The American Journal of Psychoanalysis, 2015, 75, (145–153) © 2015 Association for the Advancement of Psychoanalysis 0002-9548/15 www.palgrave-journals.com/ajp/
THE DISSOCIATIVE TURN IN PSYCHOANALYSIS* Sheldon Itzkowitz1
In his response to the Roundtable Discussions on what is effective in psychoanalytic psychotherapy, the author focuses on the renewed interest in the concept of dissociation that began to emerge toward the end of the 20th century. A contemporary psychoanalytic position informed by the impact of developmental trauma has led to an understanding of and interest in the dissociative mind. The actuality of trauma during infancy and early childhood is recognized as a key factor leading to the emergence of dissociative processes, the potential dissociative structuring of the mind, and mind being characterized by multiple, discontinuous, centers of consciousness. The therapeutic goal in the psychoanalytic work with fragmented patients is to establish communication and understanding between the dissociated self-states. The author offers two brief clinical examples of working with dissociated self-states.
KEY WORDS: basic anxiety; developmental trauma; dissociation; fragmentation; selfstates DOI:10.1057/ajp.2015.15
“My experience is what I agree to attend to.” William James
I am grateful to have been invited to participate in this discussion about what is effective in psychoanalytic psychotherapy. Almost 60 years have elapsed since the American Journal of Psychoanalysis addressed the important question “What Is Effective In The Therapeutic Process?” (Van Bark, 1957).2 Eight years later a second group of highly respected analysts were given the opportunity of addressing a similarly central question, “What Leads To Basic Change In Psychoanalytic Psychotherapy?” (Boigon, 1965).3 And now, 50 years since the last roundtable discussion we are charged with a similar task. Sheldon Itzkowitz, Ph.D., ABPP, is a Faculty member and Clinical Consultant at the NYU Postdoctoral Program in Psychotherapy & Psychoanalysis. Address correspondence to Sheldon Itzkowitz, Ph.D., ABPP, 295 Central Park West, New York, NY. 10024. *This reaction paper is part of the celebration of the 75th Anniversary of the American Journal of Psychoanalysis, Special Issue, guest edited by Dr. Robert M. Prince. Other responders to the 1956 and 1964 AJP Roundtables are: Drs. Steven D. Axelrod, Emily Kuriloff, Ronald C. Naso and Larry M. Rosenberg.
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It seems unfair because in those decades so much has changed in American culture and in the culture of psychoanalysis there is too much to choose from. In the previous roundtable discussions the participants were in agreement that acceptance of the patient for who he is, the creation and maintenance of a therapeutic atmosphere, a relationship of warmth, empathy, trust and respect, the analysis of transference, the potential usefulness of countertransference, and an understanding of the importance of attention to and analysis of the “here and now relationship” were central aspects of what makes for effectiveness in treatment. There was a distinction between intellectual insight and emotional insight as well. I was most struck by Arieti’s (1957) comment “Although some areas are dissociated or unconscious in the schizophrenic too, the main disturbance derives from the state of psychic disequilibrium, disintegration and fragmentation, rather than from the state of unconsciousness of conflicts” (p. 30). There are two important implications of Arieti’s statement. The first is that dissociation is a mental process that is not restricted to psychotic states. The second is that the schizophrenic suffers from psychic disintegration and fragmentation. It is interesting to note that Horney (1939) did not use the word dissociation more than a few times, however her cornerstone concept of basic anxiety and the resulting psychic fragmentation is somewhat similar to dissociation. Horney emphasized the centrality of the environment in development and the crucial role of trauma, inflicted by the environment in the development of psychopathology when she wrote that basic anxiety arises as a result of the child’s developing in a malicious environment causing her to feel alone and helpless and perceiving the world around her as frightening and dangerous. In the face of such traumatic psychological reality, Galdi (2007) writes, “the child gradually abandons his/her own reactions, thoughts, feelings, and all aspects of the self that are deemed a threat to his/her safety. Horney described the resulting alienation the gravest consequence of having learned to create a semblance of safety” (p. 7). Psychic fragmentation, a type of alienation from inner experiences, in the Horneyan perspective, becomes a way to cope with early, chronic, disruptive and painful experiences and an adaptation to the traumatizing environment. Dissociation has become significant both in my thinking and in my clinical work. The renewed interest in the centrality of dissociation as an essential aspect of mind, exemplified in the work of Bromberg (1998, 2006, 201l), Howell (2005, 2011), Chefetz (2015), Kluft (2000, 1992), Kluft and Fine (1993) and Stern (2003), particularly as it pertains to the overwhelming experiences of early developmental trauma—represents one of the most significant changes in our field.
