subjective experience. Dora's manifold
fears of rejection and the many ways in which these now reappeared in the transference guided
the interpretive process. But the traumatic experience occasioned by the fact that Freud
essentially dismissed her desperate efforts to gain acceptance for her version of what happened
between her and Herr K at the lake seemed to have been put to rest. Having been listened to
engaged Dora emotionally in this second analysis and appreciably eased her current difficulties.

FREUD'S 1905 REPORT OF DORA'S ANALYSIS—MORE THAN ANY OTHER of his

famous clinical histories—has fascinated me ever since my days in psychoanalytic training. I
have read all the case histories with several generations of residents in psychiatry and candidates
in psychoanalytic training. Each reading gave me new bits of understanding of the problems as
well as the treatment processes of each of Freud's patients—which is why I never tired of
reading them with each new group of residents and candidates. My fascination with Dora's
analysis has never ceased. A few years ago, when I finally set down in writing what I had
learned from Dora over the years and surveyed what had been written about her in English (P.
H. Ornstein, 1993), I thought I had “finished with her,” but this was not to be. That Freud did
not understand Dora but only “explained” her—and his explanations did not satisfy Dora and
have not satisfied many generations of psychoanalysts—has sustained my interest in her
analytic experience to this day. In addition, after completing my essay, I had so many unused
ideas left over in my notebook that needing to write another essay seemed compelling even if
not urgent.

The invitation to contribute an essay to this issue of Psychoanalytic Inquiry made writing
suddenly “urgent.” A gentle reminder about the deadline, coming when I did not yet have a
frame and a structure for my further exploration of Dora's treatment process, left me unusually
anxious. That night, to allay my anxiety, I imagined that Dora came to see me for a second
analysis.

My First Encounter with Dora

Dora was referred to me for an assessment of her current condition by her internist, because of
the intensification of a number of her psychosomatic and conversionsymptoms and because of
the deepening of her chronic but frequently “masked” depression. It was only because she was
desperate—as she herself told me—that she had been able to overcome her reluctance to accept
the referral to a psychoanalyst. She hated all doctors, but psychoanalysts were first on her list—
she said that with a bitter smile and looked straight at me. I merely replied that I understood.

“Oh, so you know my case, then? Well, I expected that.” She seemed proud for having so
quickly established her fame with me, but she also worried (and I had a chance later to confirm
my hunch) that I probably had fully accepted Freud's prejudiced views of her, and perhaps even
Deutsch's (1957), and that she therefore had no chance at an impartial hearing with any
psychoanalyst.

Accepting that her reluctance to see me was well founded,1 I responded to her questioning me
directly about my views of Freud's view of her case. I said,

I am thoroughly familiar with your analytic experience. All psychoanalysts, including me,
have been influenced by the brilliance with which Freud tracked down the meaning of your
symptoms through carefully assembling your history and the interpretation of your dreams.
However, quite a few important issues still puzzle me. Yours was a short analysis, conducted
during the early phase of the development of psychoanalysis. Neither you nor Freud was
satisfied with the therapeutic results, and you yourself complained bitterly about Freud's
approach. In the meantime … psychoanalysis too has had a chance to develop, and we can now
take a new look at your current problems and distressing life experiences.

Dora was glad to hear that psychoanalysis had progressed, and she wanted to know what
important issues continued to puzzle me. I sensed that she wanted to engage me in an
intellectual give-and-take, to see where I stood. Was I up to the task, and could I really take a
fresh look at her current state of mind and understand her past life from her perspective? Most
important, could all of that still be of benefit to her, in her mid-50s, when it never really did
much good before?

It is here that Dora touched on my own anticipatory anxieties. Who could match Freud's
brilliance? Could I be of use to her even without that? Could I engage her in an exploratory
process at least, to see whether she would be willing to undertake psychoanalysis? I consoled
myself by remembering the old saying, “On the shoulders of giants, even dwarfs can see
farther,” and realizing I had a new theory that could help me. So I said, without repudiating her
efforts as “mere” intellectualizations,2

Much could be said about Freud's views and mine ahead of time, and you would certainly be
the best person to discuss these issues with, but I want to safeguard your chances for an
impartial hearing—if that is still possible—by starting not with Freud's or my views, but with
yours. Freud's and mine will inevitably come up at every turn.

Dora seemed pleased but a bit suspicious. She did not directly say that she could not expect me
to be unbiased, but, instead, “After all this suffering, I do not know whether I could really give
myself and you a second chance.”

