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Dissociative processes bias the psychodynamics underlying the subjective experience of self and the organization of mind
Dissociative processes bias the psychodynamics underlying the subjective experience of self and the organization of mind
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Richard A. Chefetz1,2 1 Washington Baltimore Center for Psychoanalysis, Washington, DC, United States, 2 Institute of Contemporary Psychotherapy & Psychoanalysis, Washington, DC, United States
A dear friend of mine was recovering from a cardiac valve replacement in the home of his girlfriend, who was away on travel. They had become increasingly close to each other and had been dating for several years. I asked him, “So how are things going with her?” He replied, “Oh, she’s just been totally wonderful. She was so present and responsive after my surgery. I wish she were here now. It feels funny being in her home without her.” “You must miss her a lot,” I observed. “Oh, I do,” he said. “You know, I just thought about something as you asked me about her, but I hadn’t put things together. She has this odd habit of eating several crackers before she comes to bed. I always tell her to keep the crackers on her side of the bed. I don’t want to sleep on cracker crumbs. When we’re at my place, I won’t even let her in the bedroom with her crackers. What I thought of when you said I must miss her is that ever since I started staying here without her, I find myself taking several crackers to bed with me and eating them before I go to sleep!” How did my friend not know what he was doing when he was doing it and then develop awareness of it only when we talked about his loving feelings for his girlfriend? Direct infant observation (Bick, 1968; Bowlby, 1958) eventually led to an appreciation of the impact of environmental disturbances on the developing mind in contrast to metapsychological drives gone awry (Bacciagaluppi, 1994; Rayner, 1991). Similarly, a multiple self-state model of mind (Bromberg, 1998; Federn, 1940; Ferenczi, 1955; Mitchell, 1991; Stern, 1997) was a paradigm-shifting embrace of interpersonal trauma guiding the formation of mind, whether that be developmental (parental preoccupation, dismissiveness, or alternating frightening and nonfrightening behavior) or blunt trauma (rape, bullying, beating). Dissociative processes are on an equal footing with associative processes in the achievement of a coherent mind (Chefetz, 2015a; Howell, 2005). We ignore dissociative processes at our personal and clinical peril. They provide parsimonious explanations for some seemingly insoluble clinical problems: Contemporary Psychodynamic Psychotherapy. DOI: https://doi.org/10.1016/B978-0-12-813373-6.00020-9 © 2019 Elsevier Inc. All rights reserved.
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sadomasochism, addictions, treatment-resistant depression, somatization disorders, unremitting posttraumatic stress disorder, bulimia, anorexia, chronic depersonalization, fugue, and multiple personality disorder, now known as dissociative identity disorder (DID). In DID there is an inability to maintain a single, coherent, whole sense of self; the sense of self is in disarray, and a person with DID is often at a loss as to explain his or her subjective experience: “How is it that I can be so competent at work one day and then with just the slightest emotional strain end up feeling like a child who wants to hide under the desk rather than tell the boss the additional merits of my project that I just told her about yesterday?” For the bulimic patient the lament sounds like this: “I was doing so well, and then for reasons I don’t understand, when 10 p.m. came around, I became fretful, and the next thing I knew, I had ordered a pizza. My belly hurt so badly by the time I finished stuffing my mouth that I ended up hugging the toilet bowl again; and that’s the last thing I remember before waking up this morning on the bathroom floor.” It’s not that all the conditions listed above always have underlying active dissociative processes, and it’s also true that dissociative processes gone awry are common enough that the therapist should remain open to the possibility of noticing something that could be life-changing for some individuals. For example, about 40% or more of people with borderline personality disorder have a dissociative disorder, and 40% or more of people with DID have borderline personality disorder (Brand & Lanius, 2014). Dissociative symptoms in borderline personality disorder are exceedingly important in regard to recalcitrance (Korzekwa, Dell, & Pain, 2009; Kleindienst et al., 2011; Zanarini, Frankenburg, Jager-Hyman, Reich, & Fitzmaurice, 2008; Zanarini, Ruser, Frankenburg, & Hennen, 2000). Parsing the differences between dissociative and borderline adaptations to living is critical to an effective approach to psychotherapy.
A delicate balance between associative and dissociative processes Heuristically, as perception evolves, there is an unconscious sorting of mental content for salience, linking together felt experience with the ongoing narrative of the moment, and, ideally, creation of an intellectually honest and coherent appraisal. While an associative process establishes higher relevance, a dissociative process does the opposite, pruning from awareness what a mind unconsciously and automatically assesses doesn’t fit. The dissociative process also protects a mind from overload, facilitating focused attention by removing the extraneous from perception (e.g., the feeling of eyeglasses sitting on a nose), and can be actively enlisted via conscious intent (e.g., “I’m not going to think about that now, I don’t have time for it”) (Loewenstein, 1991). When our worldview can neither assimilate painful new experience nor enlarge itself to accommodate perceived danger (Horowitz, 1986), association may be halted (“I can’t think, it’s too upsetting!”), and dissociation may hold sway.