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IMPLICATIONS FOR EFFECTIVENESS AND HEALING
In its early days, the goal of psychoanalysis was to make the unconscious conscious. What was unconscious for Freud were repressed sexual and aggressive drives, residing within the mind of the developing child. An alternative psychoanalytic position, informed by recognizing the impact of developmental trauma, has led to a better understanding of and interest in the dissociative mind. In this model, the actuality of trauma during infancy and early childhood is acknowledged as a key factor, leading to the emergence of dissociative processes, the potential dissociative structuring of the mind, and the mind being characterized by multiple, discontinuous, centers of consciousness (Bromberg, 1998, 2006, 2011; Howell, 2005, 2011). This contemporary perspective retains the spirit of Freud’s original formulation but with a different twist. One might say the goal of psychoanalysis is to reassociate what has been dissociated (Richard A. Chefetz, personal communication). However, the contents of what is dissociated, or unconscious are not endogenous drives, but dissociated traumatic interpersonal—relational patterns of experience. The therapeutic goal of analysis then is the breaking down of barriers to awareness between dissociated self-states. As articulated by Bromberg, Howell, Chefetz, and others we attempt to help self-states become increasingly aware of each other as real presences in the mind and begin to establish communication and understanding between states. The healing aspect of psychoanalysis occurs as the patient develops the capacity for shared conscious experience between these formerly dissociated self-states. This develops because of the analyst’s ability and commitment to allowing different dissociated self-states to have a voice, a clear sense of legitimacy, and a relational presence in the analytic relationship. Simultaneously, there is a continually evolving process of negotiation of the interpersonal/relational aspects of the analytic relationship between the participants. The ability and skill of the analyst to work with the different ways, in which the patient has come to and is coming to know herself and the negotiation of the inevitable multiple transferences that arise, are key aspects of what is healing. As this process evolves, the patient begins to gradually develop a greater capacity for both intersubjective and intra-subjective relating. By intrasubjective relating I am referring to the development of a growing capacity for the patient to know herself more fully—a process whereby formerly dissociated self-states gradually begin to understand, appreciate, and tolerate conflicting ideas, desires and goals. Self-states become increasingly aware of each other and work cooperatively within an increasingly organized and coherent system of ways of being. This leads to the patient becoming increasingly adept at tolerating both interpersonal/relational,
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as well as intra-subjective conflict without having to resort to dissociation or self-harm. WORKING WITH DISSOCIATED STATES
Writing about dissociated states is challenging because it is difficult to paint a picture with words that accurately conveys what a self-state shift looks and feels like and how different self-states can appear in feeling tone, facial expression, mood, intellectual ability, age, and so on. It is also difficult to describe the feelings I experience in my body when a sudden, unexpected self-state switch occurs. Hence, I am offering the following examples hoping to explain and clarify what working with dissociation and dissociative processes can be like in the consulting room. Doris
Doris is a 40-year-old single, woman who came to the metropolitan area to work in the litigation department of a large, white-shoe law firm. She is a highly educated, verbally facile, woman with a semblance of a charm and an engaging manner. When angered or crossed, she uses her intellect to intimidate, often inflicting pain on those whom she feels threatened by or whom she feels have, or might betrayed her. She is a fierce negotiator often pushing issues and people to their limit. Upon encountering resistance she uses her intellectual gifts to pressure or manipulate others into abandoning their position and “Seeing the world according to Doris.” Doris is driven by a strong internal need to compete, dominate, and win, at times regardless of the consequences. When she fails to achieve her goal, whatever it may be, she suffers intense self-loathing and engages in self-destructive behavior. Once during the first year of working together she casually mentioned hearing an assemblage of internal, judgmental and critical voices. She quickly explained that the criticisms and admonitions were the very same she heard from relatives during her formative years and quickly dismissed the conversation, and my interest in the assemblage. Several months ago Doris made mention of this again. This time I heard “and felt” something. I felt uneasy, anxious, and I thought Doris looked pained. I asked if she could tell me what the assemblage of voices was saying; indeed they were cruel and critical. I asked if it would be possible for me to talk to the voice(s) directly. My request caused her to feel anxious and threatened. In her characteristic manner she became angry and began to try to intimidate. She replied, “You are in greater need of a shrink than I”. In a subsequent session, the self-state(s) she referred to as “The assemblage of voices” was prepared to talk directly with me. I explained about the importance of being able to get to know the other “ways of being Doris”
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(Chefetz, 2015) to help us understand how Doris’ mind works and get an understanding of why she had a need to be so dissociated. I learned about the concrete, rigid, cognitive style of the assemblage of voices in addition to its being identified with a particular critical, overly moralistic, and hyper-religious relative. This is one of the sources of Doris’ harsh, self-punitive, perfectionist, and critical attitudes toward herself and others. At another time I learned about several other self-states she is aware of including a young state she referred to as “the kid”. I began talking about “the kid” with “the assemblage of voices”. I explained how sad, lonely and frightened “the kid” sounded to me, and how hard she and the “assemblage of voices” must be working to keep “the kid” safe, and all the self-states organized, and behaving properly; “How exhausted you must feel having to be alert and on guard all the time”, I explained. Slowly, tears that had leant a shiny, glistening appearance to her left eye began spilling over the eyelid’s edge, moistening the lashes as they traveled down her check. As I sat watching and wondering why she was crying only from her left eye I asked, “What are you feeling right now?” Doris looking very puzzled and replied, “What do you mean?” Again I asked about her feelings and she expressed confusion, “Feelings? I don’t have any feelings. Feelings are useless and just cause trouble”. After Doris shifted back into her lawyerly self again, we tried to talk about how she was feeling and what she remembered, if anything, about the session. However, Doris’ understanding and awareness of her self-states is rather limited. As a result, she had no memory or recollection of my dialog with “the assemblage of voices”, nor did she have any awareness of feeling sad, tearful, or crying. Chris
