Erna Hoch

Talking with [mit], about [über], and in view of [auf etwas hin] something in the psychiatric encounter. An example

from Kashmir.1

[Preliminary remarks of the editors

It has become progressively clearer in this chapter that conversation as a semiotic event is situation-specific and (as

far as the participants in the conversation are concerned) role-specific. After the theoretical discussion of

conversation by [Bin] Kimura [1931-2021], [Shizuteru] Ueda [1926-2019] and [Eugen] Baer [1937- ] and the

development of a critical model of speech in medicine by [Thure] von Uexküll [1908-2004], some concluding remarks

by Mrs. Hoch may now serve to show the practical application of the ideas in concrete cases.

What she present in the way of an extreme example of an illiterate mountain farmer in Kashmir is without doubt valid

for conversation in general and represents nothing else than a fundamental indication that the semiotic event aimed

at in conversation can only take place in consideration of the social and cultural conditioning factors of the situation

and the role structure of the participants in the conversation. In Mrs. Hoch's remarks, a new element of conversation

emerges: figurative speech [bildhafte Sprechen] as a means of revealing the situation in which the sick person finds

himself.]

M. Heidegger mentions in Being and Time,2 in the section on "Being-there and Speech," "language” as the

constituting moment of speech, "the what of speech (the discussed [Beredete]), the spoken [Geredete] as such,

communication and expression."

1
“Die Gespräch mit, über und auf etwas hin in der psychiatrishcen Begegnung. Ein Beispiel aus Kaschmir,” in

Ernesto Grassi and Hugo Schmale (eds.), Das Gespräch als Ereignis. Ein semiotisches Problem, Munich: Fink, 1982,

87-96. From the series Zurich Conversations [1982, 1987, 1994], with contributions by Eugen Baer, Bin Kimura,

Shizuteru Ueda, Thure von Uexküll, and the editors.

2 Martin Heidegger, Being and Time, New York: Harper and Row, 1962, 203-210. § 34: “Da-sein und Rede.

[Sprache]”—"das Worüber der Rede (das Beredete), das Geredete als solches, die Mitteilung und die Bekundung”

(206).
When I, without yet having recourse to Heidegger's main writing, considered for myself what the essential elements of

a conversation were, the following similar characterization emerged:

1. the conversation has an object: it is "conversation about [über]" (the discussed).

2. the conversation has one or more partners; it is "conversation with [mit]" (communication).

3. the conversation, however, points or aims beyond that to something which cannot or at least not yet "come to

speech"; it is "conversation in view of something [auf etwas hin]" (expression).

In addition, there was the purely formal aspect of the conversation, i.e. what Heidegger calls "the spoken [das

Geredete]", which is of less interest to us in this context, unless we include the figurative form of the conversation.

And indeed we do. In different types of psychiatric encounters, the "about [über]", "with [mit]" and "in view of [hin auf]"

of the conversation, even the meaning [Bedeutung] of the conversation itself, receives a different emphasis. One

might assume that for the often illiterate or very poorly educated mountain farmers with whom I mainly deal the "about

[über]" of the conversation should be in the forefront [Verdergund] because of their mental limitations. However, this

is not quite the case.

Perhaps the "with [mit]" plays a lesser or at least a different role than in dealing with more emancipated

[emanzipierteren] patients, in that a less differentiated approach to this unique man is necessary. The problems and

conflicts of these ordinary folk [Leute] are not so much caused by their individual personalities [Persönlichkeit], but

rather by certain social and cultural factors that are common to a whole group of similarly situated men. Exact

knowledge of the social conditions and especially of the common family structures are therefore more important than

a specific attitude towards a certain unique human being [Menschenwesen].