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Dissociation truncates destabilizing perception (e.g., “When the attack started, there was this odd calm that took me over, and my mind stayed clear while my body wasn’t in the picture. I didn’t notice I was bleeding until it was all over.”). Persistent, intensified, dissociative processes create a problem (e.g., “There’s never been a time in my life when I felt any different even though I knew other people had reactions I wasn’t having, and I don’t think I’m normal.”). Dissociation is normal, just like association. However, too much dissociation distorts and robs us of coherent reality, just as too much association is characteristic of obsessional styles of thinking (Chefetz, 2015a) and may become an obsessional plague of isolated affect, denial, and undoing (S. Freud, 1909).
Some specific bias of unconscious activity by dissociative processes Dissociative processes are multidimensional: psychological, psychophysiological, neurobiological, and somatic. The more intense, sustained, and persistent dissociative processes wreak havoc upon perception and readily decontextualize painful experience into colorless, meaningless pablum. For example, psychic pain is enormous when a sadistic perpetrator physically or sexually brutalizes somebody and then softens the approach: “I can see you’re really hurting. I can see you’re really mad. I understand. I know you want to hit me. It’s okay. You can do it. It’ll be alright. Come on. Do it. You’ll feel a whole lot better if you just let go and hit me. I know you want to, don’t you?” Even a flicker of recognition in the victim that he or she wishes to lash out produces the perpetrator’s desired effect. If there is no flicker, the wish is correctly assumed: “See, you’re such a coward. You don’t have the guts to even try and protect yourself. The fact is, I know you like what I did to you. It’s just that you’re even more pathetic than I thought you were. You can’t even say it, you’re just pond scum and nothing more. If you were even a shadow of a person, you’d already have hit me, but you are nothing. You don’t even deserve to live. You’d do the world a favor if you just killed yourself. I’d do it, but you’re not worth the effort.”1 A child or adult mind crumbles under this onslaught. The shame of even existing predominates and cements in place a complex mix of selfhatred, fear, loathing, humiliation, and rage—none of which can be expressed outwardly, since the perpetrator then follows the diatribe with “The only thing you’re good for is to be hurt, just the way you like it.” And then the perpetrator hurts the target person yet again. Clinicians often write about anxiety or fear but rarely about terror. Intensity on the level of terror or profound shame can evoke a dissociative response. Anxiety 1
To read about the sequence of grooming efforts for pedophilic manipulation, see http://www.wvva.com/ story/16007807/penn-state-scandal-view-the-sandusky-grand-jury-transcript, the grand jury report on the activities of Jerry Sandusky at Pennsylvania State University.
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allows thinking to proceed, but fear or terror truncates that possibility (Davis, Walker, Miles, & Grillon, 2010; LeDoux & Pine, 2016). When a mind registers terror, it’s never just a little bit. There is no such thing as being half-terrified. To be in the grip of terror is to suffer an indignity, a profound sense of shame over loss of efficacy and agency. Rage may flicker to life under such an assault but is then humiliated and welded to the shame (Lewis, 1987). Fear of expressing anger often results. The circuit breaker of a dissociative process ensures emotional numbness, out-of-body experience (depersonalization), perceiving a veil covering what can be seen (derealization), partial or complete amnesia, identity confusion (forgetting one’s name), and identity alteration (e.g., “Who is that poor kid on the floor being raped? Glad I’m up here on the ceiling, safe. I’m Richard, and that kid down there is not me.”). Dissociative processes also include things like denial, isolation of affect, and disavowal. Yes, standard mechanisms of defense (Freud, 1936) have a dissociative engine under the hood. In denial the facts of a situation are kept unlinked from the counterfeit story of the event, while disavowal unlinks the reality of a behavior. In the wake of profound interpersonal trauma and dissociation, self-assertion and relatedness are feared. Anger is neither possible nor bearable. Humiliation is not tolerable. Confrontation and engaging in controversy are outside of the bounds of probability. Think of George and Martha in Who’s Afraid of Virginia Woolf (Albee, 1990) or the family scene in A Delicate Balance (Albee, 1966), or perhaps a Cat on a Hot Tin Roof is more to your illustrative liking (Williams, 2014). The toxicity of these family scenes is well known as the hell of adults. But what if you are 3 years old and in the middle of it all? An intensely activated dissociative process can be merciful at its inception, but it is a devil’s bargain when persistent.