Chris is a 40-year-old, highly successful, professional man, referred for treatment of PTSD related symptoms, interfering with his ability to perform at his usual very high level. This has undermined his sense of security and self-esteem. It soon became clear that experiences during childhood and early adolescence including sadistic, physical and emotional abuse by his mother, feeling abandoned by his father, and becoming caretaker and protector of his younger siblings were contributing factors to his vulnerability for developing PTSD as a sequela of an acute adult trauma. Chris has had several intimate relationships none of which lasted more than a year. In characterizing these relationships he described dissatisfaction stemming from repeatedly assuming the role of caretaker of his lovers. Chris explained how he yields to his lovers’ needs and demands at the cost of his own frustration and unhappiness. He has come to understand that he has never been able to allow anyone to get close to him, leaving him feeling
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lonely and unfulfilled. Chris had little insight or understanding of why this happens. In fact, he seemed surprised when he became aware there was a pattern to the way he inhabited and negotiated intimate relationships. Chris had referred to a part of himself that felt young and frightened and I suggested we try to help him get to know this part of him. I asked if he might try to move closer to his feelings and describe what he was sensing; this is what he said. “It feels like, I see a little boy, me, it’s me, I’m young, in a dark room, in a corner. I feel like I (referring to his adult self) am walking into a room and bringing the light with me. I can just barely make him out. I want to get close to him and let him know that I want to take care of him and that it’s going to be okay”. At this point I suggested to Chris that he consider asking the young part of himself to try to turn towards him and see if he could move out of the darkness just a bit, and perhaps look at him, the “adult Chris”. When this was successful I asked Chris to try to sense what that young part of him might be feeling. He responded, “Young Chris looks frightened and scared and he looks as if he’d been crying”. The next day Chris expressed his desire to work with “Young Chris” almost immediately. Once Chris felt like he could sense the young part of him I asked him to describe his feelings. He reported a deep desire to help “Young Chris”. “I want to help, I want you to know you are going to be ok.” When I asked that he focus on what the “Young Chris” part of himself was feeling he replied, “He’s very scared, frightened, he doesn’t want to move.” I asked him to try to sense if it would be ok with the “Young Chris” part of him if he were to move very slowly in his direction. Surprisingly, Chris’ body jerked and he looked as if he were angry. He explained, “I moved toward him, I reached out to him, I extended my arm, I want to hold him and help him, but he turned away and moved back into the shadows”. Chris became very critical and angry of the young part of himself, calling him “a coward, stupid, a stupid little boy, he’s ignorant, he’s a coward.” This angry, critical attack on “Young Chris” was inconsistent with the Chris I have come to know. This was not his usual manner of speaking; there was an unusual tone to his voice and he looked scornful. Chris had switched self-states, sounding similar to his critical, abusive mother. Later when we talked about his experience he explained that the manner in which he criticized “Young Chris” was the same way he had been treated by his mother, “And I learned to run away from her, I learned not go to her when she said ‘come here I love you, let me hug you’, because when I did go to her she wouldn’t hug me, she’d beat me. I learned to run away from her and I was punished for that as well.” Chris’ attempt to shed light on a previously dissociated part of himself allowed him to feel the sadness, vulnerability, and fear that had characterized his childhood. During the second attempt to make contact with the previously dissociated part of himself he acted somewhat impulsively.
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He acted on his adult, conscious desire to be helpful. The adult Chris not fully feeling how traumatized and terrified the “Young Chris” part of him is, how frightened of human contact and intimacy he is, frightened this part of himself. Later in the session Chris was both surprised and shocked by his angry, critical, and scornful reaction to this younger part, who in anticipation of being abused, retreated from the adult Chris’ attempt at contact.
DISCUSSION
These examples reflect Doris and Chris’ attempts to make contact with parts of themselves that have been dissociated. The tearful moment I witnessed when talking with Doris’ “Assemblage of voices” displayed the power and effectiveness of dissociation. The feelings in Doris that resulted in tears meandering down her face were not those of “the assemblage of voices” or those of Doris. They were the feelings of a still dissociated self-state that remain unknown and unavailable at this time. Chris’ experience afforded us a deeper understanding and him a felt sense of why close, intimate relationships have been fraught with so much anxiety and fear; why he has been so reticent to allow anyone to get close to him. In additional, his angry and scornful reaction to the retreating “young Chris” represents an internalization of his perpetrator-mother. The surprise and confusion Chris experienced as he became aware of this uncharacteristically critical part of himself, was our initial glimpse of this dissociated part of him that is identified with his mother, that is, identification with the aggressor in Ferenczi’s sense of the term (see Howell, 2014). A therapist can only work with a person’s dissociated self-states if he/she can convey to the patient his/her understanding, curiosity and desire to engage in a meaningful dialog and relationship with all the different ways in which the patient has come to be. A sensitively engaged, and attuned therapist who understands dissociative processes and the physical manifestations that often accompany them is likely to recognize these processes as they emerge in the patient and in the multiple transferences that accompany multiple self-states. And with multiple transferences come multiple countertransferences. Working within a framework of co-participation (Fiscalini, 2004) and co-construction of relationships, the analyst takes responsibility for her contribution to the relationships with each of the patient’s self-states. In doing so however, it is imperative that the analyst remains true to her self and be herself with each self-state. By engaging the patient in this manner, each of the patient’s self-states has experiences with one consistent and predictable person/analyst, which ultimately contributes to the patient’s awareness of and sharing of simultaneous self-experience.