I had my first opportunity to acknowledge interpretively the almost insurmountable difficulties

that stood in our way to engage her (and me) in this analytic process. I said,
 Your disappointing first experience with Freud would rightfully make it difficult for you to
turn to me. But when you returned to him 15 months later (and were more ready for help), you
must have felt brusquely rejected. And, many years later, though Felix Deutsch helped you with
your attacks of anxiety and somatic symptoms, after two sessions you must have felt abruptly
dismissed by him too. So, how can we expect that you will now dare to reach out and feel
welcomed by me?”

My statement opened up an avalanche of responses indicative of some beginning engagement.

Dora said that she was both disappointed and enraged at Freud, and perhaps even revengeful.

But he was so brilliant and so accurate in many of his interpretations of my dreams. He even
reconstructed childhood events that I had completely forgotten. In so many other ways, though,
he did not understand me. I often accused him of not even listening to me. He was incorrectly
overinterpreting my revengefulness. Can you see that?

Without waiting for a response, she continued,

Before I left, he said he forgave me for not having given him a chance to complete his work
with me. Well, as a second thought, he also included me, that I did not give myself a chance. I
could have kicked all those ancient Egyptian figurines off his desk and smashed them to
smithereens. Couldn't he think of me first for a change? I left in a huff, but I learned a few years
later that he took that to mean I was revengeful even then and really did not want his help when
I returned to see him. Well, he was dead wrong there—can you see my point? he also included
me, that I did not give myself a chance. I could have kicked all those ancient Egyptian figurines
off his desk and smashed them to smithereens. Couldn't he think of me first for a change? I left
in a huff, but I learned a few years later that he took that to mean I was revengeful even then
and really did not want his help when I returned to see him. Well, he was dead wrong there—
can you see my point?

She looked me straight in the eye. Again, without waiting for a response, she began talking
again, this time about the two sessions she had with Deutsch 22 years later. Dora felt that
Deutsch had astutely connected her psychogenic ear troubles with her difficulties with her
son—which was of immediate help symptomatically. Her Ménière's syndrome disappeared
before her second session with him. However, she felt that Deutsch did not like her as a person
and therefore did not offer her substantive analytic help. With remarkable self-awareness, she
reflected on their encounter, “I may have been obnoxious with my contempt for doctors and
with my incessant complaining, but he should have seen through it. Well, nobody ever does—
they don't believe I amsuffering, and they even accuse me of doing it to myself.”

She turned to me with a more direct and forceful challenge: “What makes you think you can
help me?”3 But now she waited for a response, and I knew I could not evade giving one even if I
wanted to. She had an uncanny ability to quickly “push my buttons,” but I was prepared to
contain my therapeutic optimism and tone down my response. “I don't know if I can help you or
not, but I am prepared to let you and me have a chance and find out.” I offered her as many
appointments as she needed to decide if she could work with me.

On her way out, Dora remarked that she just noticed my Hungarian accent. She knew some
analysts from Budapest, and Austrian and Hungarian analysts from the days of the Empire had
much in common. (Did this signal a good prognosis? A bad prognosis? I did not know
immediately.4 ) Then, still somewhat guardedly but with a bit of visible relief, she accepted the
next appointment.

During the ensuing three or four sessions, Dora slowly and cautiously, and with constant
scrutiny of my responses, detailed her current psychosomatic symptoms, which included an
almost intractable constipation, a vaginal discharge, and recurrence of her Ménière's
syndrome—all leftovers from earlier times but recently exacerbated. She talked of her
depression and social withdrawal, chronic fatigue, and lack of ability to concentrate. From
these, she turned to a prolonged tirade against her husband and only son, both of whom she
considered unfaithful to her. She talked of her chronic dissatisfaction with both of them and of
feeling ignored and neglected by them.

She told me that she was so disappointed and enraged with men when she left the analysis with
Freud that she did not think marriage was in the cards for her. Yet, a year or so after her single
follow-up session with Freud, she married a young and promising composer, who never really
made it. She now depicted him as a Schlemiehl—certainly in contrast to her brother Otto, who
was extremely brilliant and famous and whom she adored. Otto, with whatever attention he
showered on her and the concern he could so concretely express in action, was the only person
who could almost always get Dora out of her depression and social withdrawal.

I noticed that, on the surface, Dora paid careful attention to whether my knowledge of her past
history was accurate, as if she expected me to know the “Dora case” verbatim, but on a deeper
level she watched to see if I could be trusted to be on her side. She needed to know that I had
indeed heard her—to be heard became a key issue throughout the analysis—and would not
introduce my own hidden or not so hidden agenda, as Freud had done. When I inadvertently did
so with some remark, she was quick to call it to my attention. In turn, she constantly expected
me to question, confront, and challenge her regarding her own version of her story, as Freud had
done.

Generally, I had no great trouble in this regard, as all of Freud's critics in the literature (and my
own clinical experience by then) had alerted me to the fact that it was Freud's own version of
the truth and his blatant disregard of hers that had driven Dora away from analysis.

