The Interpreter and the Puerto Rican Syndrome
In her first visit to a psychotherapist, upon being asked by her doctor to explain what brings her in, the patient begins to tremble and, with her eyes rolled back into her head, falls to the floor, overcome by what appears to be a grand mal seizure. It’s as if to say, “I’ll show you what brings me in.” The patient lays bear the affliction that troubles her – she kicks and screams and in doing so she violently demands a response from the therapist to a need that she cannot, will not, or otherwise is unmotivated to articulate any differently.
Her symptoms have been described over time by different terms, including hysteric fits, ataques convulsives, the Puerto Rican Syndrome, and ataque de nervios. The patient experiences all the classic symptoms of ataques as now catalogued by the DSM-IV — episodes of shouting and screaming; incoherence; and the loss of muscular control that often leads to falling – but despite how familiar and familial these symptoms are, she does not know what these symptoms mean. In therapy she will work to translate these symptoms into a new idiom. In fact, one can think of psychotherapy as a series of interactions between a therapist and a patient through which they jointly develop a language that allows them to actually talk about the patient’s experience and ultimately transform it. In this endeavor, known as the talking cure, words are privileged. But ataques, like its kith and kin hysteria, stumps the aim of the talking cure insofar as action and somatization replace talk. Communication will not be limited to a speech act. However, what appeared to be an obstacle to the aims of the talking cure was soon overcome, owing to Freud’s recognition that somatic manifestations of conflict spoke a language of their own through which the body joined the conversation. Thus, in the classic cases of hysteria documented at the turn of the century, the man whose paralysis could not be accounted for by organic causes was, nonetheless, understood to be communicating his inability to stand alone in the world; or, the daughter who could not move her arm communicated the ambivalence with which she held a wish to strike out in anger. The task of the psychoanalyst was to serve as an interpreter, expanding the meaning of the patient’s symptoms.
An important question, regarding this process of interpretation is: between what languages are interpretations being made? Freud initially sought to interpret the language of the unconscious, making the unconscious conscious. As clinical practice evolved, it became more apt to think of the therapist’s task as translating the patient’s symptoms and complaints into the language of intrapsychic conflicts and compromise formations. Other interpretations took the form of translating a physical symptom into a diagnostic label, such as when a patient describes feeling butterflies in his stomach, and the therapist refers to this experience as anxiety. Ultimately, these interpretations aim to give the patient insight into the motivations that lay behind seemingly inexplicable feelings, sensations, thoughts, and behaviors.
When ataques came to the attention of Western psychiatry (in the 1940s and 50s, as a large number of Puerto Rican men began serving in the military), they labeled the symptoms, perhaps without unintended prejudice, the Puerto Rican Syndrome. Despite it having been discovered by psychiatry through males – the syndrome was more prevalent in Puerto Rico among females. Furthermore, it was hardly considered a psychiatric illness. Rather, ataques were recognized as an expression of emotional distress meant to enlist social and familial support. Less evident from this emphasis on ataques as a means for enlisting support, was the fact, elucidated by psychoanalysis as well as anthropology and sociology, that ataques also allowed for the expression of disavowed aggression. In a culture where gender roles stressed self-sacrifice and suffering as a feminine ideal (an ideal termed marianismo and tied to the image of the Virgin Mary), ataques provided a culturally-sanctioned way of simultaneously expressing and disavowing aggression. The woman, who is overcome by an ataque, is thought to lack agency to the point of losing control over her own body.
In a discussion of ataques with a group of Hispanic psychology students, familiar with the symptoms, I asked the students about their understanding of ataques, including the expected response from the person witnessing the ataques, and some common modes of intervening. One question threw into sharp relief the main difference between ataques and a panic attack, a diagnostic entity with which ataques are often confused: “Would a person ever suffer an ataque when home alone?” The pointed response from a student was: “Why would you waste an ataque?” Her response highlighted the fact that ataques are a communicative act, a piece of theatre meant to be witnessed. The problem arises when the act is performed before the wrong audience, one who cannot understand their role in the performance, or what the ataque is meant to communicate. The psychiatrist, the therapist, and other health professionals, become unwittingly the wrong audience insofar as the language that they use to decipher the ataques represents a foreign dialect, influenced by psychiatric discourse, which ultimately contributes to the patient’s sense of self-alienation. The patient who adopts her psychiatrist’s term panic attacks to replace the native term ataques is no closer to understanding what afflicts her and why.
In his book, On Being Normal and Other Disorders: A Manual for Clinical Psychodiagnostics, Paul Verhaeghe illustrates some fundamental differences between medical diagnoses and clinical psychodiagnostics. In medical diagnoses, the doctor gathers individual symptoms into a broader, generalized category. That is to say, he goes from the particulars to the universal. In psychodiagnostics, Verhaeghe shows, the symptoms cannot be understood independent of how they refer to the unique aspects of the person’s present and past relationships. The diagnosis must take into account the particular; the symptoms must be contextualized in order to render them sensible. The symptoms are inevitably a referent to a relationship with an other.
In the case of ataques, the symptoms have been de-contextualized on different levels creating a state of alienation for the subject. On one level, there is the cultural and geographical dislocation of ataques. They afflict a woman in a setting where those around her are unfamiliar with the signs of her affliction. When an ataque happens in Puerto Rico, it is a recognizable sign of distress, where a spectator may ask what brought it on, but will never need to ask what it is. When an ataque happens outside of its natural milieu, the unfamiliar witness is left dumbfounded, helpless, and frightened; and thus, the need to give “it” a diagnostic label whereby in the act of calling “it” something, “it” is contained, even if misrecognized.
The term “Puerto Rican Syndrome”, as Patricia Gherovici points out, became a label that even psychiatrists in the Island adopted, denoting the need to fit ataques into a sterile psychiatric nomenclature. Gherovici ponders on this need that Island psychiatrists had to distance themselves from the familial term ataques by embracing the term Puerto Rican Syndrome, whereby they adopted an imported term for a domestic manifestation. In doing so, they rendered pathological a normative phenomenon with which they were culturally and personally familiar.
To the extent that ataques express feelings that ought not be known directly, such as aggressive impulses and sexual desires, they are experienced as uncanny and mystical in nature, speaking for something outside the subject. Psychiatric terminology, be it terms like panic attacks, hyperkinetic seizures, or the now defunct term Puerto Rican Syndrome, inevitably erase the patient’s subjectivity. And, paradoxically, herein lays one of its values for the ataques patient. Unconsciously, the patient is motivated to not recognize herself and be misrecognized by medical terminology. The way back to the center of the patient’s subjective experience is to situate the symptoms in the context of the person’s impulses, wishes, desires, and fears. In therapy, the challenge rests in interpreting the symptoms back into a language that was known all along, but which the patient was motivated to forget. In the course of psychoanalysis, the paradoxical motivation for forgetting and adopting a language in the service of misrecognition, be it the language of somatic experience, or the medical terminology “imported” from without, is elucidated. What the history of the term Puerto Rican Syndrome bears witness to is that the motivation for forgetting and for misrecognition is not the patient’s alone, but is shared by the medical and psychiatric establishment.
Gherovici, P. (2003). The Puerto Rican Syndrome. New York: The Other Press.
Verhaeghe, P. (2004). On Being Normal and Other Disorders: A Manual for Clinical Psychodiagnostics. New York: The Other Press.