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As dissociated self-states become manifest, fear, confusion, and anxiety may accompany the growing awareness of these states. The goal of the working through process is not necessarily the consolidation of self-states into a single, integrated individual. The goal of analysis is working toward resolving the need for and reliance upon dissociation as a means of protecting the self. During infancy and early childhood dissociative processes, and the dissociative structure of the mind develops in response to developmental trauma. Dissociation preserves the child’s sanity by encapsulating experience that is too overwhelming, emotionally flooding, and beyond the child’s limited emotional and cognitive ability to cope. As selfstates become less dissociated and more associated, the capacity for simultaneous shared experience increases and the patient begins to feel a more coherent sense of self. The healing aspect of working with dissociated self-states emerges not only with the therapist helping the person become aware of her previously dissociated states, but in helping the person understand and negotiate meaningful forms of relatedness with these heretofore unknown parts of herself. A sense of unity or wholeness, even if illusory, can only emerge when all of the previously dissociated states are comfortable enough and trust each other enough to release the strangle hold that is dissociation so that they can simultaneously share in self experience.
ACKNOWLEDGEMENTS
The author wishes to thank Philip Bromberg and Elizabeth Howell for their profound influence on his work. He also wishes to thank Robert Prince for his assistance in the preparation of this paper, and Giselle Galdi for explaining the importance of Horney’s ideas of basic anxiety and its relationship to dissociation.
NOTES 1. Sheldon Itzkowitz, Ph.D., ABPP is a Faculty member and Clinical Consultant at the NYU Postdoctoral Program in Psychotherapy & Psychoanalysis, Guest Faculty, the Eating Disorders, Compulsions, and Addictions Program of The William Alanson White Institute, and on the teaching and supervisory faculty of the National Institute for the Psychotherapies training program in psychoanalysis. Dr. Itzkowitz is an associate editor of Psychoanalytic Perspectives. He is in full time practice in Manhattan where he practices psychoanalysis, psychoanalytic psychotherapy, and provides clinical supervision. Dr. Itzkowitz has presented his work with extremely dissociated individuals both nationally and internationally. 2. The Roundtable Discussion, “What is effective in the therapeutic process?” took place at the Annual Meeting of the American Psychiatric Association in Chicago, Illinois on May 1, 1956.
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Bella S. Van Bark, M.D. moderated the panel. Other presenters were Elizabeth Kilpatrick, M.D., Lewis Wolberg, M.D., Marianne Horney Eckardt, M.D., Frederick A. Weiss, M.D., Leslie H. Farber, M.D., Louis E. DeRosis, M.D., and Silvano Arieti, M.D. 3. The Scientific Program Committee of the Association for the Advancement of Psychoanalysis, under the chairmanship of Dr. Frederick A. Weiss, arranged the Roundtable Discussion, “What Leads to Basic Change in Psychoanalytic Therapy?” at the New York Academy of Medicine in the Spring of 1964. Melvin Boigon, M.D. moderated the panel. Other participants were William V. Silverberg, M.D., Frederick A. Weiss, M.D. and Alfred H. Rifkin, M.D.
REFERENCES Arieti, S. (1957). What is effective in the therapeutic process? American Journal of Psychoanalysis 17(1), 30–33. (Republished in: R. Prince (Ed.) (2015). Special Issue. What is effective in psychoanalytic psychotherapy? A historical reprise. American Journal of Psychoanalysis, 75(2), 217–223. van Bark, B. S., Wolberg, L. R., Eckardt, M. H., Weiss, F. A., Farber, L. H., De Rosis, L. & Arieti, S. (1957). What is effective in the therapeutic process? The American Journal of Psychoanalysis, 17(1), 3–33. Boigon, M. (1965). What leads to basic change in psychoanalytic therapy? A roundtable discussion. The American Journal of Psychoanalysis, 25(2), 129–141. Bromberg, P. (1998). Standing in the spaces. New York: Psychology Press. Bromberg, P. (2006). Awakening the dreamer: Clinical journeys. New York: The Analytic Press. Bromberg, P. (2011). The shadow of the Tsunami. New York: Routledge. Chefetz, R. A. (2015). Intensive psychotherapy for persistent dissociative processes: The fear of feeling real. New York: W.W. Norton. Fiscalini, J (2004). Coparticipant psychoanalysis: Toward a new theory of clinical inquiry. New York: Columbia University Press. Galdi, G. (2007). The analytic encounter: A scene of clashing cultures. American Journal of Psychoanalysis, 67(1), 4–21. Horney, K. (1939). New ways in psychoanalysis. New York: Norton. Howell, E. F. (2005). The dissociative mind. New York: Routledge. Howell, E. F. (2011). Understanding and Treating dissociative identity disorder: A relational approach. New York: Routledge. Howell, E. F. (2014). Ferenczi’s concept of identification with the aggressor: Understanding dissociative structure with interacting victim and abuser self-states. The American journal of psychoanalysis, 74(1), 48–59. Kluft, R. P. (1992). Discussion: A specialist’s perspective on multiple personality disorder. Psychoanalytic inquiry, 12(1), 139–171. Kluft, R. P. & Fine, C. G. (Eds.) (1993). Clinical perspectives on multiple personality disorder. Washington DC: American Psychiatric Press. Kluft, R. P. (2000). The psychoanalytic psychotherapy of dissociative identity disorder in the context of trauma therapy. Psychoanalytic inquiry, 20(2), 259–286. Stern, D. (2003). Unformulated experience. Hillsdale, NJ: The Analytic Press.