In any event, I saw my task with Dora essentially as follows. I was to try to discern her self-
experience in whatever shape, form, or content she expressed it; translate the meaning of her
experiences whenever she seemed unaware of some aspects of them; and reflect repeatedly what
I heard her say and how I understood her. I wanted her to know how I listened and what I
thought about what I heard. I made statements tentatively in order to give Dora ample
opportunity to correct me or to elaborate on what I had said if or whenever I came close to her
subjective experience. I did not see my role and function in confronting her or challenging the
truth or the reality of her statements. Rather, my role and function crystallized in my attempts to
grasp her subjective (intrapsychic) reality and put it into words—with the idea that, if I could
successfully do so, she would progressively tell me more, on her own, without my confronting
or persuading her or trying to “outsmart” her and catch her in contradictions. (Freud had taken
that approach with her, and it had been unsuccessful.)
Let me illustrate. During a session, Dora complained that her days were empty and
uninteresting—she had not read a book in months; her husband was preoccupied and withdrawn
from her; her son was frequently out partying, which always made her curious regarding his
affairs; and she could not settle down to anything constructive the previous few weeks. In her
restlessness, she cleaned the kitchen even though it did not need cleaning, vacuumed the carpet
even though it was not dusty, and even drove her husband out of his study so that should clean it
in a great fury—all without relieving her anxiety and despair.

“No wonder,” I said after a while. “Feeling like an uncultivated Hausfrau, and a foolish one at
that, robbed you of your ability to read and to enjoy occupying your mind.”

Indicating some awareness of her identification, she smiled and said, “Okay, so you do
remember what Freud said about my mother. I am horrified that I become just like my mother at
times. She drove us crazy with her compulsive and foolish cleanliness. She cared more for the
house, the furniture, than for us, Otto, me, and my father.”

I said something rather insignificant in response (something I can no longer remember). Dora's
eyes lit up a bit, and she remarked that Otto used to say the same thing to her and that it had
always made her feel better.5 A few minutes later, at the end of the session, she said that she'd
like to try another analysis. On leaving the office, she commented on “how beautifully my plant
was growing.”6

I need only add to these initial impressions and trial interventions that Dora's flirtatiousness, on
which Deutsch remarked, was largely absent during these sessions—perhaps because of her
depression, but also perhaps because what Deutsch had called flirtatiousness seemed to me an
effort on Dora's part to engage me and to evoke some visible response to herself as a person. In
viewing her behavior exclusively as sexually seductive, Deutsch had misunderstood her main
message and ultimately rejected her reaching out to him for an emotional connection, for
acceptance and validation. As our period of exploration was coming to a close and Dora's
depression was lifting to a small degree, she began wearing more stylish cloths and shorter
skirts. During a few sessions, after I was quiet for a time, she withdrew from me, pulled her legs
up in her chair, curled up a bit, and casually played with her purse. On these occasions, her
thighs were exposed somewhat, but at this point her actions seemed more like protective
withdrawal than flirtatious exhibitionism.

The Psychoanalytic Process

As I wanted to give Dora extra time to decide if she wanted a second analysis with me, I
described the extended exploration under a separate heading. In reality, the psychoanalytic
process begins with the very first encounter. Separating the initial exploration is done only
because of the analyst's way of reporting, whereas the entire analytic experience is of one cloth
for both patient and analyst.

When Dora lay down on the couch, the climate in the office changed almost instantaneously.
Dora was uncomfortable and anxious. She felt a great distance between us and missed the visual
contact. She later said that she needed to hear my tone of voice to register the content of what I
said, because she could not tell by my facial expression if I could be trusted. Not watching me
left her feeling unsure, confused, and, ultimately, very much alone. She counted on my talking a
lot, which she knew would not happen. After a while, she began filling the silence with
reminiscences and complaints to avoid the excruciating pain deriving from her fear that I did not
care about her and most likely found her as obnoxious as Deutsch had—but I wanted to treat a
famous patient, and that is why I offered Dora an analysis.

Dora's feeling betrayed and used by everybody she loved now included her husband and only
son.7 All of this was most painful, and Dora sounded as if she could not get beyond recounting
past hurts. For some time, she complained with great fury and deprecating remarks of not
making any progress and of my not understanding anything beyond Freud's ideas about her
problems. At one point, when I was particularly stymied in responding to her complaints and
had been quiet for some time, I noticed that Dora was playing with her purse, opening it and
closing it and rummaging in it with her fingers. Freud, on a similar occasion, confronted Dora
with the fact (sic) that this action was a symbolic reenactment of masturbation, and he viewed it
as one of the causes of Dora's hysteria.