Nevertheless, the "with [mit]" of the conversation, which is also important in this situation, places certain demands on

the psychiatrist. Just "getting into conversation [ins Gespräch zu kommen]" is not always easy. First of all, the

relatives who bring the patient to the doctor already consider the patient as an "object [Objekt]", "about [über]" which

information is given and talked about, and no longer as a partner [Partner], a subject [Subjekt], "with [mit]" whom one

can talk. Often it is very difficult to really get into direct contact with the patient and to be allowed to listen to him and

ask him questions.

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Secondly, when one has lived among such people for some time, one learns that the consultation with the native

healer—whether he is an Ayurvedic or Unani [two traditional medical approaches] doctor or Sadhu [religious

mendicant or yogi], pir [spiritual guide] or faqir [holy man]—hardly requires a conversation. In accordance with the

usual procedures of these healers [Heiler], it also happens in our modern psychiatric polyclinic that a patient simply

holds out his hand silently, not as a greeting but so that one should feel his pulse. Questions on the part of the doctor

often cause astonishment or even disillusionment, since one had assumed that the miracle-working doctor was

omniscient and should know immediately, even without questions, only through his experienced gaze and perhaps

the palpation of the pulse, what the condition of the patient was. The answer to this silent offer should then consist in

an equally silent administration or prescription of a medicine, or in the case of a non-medical healer, in the handing

over of an amulet or the organization of a smoking procedure. If, however, according to the expectations of the

Western-oriented psychiatrist, a conversation is held, it soon becomes apparent that the patient not only knows very

little about the inside of his body and its functions, but is also hardly aware of his moods [Stimmungen] and feelings

[Gefühle] and their connection with recent experiences. Under these circumstances, the "about [über]" of the

conversation—in the sense of a joint bargaining about an already present "object [Gegenstand]t"—recedes into the

background, and the “in view of something [auf etwas him]" takes on more significance. However, the "something

[Etwas]" toward which the conversation now aims is, for the time being, in a very mundane sense, simply something

the patient is not yet aware of, and therefore still beyond language, and not something so "spiritual [Geistige]" that it

could not under any circumstances find linguistic expression.

While the search for possible problems and conflicts proceeds rather concretely in the form of a "tour d'horizon

[overview]" of all the different areas of life, if I cannot immediately recognize intuitively where the shoe pinches, I

prefer to use pictures for making clear physical functions and psychosomatic connections and, to a certain extent,

also for explaining therapeutic benefits. The patient must be made aware of something he has not known before, and

for this purpose I point to a situation or a process which is already familiar to him and which has something in

common with what is to be explained. Whenever possible, I choose an image from the patient's sphere of life and

work, so that I can be sure that he does not only know it from hearsay [vom Hörsagen], but that he has experienced

or even experienced it in the flesh [leibhaftig]. If this is the case, then the picture should not simply lead to a purely

intellectual understanding of what is to be explained, but should lead the patient to experience not only the picture

[Bild] he already knows, but also the aspect [Aspekt] of himself that is still unknown to him—whether it is a physical

function or a connection between his symptoms and some event in his bodily-mental wholeness [leib-seelisch

Ganzheit].

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Another advantage of using images [Bilder] is that they do not abruptly reveal something for which the patient may

not yet be ready, thus avoiding "resistance [Widerstand]" in Freud's language. The peculiar mixture of concealing

[Vehüllen] and revealing [Enthüllen], which is inherent in every image, similar to a dream, makes it possible in this

way to convey explanations and insights "in stock [auf Vorrat]", so to speak, so that the person concerned—in this

case the patient—may only gradually learn to recognize fully what is concealed in the image, according to his own

level of maturation. In this context, I would like to refer to the passages in the New Testament (Mt 13:10 ff. and Mk

4:10 ff.), in which Christ, following the parable [Gleichnis] of the sower, answers the question of his disciples why he

so often speaks in parables.3

3
Holy Bible, Mt. 13:10 ff.; Mk. 4:17 ff. The passages Hoch refers to run as follows (King James Version), where

‘parable’ renders παραβολή (comparison for purposes of illustration):

Matthew 13:13-17

13
Therefore speak I to them in parables: because they seeing see not; and hearing they hear not, neither do they

understand.