THE DISSOCIATIVE TURN IN PSYCHOANALYSIS* Sheldon Itzkowitz1
In his response to the Roundtable Discussions on what is effective in psychoanalytic psychotherapy, the author focuses on the renewed interest in the concept of dissociation that began to emerge toward the end of the 20th century. A contemporary psychoanalytic position informed by the impact of developmental trauma has led to an understanding of and interest in the dissociative mind. The actuality of trauma during infancy and early childhood is recognized as a key factor leading to the emergence of dissociative processes, the potential dissociative structuring of the mind, and mind being characterized by multiple, discontinuous, centers of consciousness. The therapeutic goal in the psychoanalytic work with fragmented patients is to establish communication and understanding between the dissociated self-states. The author offers two brief clinical examples of working with dissociated self-states.
KEY WORDS: basic anxiety; developmental trauma; dissociation; fragmentation; selfstates DOI:10.1057/ajp.2015.15
“My experience is what I agree to attend to.” William James
I am grateful to have been invited to participate in this discussion about what is effective in psychoanalytic psychotherapy. Almost 60 years have elapsed since the American Journal of Psychoanalysis addressed the important question “What Is Effective In The Therapeutic Process?” (Van Bark, 1957).2 Eight years later a second group of highly respected analysts were given the opportunity of addressing a similarly central question, “What Leads To Basic Change In Psychoanalytic Psychotherapy?” (Boigon, 1965).3 And now, 50 years since the last roundtable discussion we are charged with a similar task. Sheldon Itzkowitz, Ph.D., ABPP, is a Faculty member and Clinical Consultant at the NYU Postdoctoral Program in Psychotherapy & Psychoanalysis. Address correspondence to Sheldon Itzkowitz, Ph.D., ABPP, 295 Central Park West, New York, NY. 10024. *This reaction paper is part of the celebration of the 75th Anniversary of the American Journal of Psychoanalysis, Special Issue, guest edited by Dr. Robert M. Prince. Other responders to the 1956 and 1964 AJP Roundtables are: Drs. Steven D. Axelrod, Emily Kuriloff, Ronald C. Naso and Larry M. Rosenberg.
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ITZKOWITZ
It seems unfair because in those decades so much has changed in American culture and in the culture of psychoanalysis there is too much to choose from. In the previous roundtable discussions the participants were in agreement that acceptance of the patient for who he is, the creation and maintenance of a therapeutic atmosphere, a relationship of warmth, empathy, trust and respect, the analysis of transference, the potential usefulness of countertransference, and an understanding of the importance of attention to and analysis of the “here and now relationship” were central aspects of what makes for effectiveness in treatment. There was a distinction between intellectual insight and emotional insight as well. I was most struck by Arieti’s (1957) comment “Although some areas are dissociated or unconscious in the schizophrenic too, the main disturbance derives from the state of psychic disequilibrium, disintegration and fragmentation, rather than from the state of unconsciousness of conflicts” (p. 30). There are two important implications of Arieti’s statement. The first is that dissociation is a mental process that is not restricted to psychotic states. The second is that the schizophrenic suffers from psychic disintegration and fragmentation. It is interesting to note that Horney (1939) did not use the word dissociation more than a few times, however her cornerstone concept of basic anxiety and the resulting psychic fragmentation is somewhat similar to dissociation. Horney emphasized the centrality of the environment in development and the crucial role of trauma, inflicted by the environment in the development of psychopathology when she wrote that basic anxiety arises as a result of the child’s developing in a malicious environment causing her to feel alone and helpless and perceiving the world around her as frightening and dangerous. In the face of such traumatic psychological reality, Galdi (2007) writes, “the child gradually abandons his/her own reactions, thoughts, feelings, and all aspects of the self that are deemed a threat to his/her safety. Horney described the resulting alienation the gravest consequence of having learned to create a semblance of safety” (p. 7). Psychic fragmentation, a type of alienation from inner experiences, in the Horneyan perspective, becomes a way to cope with early, chronic, disruptive and painful experiences and an adaptation to the traumatizing environment. Dissociation has become significant both in my thinking and in my clinical work. The renewed interest in the centrality of dissociation as an essential aspect of mind, exemplified in the work of Bromberg (1998, 2006, 201l), Howell (2005, 2011), Chefetz (2015), Kluft (2000, 1992), Kluft and Fine (1993) and Stern (2003), particularly as it pertains to the overwhelming experiences of early developmental trauma—represents one of the most significant changes in our field.