I said to Dora, “Although you had been silent, nevertheless I felt that you were talking to me as
you were playing with your purse.” She said reflectively, “I just noticed it myself. Freud used to
comment on it. But why would it happen now? You never talked to me about masturbation?”

“But I was silent,” I said, “and you felt I was distant, inattentive, and uncaring. All you could do
is withdraw from me and play with yourself. Masturbation seems to have been one of your ways
to try to stir some feelings in your body, not to feel the pain of loneliness and isolation.” I
remembered one of Freud's statements. He could carefully tuck away an observation like mine
and then “use it against Dora” at the appropriate moment. In other words, he did not analyze
what the masturbation itself was all about, what function or purpose it served. His theory did not
allow for that.

Dora instantly recalled the memory she had described for Freud—of being a young child sitting
on a floor, in a corner, sucking her left thumb, and tugging with her right hand at the lobe of her
brother's ear as he sat quietly beside her.

In response to her ensuing associations about sexual matters—her lifelong frigidity, her refusal
to have intercourse with her husband, her insatiable curiosity as to what her son did on his
dates—I told her repeatedly and in various ways that I understood her masturbation not so much
as a search for forbidden sexual pleasure (she never reported pleasurable excitement with it) but
as a soothing, calming, or self-stimulating activity that did not require anyone else. She could do
it whenever she wanted to—she herself controlled it.

“No,” she said, “sometimes it controlled me. It had become a compulsion.”

After these exchanges, I finally had a better understanding of the meaning of Dora's prolonged
and repetitious recounting of past hurts and her not being able to get beyond them. This was her
way now of not letting herself revive old wishes, fantasies, and needs in relation to me. I was
then able to offer her a tentative explanation of the meaning of her experience on the couch—
her needing to recount the past so that she could both forestall experiencing it and hopefully
find a way to resolve it here with me. These were conflicting feelings she has been struggling
with for some time.
She interrupted me and said,

You are right, but the other day I did experience them. I didn't tell you how accurate your
observation was. I did feel miles away from you, back in that little corner of our house, where I
sucked my thumb or masturbated. I was ashamed to tell you that, when you talked about my
purse, I was actually thinking about masturbation. I wanted it to be pleasurable, but it wasn't. I
am frigid even when I do it myself. Is that possible?8

This exchange—an indication of increasing trust—may well have been a turning point in the
analysis. Externally, Dora soon looked more at ease. She dressed more carefully, was less
neglectful of her personal appearance, wore makeup, and seemed less depressed. Internally, and
in relation to me, she was less vigilant and guarded. She also became freer in speaking to me
and seemed more self-reflective. Although at first I was hard put to pinpoint a deepening of the
analytic engagement, I soon noted that I could do no wrong in her eyes, say nothing wrong, and
she clung to every word I said. The content of her reminiscences began sounding different. She
talked with admiration of her brother Otto and her father of earlier years, whom she then had
loved dearly. She recalled many of the joyful occasions involving Mr. K, whom she knew as a
friend of her family, and his attentiveness to her. She spoke little of her mother, and what she
said was not complimentary—she despised her.

During this period, many of Dora's overt symptoms abated. They recurred only during or after
vacations, unplanned cancellations, or when I was inadvertently confronting her, being critical
of her, or missing the subtleties of her subjective experience of “blissful excitement.” She
dressed up more elegantly, you might say seductively, for her sessions. I had a hunch that my
calling attention to this seductiveness and her now mutedly but more likely “flirtatious”
behavior would have been a serious mistake, until their meaning and purpose could be better
understood and interpreted entirely from within Dora's vantage point, from the perspective of
her self-experience and not mine. What would have been gained by simply pointing them out, if
one could not tentatively offer a meaning to get Dora's assent or disagreement?

Now I describe a dramatic exchange that ultimately contributed to an understanding of a

significant part of Dora's basic problems and to reanalysis of her relation to Mr. K and her father
(and later to Mrs. K and her mother).

One day I left my office key at home and had to keep using the doorknob to lock and unlock the
consulting room door as patients entered and left. My thought was to make sure that no one
could unexpectedly open the door from the outside while a session was in progress. When Dora
entered the room, she saw me lock the door. She said nothing at first. She breathed deeply—her
old breathing difficulty (dyspnea) seemed to recur—and she moved about anxiously on the
couch, as if she wanted to run. Finally, she burst out crying. She did not know why, but she
thought of getting off the couch, hitting me across the face, and running home.