14
And in them is fulfilled the prophecy of Esaias, which saith, By hearing ye shall hear, and shall not understand; and

seeing ye shall see, and shall not perceive:

15
For this people's heart is waxed gross, and their ears are dull of hearing, and their eyes they have closed; lest at

any time they should see with their eyes and hear with their ears, and should understand with their heart, and should

be converted, and I should heal them.

16
But blessed are your eyes, for they see: and your ears, for they hear.

17
For verily I say unto you, That many prophets and righteous men have desired to see those things which ye see,

and have not seen them; and to hear those things which ye hear, and have not heard them.

Mark 4:33-34

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I can best illustrate all this with an example. Let us assume that a patient has already gone from one doctor to

another with complaints such as "palpitations, dizziness, pain in all limbs.” Each of them has assured him that

"nothing is wrong with him"; but each of them has prescribed him expensive medicines anyway. The patient has lost

confidence in the doctors and is at a loss as to what to believe. I could now explain to him in a "scientific" way, with as

many foreign words as possible, that he suffers from a “functional dystonia of the autonomic nervous system as a

reaction to stress". This would perhaps arouse the patient's respect for my erudition, but no understanding

whatsoever. I have to look for a language that also has meaning for him. I use the image of a "tonga" (two-wheeled

vehicle pulled by a horse, as it is still common in Kashmir, even to some extent in city traffic) with a harnessed horse.

Let us now assume that every time the vehicle starts moving, its gait is irregular and bumpy. What should be done?

Yes, of course, first examine the "tonga" and the horse thoroughly! Make sure that every nail, every screw on the

carriage is tight, that everything is properly assembled, that the wheel axles are properly lubricated, that the horse is

well fed, properly hoofed, and that the reins and bridle are in good condition and properly fitted. Let us assume that all

this is in order. If the carriage still bucks and jumps as soon as it starts moving, what else could be wrong with it?

In certain cases it may be the patient who gets the idea that the carriage driver also plays a role. In other cases I

must suggest the answer even to the perplexed interlocutor, whom I naturally try to involve as much as possible by

asking questions: "What does this carriage driver have in his one hand?"—“The reins"—“Yes, and in the other

hand?"—“The whip.”—“And if this carriage driver does not know when to use the whip and when to use the reins or

the brake, and, for example, uses both at the same time, what happens?"—“Yes, then the ride cannot go smoothly."

Then I explain that every organ in the body is controlled by two different nerves, one of which acts like a rein or brake,

the other like a driving whip. “And who is the carriage driver?”—“Yes, the head.”—If, however, in the "head", in the

"brain" of man, there is discord [Zwiespalt] as to whether one should go forward or rather stop or even go backwards

33
And with many such parables spake he the word unto them, as they were able to hear it.

34
But without a parable spake he not unto them: and when they were alone, he expounded all things to his disciples.

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in a certain situation, then there is confusion, and one or the other organ, although in itself quite healthy, can no

longer do its work properly. Until now, the doctors had only examined the carriage and the horse, and according to

the methods at their disposal; they were quite right that there was nothing wrong with them. Now, however, it should

be examined whether the carriage driver is also able to do his job properly.

Whether there is any situation in the patient's life—he is asked further—that he wants to or should approach, but at

the same time hesitates or even shrinks back from?—The patient cannot always answer, and I often have to try to

point out possible problems based on my intuition or my knowledge of the socio-cultural conditions: Is it perhaps

rising anger that must be restrained out of consideration for others or fear of others? Does the young man perhaps

want to marry, but at the same time shy away from the responsibility that comes with it? Does the young married

woman insist that her husband leave his parents' home, that is, the clan family, while she, on the other hand, is in no

way prepared to run her own household and care for her children without the help of her mother-in-law? Has a

peasant perhaps entrusted himself to the guidance of a "pir" who now sets him tasks which bring him into conflict with

his worldly appetites and duties? Often it is possible to uncover such relationships as the cause of the physical

symptoms or the psychological upset and then to help the patient to resolve such conflicts.