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IMPLICATIONS FOR EFFECTIVENESS AND HEALING
In its early days, the goal of psychoanalysis was to make the unconscious conscious. What was unconscious for Freud were repressed sexual and aggressive drives, residing within the mind of the developing child. An alternative psychoanalytic position, informed by recognizing the impact of developmental trauma, has led to a better understanding of and interest in the dissociative mind. In this model, the actuality of trauma during infancy and early childhood is acknowledged as a key factor, leading to the emergence of dissociative processes, the potential dissociative structuring of the mind, and the mind being characterized by multiple, discontinuous, centers of consciousness (Bromberg, 1998, 2006, 2011; Howell, 2005, 2011). This contemporary perspective retains the spirit of Freud’s original formulation but with a different twist. One might say the goal of psychoanalysis is to reassociate what has been dissociated (Richard A. Chefetz, personal communication). However, the contents of what is dissociated, or unconscious are not endogenous drives, but dissociated traumatic interpersonal—relational patterns of experience. The therapeutic goal of analysis then is the breaking down of barriers to awareness between dissociated self-states. As articulated by Bromberg, Howell, Chefetz, and others we attempt to help self-states become increasingly aware of each other as real presences in the mind and begin to establish communication and understanding between states. The healing aspect of psychoanalysis occurs as the patient develops the capacity for shared conscious experience between these formerly dissociated self-states. This develops because of the analyst’s ability and commitment to allowing different dissociated self-states to have a voice, a clear sense of legitimacy, and a relational presence in the analytic relationship. Simultaneously, there is a continually evolving process of negotiation of the interpersonal/relational aspects of the analytic relationship between the participants. The ability and skill of the analyst to work with the different ways, in which the patient has come to and is coming to know herself and the negotiation of the inevitable multiple transferences that arise, are key aspects of what is healing. As this process evolves, the patient begins to gradually develop a greater capacity for both intersubjective and intra-subjective relating. By intrasubjective relating I am referring to the development of a growing capacity for the patient to know herself more fully—a process whereby formerly dissociated self-states gradually begin to understand, appreciate, and tolerate conflicting ideas, desires and goals. Self-states become increasingly aware of each other and work cooperatively within an increasingly organized and coherent system of ways of being. This leads to the patient becoming increasingly adept at tolerating both interpersonal/relational,
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as well as intra-subjective conflict without having to resort to dissociation or self-harm. WORKING WITH DISSOCIATED STATES
Writing about dissociated states is challenging because it is difficult to paint a picture with words that accurately conveys what a self-state shift looks and feels like and how different self-states can appear in feeling tone, facial expression, mood, intellectual ability, age, and so on. It is also difficult to describe the feelings I experience in my body when a sudden, unexpected self-state switch occurs. Hence, I am offering the following examples hoping to explain and clarify what working with dissociation and dissociative processes can be like in the consulting room. Doris
Doris is a 40-year-old single, woman who came to the metropolitan area to work in the litigation department of a large, white-shoe law firm. She is a highly educated, verbally facile, woman with a semblance of a charm and an engaging manner. When angered or crossed, she uses her intellect to intimidate, often inflicting pain on those whom she feels threatened by or whom she feels have, or might betrayed her. She is a fierce negotiator often pushing issues and people to their limit. Upon encountering resistance she uses her intellectual gifts to pressure or manipulate others into abandoning their position and “Seeing the world according to Doris.” Doris is driven by a strong internal need to compete, dominate, and win, at times regardless of the consequences. When she fails to achieve her goal, whatever it may be, she suffers intense self-loathing and engages in self-destructive behavior. Once during the first year of working together she casually mentioned hearing an assemblage of internal, judgmental and critical voices. She quickly explained that the criticisms and admonitions were the very same she heard from relatives during her formative years and quickly dismissed the conversation, and my interest in the assemblage. Several months ago Doris made mention of this again. This time I heard “and felt” something. I felt uneasy, anxious, and I thought Doris looked pained. I asked if she could tell me what the assemblage of voices was saying; indeed they were cruel and critical. I asked if it would be possible for me to talk to the voice(s) directly. My request caused her to feel anxious and threatened. In her characteristic manner she became angry and began to try to intimidate. She replied, “You are in greater need of a shrink than I”. In a subsequent session, the self-state(s) she referred to as “The assemblage of voices” was prepared to talk directly with me. I explained about the importance of being able to get to know the other “ways of being Doris”
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(Chefetz, 2015) to help us understand how Doris’ mind works and get an understanding of why she had a need to be so dissociated. I learned about the concrete, rigid, cognitive style of the assemblage of voices in addition to its being identified with a particular critical, overly moralistic, and hyper-religious relative. This is one of the sources of Doris’ harsh, self-punitive, perfectionist, and critical attitudes toward herself and others. At another time I learned about several other self-states she is aware of including a young state she referred to as “the kid”. I began talking about “the kid” with “the assemblage of voices”. I explained how sad, lonely and frightened “the kid” sounded to me, and how hard she and the “assemblage of voices” must be working to keep “the kid” safe, and all the self-states organized, and behaving properly; “How exhausted you must feel having to be alert and on guard all the time”, I explained. Slowly, tears that had leant a shiny, glistening appearance to her left eye began spilling over the eyelid’s edge, moistening the lashes as they traveled down her check. As I sat watching and wondering why she was crying only from her left eye I asked, “What are you feeling right now?” Doris looking very puzzled and replied, “What do you mean?” Again I asked about her feelings and she expressed confusion, “Feelings? I don’t have any feelings. Feelings are useless and just cause trouble”. After Doris shifted back into her lawyerly self again, we tried to talk about how she was feeling and what she remembered, if anything, about the session. However, Doris’ understanding and awareness of her self-states is rather limited. As a result, she had no memory or recollection of my dialog with “the assemblage of voices”, nor did she have any awareness of feeling sad, tearful, or crying. Chris