I said, “Just like you did to Mr. K at the lake.” She was taken aback. She had not yet made the
connection, but my comment calmed her and made her reflective. She said,

Why would I want to do that to you? You didn't try to seduce me. [Brief silence] Ach, Du
Lieber Gott, now I know. I saw you lock the door—I barely noticed it. [Silence] Here we go
again. I trusted you, and now you are going to make a pass at me. I didn't really think that—I
am only putting into words what I now recognize I must have felt. Freud would say that I
wanted to seduce you, but I disowned that wish and attributed it to you. It must be right, but I
did n't feel it.… Freud would say that is how the unconscious works—it splits off the affect. You
have the thoughts, but without the affect you can pass it off as foolishness. He would pick up
every clue, and he would finally corner me. I had no other evidence, except my own feelings,
and he seemed to discount them when they didn't fit in with his ideas. He never listened to me.
He only listened to his own inner voice. You know the funny part, or the tragic part for me, is
that his ideas were also correct in many ways, but he didn't take into consideration some
important feelings of mine. He brushed them aside. You never seem to do that or …
mostlynever!

And she laughed.

Exchanges like these, around greater or lesser disruptions of Dora's idealized view of me,
occurred frequently and necessitated interpretive repair. At such times, Dora's suspiciousness
(or, at other times, her flirtatiousness and seductiveness) increased as manifestations of these
disruptions and required careful attention. These disruptions occurred when I was silent for
longer than usual or when Dora feared I did not like her. These disruptions, and their
interpretive repair, allowed us to understand more about Dora's vulnerabilities (e.g., her fear of
my not being interested in her or my not liking her). These experiences also led us to
reconstruct, in the ensuing period, that Dora adored the Ks, both husband and wife. This
expression was of her longing for a set of parents more desirable than her own. For Dora, the
Ks' turning against her had been excruciatingly painful. She had taken care of their two children
the way she would have liked to have been taken care of by her own parents and now by the Ks.
She had turned from her father to Mr. K, who at first had been a more reliable, more
consistently adoring father-substitute—he had been attentive and caring and had showered her
with gifts—in relation to whom she could perhaps grow up and become a woman. When sexual
thoughts entered her mind, which they unquestionably did, they were subordinated to a need for
reliable, idealized parents—parents she had never really had. Early actualization of these sexual
or sexualized wishes would have seriously thwarted her development. Sensing this, Dora
realized that all of Mr. K's attempts to seduce her, nobly motivated as these might have been in
his own mind (and in Freud's!), were disappointingly self-serving—a betrayal of her trust. She
had felt used by Mr. K just because, as he said, he “got nothing from his wife.”

Dora: In one respect, Freud was right—I did summon something from my relation to my father
(that I put in my own and Mr. K's way). I didn't quite know what Freud meant. But this
“something” was not what I thought about sex. The disgust I felt was at Mr. K's proposal, not at
sexuality per se, as Freud had thought. Can you see that?

PHO: Yes, I can. Your disgust was at the man who was about to destroy the experience you
needed to grow up and get away from the household in which no one (except your brother)
could be counted on to be decent, truthful, strong, loving, caring, and responsive to your
needs—as you have told me so many times.

Dora: Freud expected me to respond as a mature woman as early as age 14—but certainly later,
at 18, when Mr. K proposed to me at the lake. Freud wanted me to accept what he interpreted as
a serious marriage proposal, and I took it that Freud wanted meto go to bed with Mr. K.
Doyouseehow monstrous that was?
PHO: Yes, Mr. K was still a married man then.… I hear you say that you felt painfully
misunderstood by everyone, including Freud, and that your feelings were discounted. And now
we know that it is only in a nonsexual, nonsexualized relation to the father that little girls can
grow up and away from family ties and seek a loving, sexual partner outside the

family—and you are telling me it was not sex that you were seeking then. Am I right?

Dora: Yes, that is it—but Freud never believed me.

Dora had not been able to meet Freud's expectation that she should have responded to Mr. K's
sexual advances. For Freud, that was the starting point for his viewing Dora's responses to Mr.
K as that of a “hysteric.” Dora had known this and resented it deeply, and she resented it even
today. Despite that resentment, somewhere in her was a lingering admiration for Freud and his
brilliance. But how could Freud have insisted on interpreting her behavior and her dreams as
reflecting repressed sexual wishes that interfered with her “normal” sexual responses to Mr. K?
The most painful part of her analysis with Freud was that he did not believe her version of the
incident at the lake. To add to this insult, her parents did not believe her either. Dora was
particularly distressed that her father did not believe her because of selfish reasons of his own—
we wanted to continue his affair with Mrs. K. The up-until-then beloved Ks not only denied the
entire incident, but they maligned Dora with the accusation that it was all a fantasy on her part.
To justify their accusation, they referred to Dora's eagerly reading about sexual matters in
Mantegazza's Physiology of Love whenever she was at their home.