However, it [sometimes] happens that the initial triggering situation is so far in the past or was perhaps so trivial and

minor that it can no longer be guessed or has already lost its importance. In such cases, the fear [Angst] of fear

[Angst] has often set in motion a vicious circle in which, detached from the original event, physical sensations and

feelings triggered by them mutually reinforce and entrain each other. Now it is necessary to at least bring back to its

reasonable dimensions the response of the bodily functions to the movements of the mind which is felt as

threatening, and vice versa, and to show the positive aspects of it.

I usually need the image of a vehicle again, but this time the bus, to explain the harmlessness of palpitations, the

most frequently stated and most feared vegetative symptom: That is to say, all our patients have been in a "bus"

since there is no railroad in Kashmir and since all the public traffic is done by motor vehicles, especially big buses. So

I ask: "What happens if the engine has already started but the bus can't leave yet, maybe because the driver forgot

something or you have to wait for a passenger rushing [to catch the bus]?" Usually the patient can then remember

what he has often experienced, namely, that the engine then rattles and makes the whole vehicle tremble. "Is it

correct," I ask, "that the driver would conclude from this that there was something wrong with his engine and therefore

would not drive off?"—“No.” Once he is driving, the noise and the trembling stop or at least become less."—“You

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see," I explain, "that is also the case with your heart. It is ready for something, but at the same time it is held back

from it. If you hesitate, you will never be sure that everything is really all right. But if you go forward courageously, you

will see that nothing dangerous will happen. Often I try to teach the patient a little verse that rhymes in Urdu, so that

he can always remember what he has learned. In German, it would go something like this:

“Angst als Krankheit nicht versteh!

Sie heißt nur: Mach Dich auf und geh!"

"Understand fear as a disease? No!

It only means: Get up and go!"

Occasionally, when the patient is a little more sophisticated, I also try to point out to him that language already

creates a picture of what is going on inside him. While the German word ‘Angst’ or even ‘Beklemmung’ indicates a

state of constriction, of being "caught in the middle," the Urdu term "grabrahat," which is used for palpitations and

anxiety at the same time—as far as I can tell—seems to refer to a situation in which the person is "standing on the

precipice" while high cliffs tower up behind him. Finally, the Kashmiri expression "dil rawan" literally means "the heart

runs away" or "gets lost," so it has a similar meaning to the Swiss-German "the heart sinks [fällt mir in die Hosen]."

The imagery of such expressions can also often be the basis for a fruitful conversation that can provide the patient

with insight into his condition and problems. Possibly even the patient himself brings a figurative comparison like the

woman who, pointing to her restlessly throbbing heart, described: "There’s a clock running in here, but it has nothing

to run on."

One can see that for one and the same situation, or more precisely, for the explanation of a certain psychosomatic

symptom, a whole series of images can be used. It is always necessary to choose the image which, firstly, is closest

to the patient's sphere of life and, secondly, at the same time has the greatest analogy with what is to be explained.

One may ask me why I use two different vehicles, the two-wheeled horse-drawn carriage and the bus, for my

explanation of psychosomatic relationships and not just one of these two images right from the start. Well, the rattling

and trembling of the engine ready to go has been experienced by the patient himself, and it cannot be adequately

demonstrated with the horse and cart. If, on the other hand, I were to use a bus from the beginning to illustrate the

driving and braking functions of the two parts of the autonomic nervous system, this would be less vivid and not as

close to the experience of the patient, who is not familiar with the hidden mechanics of a motor vehicle, as the whip

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and reins of a horse-drawn carriage, which everyone can see openly and which he has perhaps already held in his

hands.