Chris is a 40-year-old, highly successful, professional man, referred for treatment of PTSD related symptoms, interfering with his ability to perform at his usual very high level. This has undermined his sense of security and self-esteem. It soon became clear that experiences during childhood and early adolescence including sadistic, physical and emotional abuse by his mother, feeling abandoned by his father, and becoming caretaker and protector of his younger siblings were contributing factors to his vulnerability for developing PTSD as a sequela of an acute adult trauma. Chris has had several intimate relationships none of which lasted more than a year. In characterizing these relationships he described dissatisfaction stemming from repeatedly assuming the role of caretaker of his lovers. Chris explained how he yields to his lovers’ needs and demands at the cost of his own frustration and unhappiness. He has come to understand that he has never been able to allow anyone to get close to him, leaving him feeling
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lonely and unfulfilled. Chris had little insight or understanding of why this happens. In fact, he seemed surprised when he became aware there was a pattern to the way he inhabited and negotiated intimate relationships. Chris had referred to a part of himself that felt young and frightened and I suggested we try to help him get to know this part of him. I asked if he might try to move closer to his feelings and describe what he was sensing; this is what he said. “It feels like, I see a little boy, me, it’s me, I’m young, in a dark room, in a corner. I feel like I (referring to his adult self) am walking into a room and bringing the light with me. I can just barely make him out. I want to get close to him and let him know that I want to take care of him and that it’s going to be okay”. At this point I suggested to Chris that he consider asking the young part of himself to try to turn towards him and see if he could move out of the darkness just a bit, and perhaps look at him, the “adult Chris”. When this was successful I asked Chris to try to sense what that young part of him might be feeling. He responded, “Young Chris looks frightened and scared and he looks as if he’d been crying”. The next day Chris expressed his desire to work with “Young Chris” almost immediately. Once Chris felt like he could sense the young part of him I asked him to describe his feelings. He reported a deep desire to help “Young Chris”. “I want to help, I want you to know you are going to be ok.” When I asked that he focus on what the “Young Chris” part of himself was feeling he replied, “He’s very scared, frightened, he doesn’t want to move.” I asked him to try to sense if it would be ok with the “Young Chris” part of him if he were to move very slowly in his direction. Surprisingly, Chris’ body jerked and he looked as if he were angry. He explained, “I moved toward him, I reached out to him, I extended my arm, I want to hold him and help him, but he turned away and moved back into the shadows”. Chris became very critical and angry of the young part of himself, calling him “a coward, stupid, a stupid little boy, he’s ignorant, he’s a coward.” This angry, critical attack on “Young Chris” was inconsistent with the Chris I have come to know. This was not his usual manner of speaking; there was an unusual tone to his voice and he looked scornful. Chris had switched self-states, sounding similar to his critical, abusive mother. Later when we talked about his experience he explained that the manner in which he criticized “Young Chris” was the same way he had been treated by his mother, “And I learned to run away from her, I learned not go to her when she said ‘come here I love you, let me hug you’, because when I did go to her she wouldn’t hug me, she’d beat me. I learned to run away from her and I was punished for that as well.” Chris’ attempt to shed light on a previously dissociated part of himself allowed him to feel the sadness, vulnerability, and fear that had characterized his childhood. During the second attempt to make contact with the previously dissociated part of himself he acted somewhat impulsively.
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He acted on his adult, conscious desire to be helpful. The adult Chris not fully feeling how traumatized and terrified the “Young Chris” part of him is, how frightened of human contact and intimacy he is, frightened this part of himself. Later in the session Chris was both surprised and shocked by his angry, critical, and scornful reaction to this younger part, who in anticipation of being abused, retreated from the adult Chris’ attempt at contact.
DISCUSSION
These examples reflect Doris and Chris’ attempts to make contact with parts of themselves that have been dissociated. The tearful moment I witnessed when talking with Doris’ “Assemblage of voices” displayed the power and effectiveness of dissociation. The feelings in Doris that resulted in tears meandering down her face were not those of “the assemblage of voices” or those of Doris. They were the feelings of a still dissociated self-state that remain unknown and unavailable at this time. Chris’ experience afforded us a deeper understanding and him a felt sense of why close, intimate relationships have been fraught with so much anxiety and fear; why he has been so reticent to allow anyone to get close to him. In additional, his angry and scornful reaction to the retreating “young Chris” represents an internalization of his perpetrator-mother. The surprise and confusion Chris experienced as he became aware of this uncharacteristically critical part of himself, was our initial glimpse of this dissociated part of him that is identified with his mother, that is, identification with the aggressor in Ferenczi’s sense of the term (see Howell, 2014). A therapist can only work with a person’s dissociated self-states if he/she can convey to the patient his/her understanding, curiosity and desire to engage in a meaningful dialog and relationship with all the different ways in which the patient has come to be. A sensitively engaged, and attuned therapist who understands dissociative processes and the physical manifestations that often accompany them is likely to recognize these processes as they emerge in the patient and in the multiple transferences that accompany multiple self-states. And with multiple transferences come multiple countertransferences. Working within a framework of co-participation (Fiscalini, 2004) and co-construction of relationships, the analyst takes responsibility for her contribution to the relationships with each of the patient’s self-states. In doing so however, it is imperative that the analyst remains true to her self and be herself with each self-state. By engaging the patient in this manner, each of the patient’s self-states has experiences with one consistent and predictable person/analyst, which ultimately contributes to the patient’s awareness of and sharing of simultaneous self-experience.