At some point, we concluded that Dora's “analytically inflicted trauma” was that everyone, even
her analyst, did not believe her. Throughout her work with Freud, she had struggled vehemently
but unsuccessfully against this trauma. The interval between walking out on him and returning
15 months later—wanting to continue but being rebuffed—shows how central the issue of
wanting to be believed (and thereby rehabilitated) was for her. She succeeded in having the Ks
acknowledge the validity of her version of the events at the lake. Having obtained that desired
validation, she felt vindicated and ready for further work with Freud, but she also wanted to
show him that she had accomplished what she had so desperately wanted him to help her with.

I was then able to say, “I view your entire experience with Freud as your struggle to get him to
believe you. When you returned to him, you proudly presented that even the Ks acknowledged
that you were right about the incident at the lake.” Dora interjected, “Especially that my rebuffs
of Mr. K's sexual advances were justified.” She vigorously assented to my characterization of
her experience with Freud and said, “If he had done what you are doing, if he had listened and
believed me, all my resistance, as he called it, would have melted away, and I would have
stayed with him for more work.”

These last few exchanges indicated to me that Dora was now ready for further analytic work—
after she consolidated her well-deserved triumph and could feel that I trusted her and listened to
her.

Working Through and Termination

All this visible progress not with standing, again and again the working-through brought back
(as it usually does) the core issues of Dora's current life experiences and their transference
manifestations in many different configurations. In one form or another, these issues had to do
with whether hertruth was accepted or not, whether she was trusted or not, whether she was
paid close attention to or disregarded and neglected. The recurring themes also included Dora's
concern that I would insist on the validity of my own ideas, my own judgments about her as a
person, rather than focus on exploring her deeply anchored fear of not mattering to anyone—her
husband, her son, and now her analyst. On Dora's return, Freud did not affirm her belated
triumph; he did not accept it, and he did not revise his earlier emphasis on elucidating the
infantile sources of her hysteria to instead appreciating her immediate predicament.

I shall not recount in detail this period of our analytic work together. I shall only summarize it
around one significant dream Dora presented at the time we contemplated termination.

One day, Dora came early for her session and saw another woman patient leave my office. She
said nothing about her during that session, but the next day she remarked how beautiful the
patient was, and she spoke about a friendly exchange between my secretary and the patient.
Then she remained silent for a while. I asked, “Is there anything more you are struggling to say
or not to say about this?” “Yes,” she said hesitantly, “I did not want to say that I imagined you
liking her more than me. And your secretary too—she never spoke to me in such a friendly
way.” I replied, “What made you not want to tell this to me?” Dora said, “I was embarrassed. I
am ashamed that I am still worried that you don't like me. It still haunts me after all this time
that you may find me obnoxious!” Before I had a chance to say anything, she continued, “I just
remembered, I had a dream last night that disturbed me. No wonder I almost forgot to tell you
about it.” Dora reported her dream:

I had a late-afternoon or evening appointment. There was a strange silence in the building.
The waiting room was empty, and your secretary was gone. The patient I saw yesterday came
out of your office—she was surprised to see me here—and quickly tried to straighten her blouse
and tuck it inside her skirt. I was frightened when I entered your office and didn't want to lie
down on the couch. At that moment, I woke up anxious and breathless.

By now, Dora needed no prodding to begin to interpret her dream.

Dora: My feeling in the dream was eerily foreboding. Why did I dream that I came here in the
afternoon or evening, your last appointment? On the surface, it's a sexual dream. Did I want you
to seduce me, as I pictured you had done with that beautiful woman? Did I put her in my place
in the dream? Was I frightened to enter the office and lie down on the couch because of what I
wanted?

PHO: What are your own answers to all those questions?

Dora: Freud always said that where there is a fear there is a wish. Did I wish to be seduced by
you?

PHO: The phrase you actually used stuck in my mind. You said, “On the surface, it's a sexual
dream.” What did you mean?”

Dora: [Thinking for a while] There must be something more deeply hidden, even less acceptable
to me than my sexual wishes for you—which I am not even aware of and certainly do not feel.
PHO: Dora, I have an idea, based on all that we have talked about throughout our work
together. I wonder what you think of it. The deeper thought, the deeper wish, might be that I
should like you as much as or even more than the patient you saw walking out of my office.
You emphasized my secretary's friendly exchange with her—a friendliness you had never
experienced with my secretary. Could the sexual seduction,

on the surface, be your way of disguising that wish for appreciation and friendship, because you
said yesterday how embarrassed you were about still needing that reassurance from me at every
turn?

Dora: I feel like crying now and don't know why. [Silence] Well, I do know. I reacted to the fact
that you understood my deeper feelings before I knew what they were, and you let me gropingly
get there myself. You are so careful not to insist on your analytic truth—that would hurt me. It
crippled me when Freud did that. But why wasn't it good enough when the Ks and my parents
finally gave me the satisfaction that I was right all along? Will I ever be rid of that need and not
search for restitution everywhere?