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As dissociated self-states become manifest, fear, confusion, and anxiety may accompany the growing awareness of these states. The goal of the working through process is not necessarily the consolidation of self-states into a single, integrated individual. The goal of analysis is working toward resolving the need for and reliance upon dissociation as a means of protecting the self. During infancy and early childhood dissociative processes, and the dissociative structure of the mind develops in response to developmental trauma. Dissociation preserves the child’s sanity by encapsulating experience that is too overwhelming, emotionally flooding, and beyond the child’s limited emotional and cognitive ability to cope. As selfstates become less dissociated and more associated, the capacity for simultaneous shared experience increases and the patient begins to feel a more coherent sense of self. The healing aspect of working with dissociated self-states emerges not only with the therapist helping the person become aware of her previously dissociated states, but in helping the person understand and negotiate meaningful forms of relatedness with these heretofore unknown parts of herself. A sense of unity or wholeness, even if illusory, can only emerge when all of the previously dissociated states are comfortable enough and trust each other enough to release the strangle hold that is dissociation so that they can simultaneously share in self experience.
ACKNOWLEDGEMENTS
The author wishes to thank Philip Bromberg and Elizabeth Howell for their profound influence on his work. He also wishes to thank Robert Prince for his assistance in the preparation of this paper, and Giselle Galdi for explaining the importance of Horney’s ideas of basic anxiety and its relationship to dissociation.
NOTES 1. Sheldon Itzkowitz, Ph.D., ABPP is a Faculty member and Clinical Consultant at the NYU Postdoctoral Program in Psychotherapy & Psychoanalysis, Guest Faculty, the Eating Disorders, Compulsions, and Addictions Program of The William Alanson White Institute, and on the teaching and supervisory faculty of the National Institute for the Psychotherapies training program in psychoanalysis. Dr. Itzkowitz is an associate editor of Psychoanalytic Perspectives. He is in full time practice in Manhattan where he practices psychoanalysis, psychoanalytic psychotherapy, and provides clinical supervision. Dr. Itzkowitz has presented his work with extremely dissociated individuals both nationally and internationally. 2. The Roundtable Discussion, “What is effective in the therapeutic process?” took place at the Annual Meeting of the American Psychiatric Association in Chicago, Illinois on May 1, 1956.
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Bella S. Van Bark, M.D. moderated the panel. Other presenters were Elizabeth Kilpatrick, M.D., Lewis Wolberg, M.D., Marianne Horney Eckardt, M.D., Frederick A. Weiss, M.D., Leslie H. Farber, M.D., Louis E. DeRosis, M.D., and Silvano Arieti, M.D. 3. The Scientific Program Committee of the Association for the Advancement of Psychoanalysis, under the chairmanship of Dr. Frederick A. Weiss, arranged the Roundtable Discussion, “What Leads to Basic Change in Psychoanalytic Therapy?” at the New York Academy of Medicine in the Spring of 1964. Melvin Boigon, M.D. moderated the panel. Other participants were William V. Silverberg, M.D., Frederick A. Weiss, M.D. and Alfred H. Rifkin, M.D.
REFERENCES Arieti, S. (1957). What is effective in the therapeutic process? American Journal of Psychoanalysis 17(1), 30–33. (Republished in: R. Prince (Ed.) (2015). Special Issue. What is effective in psychoanalytic psychotherapy? A historical reprise. American Journal of Psychoanalysis, 75(2), 217–223. van Bark, B. S., Wolberg, L. R., Eckardt, M. H., Weiss, F. A., Farber, L. H., De Rosis, L. & Arieti, S. (1957). What is effective in the therapeutic process? The American Journal of Psychoanalysis, 17(1), 3–33. Boigon, M. (1965). What leads to basic change in psychoanalytic therapy? A roundtable discussion. The American Journal of Psychoanalysis, 25(2), 129–141. Bromberg, P. (1998). Standing in the spaces. New York: Psychology Press. Bromberg, P. (2006). Awakening the dreamer: Clinical journeys. New York: The Analytic Press. Bromberg, P. (2011). The shadow of the Tsunami. New York: Routledge. Chefetz, R. A. (2015). Intensive psychotherapy for persistent dissociative processes: The fear of feeling real. New York: W.W. Norton. Fiscalini, J (2004). Coparticipant psychoanalysis: Toward a new theory of clinical inquiry. New York: Columbia University Press. Galdi, G. (2007). The analytic encounter: A scene of clashing cultures. American Journal of Psychoanalysis, 67(1), 4–21. Horney, K. (1939). New ways in psychoanalysis. New York: Norton. Howell, E. F. (2005). The dissociative mind. New York: Routledge. Howell, E. F. (2011). Understanding and Treating dissociative identity disorder: A relational approach. New York: Routledge. Howell, E. F. (2014). Ferenczi’s concept of identification with the aggressor: Understanding dissociative structure with interacting victim and abuser self-states. The American journal of psychoanalysis, 74(1), 48–59. Kluft, R. P. (1992). Discussion: A specialist’s perspective on multiple personality disorder. Psychoanalytic inquiry, 12(1), 139–171. Kluft, R. P. & Fine, C. G. (Eds.) (1993). Clinical perspectives on multiple personality disorder. Washington DC: American Psychiatric Press. Kluft, R. P. (2000). The psychoanalytic psychotherapy of dissociative identity disorder in the context of trauma therapy. Psychoanalytic inquiry, 20(2), 259–286. Stern, D. (2003). Unformulated experience. Hillsdale, NJ: The Analytic Press.