PHO: You will always have these needs—adulthood does not do away with them. Your wish
that your husband and son should be more attentive and caring is quite natural. Your fear of not
being liked and trusted will appear from time to time—hopefully without overwhelming you.
By now you are familiar with these feelings, you know what triggers them, and they seem to be
more under your control than before. Your chance encounter with the other patient brought
these feelings to the surface. But these feelings are always there. You attempted to suppress
them, but your dream brought them to our attention for another opportunity for you to master
them. What do you think of that?

Dora: I wish I could accept my needs and feelings the way you do. But I can't yet.

PHO: Not yet, but this recognition is a part of mastery. We are getting there.

This exchange heralded the termination of Dora's second analysis. She set the date several
weeks hence, and, when she departed, she thanked me for my patience and caring. We both had
tears in our eyes.

Postscript

In a “live analysis,” only after termination can the analyst have a reasonably comprehensive
overview of what patient and analyst experienced. With the analysis still in progress, the analyst
cannot see the forest for the trees. The effort at empathic immersion in the immediate
experience takes precedence so that the patient can feel that the undertaking is his or
heranalysis.9

Before I express my views on what transpired in this “imaginaryanalysis,” I wish to make some
introductory comments to put my method into a clearer perspective for the reader of this
“clinical report.”

For Dora, an external, judgmental, observational stance (e.g., Freud's), even with strict
adherence to neutrality and abstinence (which Freud did not maintain), would merely have
repeated the trauma of her first analysis (see P. H. Ornstein, 2003a). In this imaginaryanalysis,
however, and having dealt with Freud's analysis of Dora extensively before (P. H. Ornstein,
1993), I had a prior vision of how far this reanalysis needed to go and could go in order to
illustrate a new clinical approach and to contrast it with Freud's scientific interest in elucidating
the structure of hysteria. I had a therapeutic interest in analyzing Dora.

I offer some tentative general conclusions about the psychoanalytic process (as I imagined it in
Dora's case) and explicate what “occurred” in our work together. Doing so required an empathic
immersion in what Dora presented, and particularly in the way she experienced me. This
empathic immersion is what guided my interventions. I had to formulate what I had tentatively
understood from within her subjective perspective.

Imaginary though this analysis had to be, the “facts” came from Freud's analysis of Dora—as a
background for what I imagined she would have presented to me for a second analysis later in
life. Added to this were my clinical experiences with other “Dora-like” women and the clinical
perspective I had gained by adopting Kohut's (1971, 1977, 1984) self psychology as my
psychoanalysis(P.H.Ornstein, 2003b). Although Freud (1905) clearly acknowledged that he
focused on elucidating the “internal structure of a case of hysteria” and omitted discussion of
the “technique of analysis” (p. 112), my focus, as already mentioned, was on the therapeutic
process rather than on the putative causes and structure of Dora's “hysteria.” I limited my
interest to what could be understood about Dora's problems from what emerged for us within
the treatment process itself.10 My focus also demanded that I concentrate on and respond mainly
to what had become activated in our relations, as that was what Dora complained about—her
fear of not being liked, trusted, or believed. The past—Dora's old complaints to Freud about her
father, mother, and the Ks and about Freud himself for not believing her—no longer bothered
her. These issues were settled. But what all that experience had done to her self-esteem
remained central, and this is what she presented to me and sought to remedy, along with the
problems that subsequently emerged in her relation with her husband and son.

These preliminary comments permit me now to make the nature of Dora's transferences more
explicit—as their manifestations and the way I addressed them in as simple a language as I
could might have eluded the casual reader. I assume that those familiar with self psychology
have already noticed that Dora's need to be listened to—to be appreciated, trusted, and valued
for her many capabilities—indicated the emergence of a mirror transference, essentially a
validation of her self-experience. This transference remained central throughout the analysis,
but occurred with decreasing insistence and urgency. The need to be admired included Dora's
ability to manage her life reasonably well after her family lost its fortune after World War I. The
same applied to the way she succeeded in surviving during the Nazi occupation of Austria
before her forced emigration—which she described in great detail. She wanted to be seen as a
capable adult under the most stressful circumstances, and she surely was (see Decker, 1991).
Side by side with Dora's mirror transference, her need for an idealized analyst also emerged—
initially very briefly, and then giving way to the more sustained mirror transference. After the
mirror transference was worked through to a reasonable degree, the idealizing transference
reappeared, but it always remained more in the background.

At this point, the reader might wonder what happened to the necessary defenseanalysis. I realize
that the data do not speak for themselves if one brings a very different set of expectations
(theories) to bear on the clinical process. Therefore, I give examples of those moments in which
I dealt with Dora's self-protective (defensive) attitude and behavior(Ornstein, 1991).

I considered Dora's reluctance to enter analysis to be based on her fear of retraumatization,

which was justified by her prior experience. My acceptance diminished her defensiveness and
established an initial sense of trust. Dora often hesitated to put some of her feelings and
thoughts into words; for example, she delayed talking about her experience of having seen a
beautiful woman leave my office. In the course of our dialogue about this, I asked, “Is there
anything more you are struggling to say or not to say about this?” Rather than confronting her
about her withholding, and exhorting her to say it all, my question left her with the decision as
to what she would tell me. This was in keeping with defenseanalysis from a self-psychological
perspective. We recognize that defenses are the patient's best available protections against
retraumatization. This recognition helps to safeguard establishment and maintenance of the
requisite analytic attitude. Rather than confront the patient with his or her defensive behavior,
the analyst interprets the behavior along with its motive. In Dora's case, the motive was fear of
retraumatization.

I conclude by reflecting on what I have learned from Dora during our analytic endeavor. My
experience with her11 contributed to my transformation as a psychoanalyst (see P. H. Ornstein,
2004a). First and foremost, it altered my “technique-centered” approach (inculcated during my
training) into one in which I learned to pay overriding attention to the evolving relations Dora
and I developed with each other. Her needs, as expressed in the transference, turned my external
observer's position decisively into striving to establish and maintain (as much as was possible)
an “empathic immersion” in her experience. Her needs for acceptance, affirmation, and
recognition, as well as her fear that I did not like her, expressed in manifold ways, became the
“read thread” of the core of her analytic experience. This experience brought home to me the
central significance of the process of analysis. This process, which became my most reliable
guide in participating in any analysis, transformed my earlier, technique-centered approach into
a process-centered one (P. H. Ornstein, 2004b).

Thanks to Dora and the “other Doras” in my clinical practice, I was thus able to become,
through the inevitable, ongoing struggles, a more flexible, spontaneous, “human” participant in
the analytic process. The tears in our eyes as we parted attest to the changes she helped bring
about in me as an analyst.

Footnotes

1
Accepting her reluctance did not prevent me from later analyzing that reluctance; in fact,
acceptance enhanced the analysis.

2
Here I deliberately avoided an interpretation of Dora's intellectualizations as her defense.

3
I accepted Dora's challenge in this question rather than point to its presumed hostile
aggression.

4
Her remark turned out to reflect a positive reaction toward me and toward the analysis.
5
Dora's association to her brother Otto again reflected her positive reaction toward our work
together.

6
Dora's remark about my plant was a clear indication of her hopefulness regarding this “second
analysis.”

7
Remarkably, Dora did not speak about female friends. She liked one of her cousins, and she
loved and admired Mrs. K, until she was betrayed by her.

8
The emergence of sexuality, when there is no longer a need to “fight” for recovery of self-
esteem and to be treated with respect and trust, is a sequence frequently observed in any
analysis not conducted with a relentless pursuit of the patient's defensive attitude and behavior.

9
Freud did not give Dora this experience. Her father brought her to Freud with his explicit
desire that she stop insisting he break off his affair with Mrs. K. Dora knew this.

10
This self-imposed limit left me with the question of the relation between the “science” and the
“therapy” in psychoanalysis—which I take up in another paper, “Psychoanalysis: Is the Science
Destroying the Therapy?” (P. H. Ornstein, 2004b; cf. Holzman, 1985).

11
Needless to say, this experience included all my readings about Dora, as well as my 1993
essay, “Did Freud Understand Dora?” in which I claimed he did not.

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Decker , H. S. (1991), Freud, Dora and Vienna1900. New York: Free Press .

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Deutsch , F. (1957), A footnote to Freud's “Fragment of an analysis of a case of hysteria.”
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3
Freud , S. (1905), Fragment of an analysis of a case of hysteria. Standard Edition, 7 : 7-122.
London: Hogarth Press , 1953 . (SE.007.0001A)

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Holtzman , P. S. (1985), Psychoanalysis: Is the therapy destroying the science? J. Amer.
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5
Kohut , H. (1971), The Analysis of the Self. New York: International Universities Press .
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6
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9
Ornstein , P. H. (1993), Did Freud understand Dora? In: Freud's Case Studies—Self
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10
Ornstein , P. H. (2003a), Neutrality and abstinence: Obstacles to psychoanalysis in depth.
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11
Ornstein , P. H. (2003b), Why and how is self psychology my psychoanalysis? Presented at
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12
Ornstein , P. H. (2004a), The elusive concept of the psychoanalytic process. J. Amer.
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13
Ornstein , P. H. (2004b), Psychoanalysis: Is the science destroying the therapy? In
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