The parsimony of a multiple self-state model of mind An activated dissociative process leads to unintegrated remnants of infancy, childhood, latency, teenage, and early adult years, naturalistically congealing isolated self-states, as if without meaning or relationship, into a disorganized/disoriented arrangement (Main & Morgan, 1996). A model of mind in the clinician’s mind that is a match for the patient’s mind is uplifting for the patient and contributes to the feeling of being understood. A person wrote to me, after a recent consultation at which I administered the Cambridge Depersonalization Scale, “. . . the test you had me do was the first one given to me that actually spoke to me, that came closest to articulating what I am feeling, which is that I feel more fractured and disintegrated of late and it really isn’t fun.” This feeling of the clinician “getting it about me” is worth its weight in gold and then some. The challenge is to have a model that both fits the way people are and is anchored firmly in science. It is our good fortune that clinical science has finally caught up with our humanity. Sophisticated analyses of mother infant interaction show microattunements to nonverbal experience (Beebe et al., 2016) that likely underlie the feeling of being
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understood. The mental states of infancy persist into adulthood as patterned behaviors (Hesse, 1999; George, Kaplan, & Main, 1996; Lyons-Ruth, 2003; Main & Goldwyn, 1985; Ogawa, Sroufe, Weinfield, Carlson, & Egelend, 1997; Van IJzendoorn, 1995). Bowlby’s original descriptions of deactivation, segregated subsystems, and defensive exclusion (all dissociative processes) are part of enduring internal working models of self and the world (self-state formation) elaborated as the patterns of attachment in relation to discrete, repetitive, enduring behavioral states (Bowlby, 1980; Bretherton, 1992). Bowlby noted Anna Freud and Dorothy Burlingham’s observations at the Hampstead clinic: “children will cling even to mothers who are continually cross and sometimes cruel to them. The attachment of the small child to his mother seems to a large degree independent of her personal qualities” (Burlingham & Freud, 1942, p. 47, in Bowlby, 1958, p. 353). Bowlby also observed, “The extent to which the attachment seems to be independent of what is received is very plain in these records.” The child has a social tie to the mother, a way of “being with” the mother. These ways of being are what I observe in my adult dissociative patients who have “different ways of being” for different relational constellations that solidify into “different ways of being me.” The fabric of mind is relational. A multiple self-state model of mind is inclusive of these perspectives. Putnam’s discrete behavioral state model of mind (Putnam, 1997) was based significantly upon the observational work of Peter Wolff (1987) and later advanced that model (Putnam, 2016) to make use of the concept of “state spaces” promulgated by the work of the “baby watchers” in their study of infants and sleep patterns. The organization of self occurs in a naturalistic fashion (Stechler & Kaplan, 1980) that creates a knitting together of multiple states of being to provide the illusion of a unitary self. These are the states of mind that undergird the feeling of having a mind (Siegel, 1999). Wolff’s careful descriptions of the behavioral islands that infants occupy in one state or another—sleep, active alert, distress, hungry, and so on—easily comport with the notion of the healthy parent who builds bridges between islands as the attuned mother knows when her baby is about to need something. Healthy parents can feel the need before they can even tell you how they know it. Bowlby recognized how parents who never learned to be responsive to the needs of others—who lack bridge-building skills or who oppose building bridges that might threaten their own stability—can have a powerful formative effect on the mind of the child, as psychodynamics take a direct hit and become indelibly biased toward isolating selfstates and favoring discontinuity of self and other perception. Putnam’s borrowed concept of the state space derived from mapping things such as heart rate, respiratory rate, and physical movement in three dimensions allowed computer plotting of behavioral patterns. These patterns repeated as a sequential and somewhat predictable series of state changes that involved movement from states such as active alert to hungry, satiated, sleepy, inactive alert, and so on. Of note was that some state space shifts were unidirectional, for example, from satiated to sleepy; shifts from sleepy to satiated did not occur. It is more challenging to track state-space shifts in adults, but in highly dissociative individuals the switches
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are more obvious, since there may be a change in posture, a change in the person’s fund of knowledge, an abridged life history, a constricted range of affect, time distortion (state-related flashback quality misattributions of year, place, and situation), or elevated adrenalin secondary to anticipation of abuse. Wise clinicians learn to watch a patient’s respiratory rate and depth of respiration, degrees of physical tension, stigmata of rapid heart rate (e.g., venous neck pulsations), and tapping of fingers or foot or leg movement as signs of affective disturbance that may not be conscious for the patient and represent an impending or already completed statespace change that would predict future behavior. These switches are observable as unpredictable or unreliable behaviors and a changeable worldview; discontinuity of experience is the password for understanding such a person’s life and clinical presentation (Chefetz, 2015b). It’s as if two different people, with different sensibilities, take turns speaking while appearing to be one person. It can be confusing. For example, an especially sophisticated upper-level manager in a large corporation had, in her early childhood, hidden in a closet to escape repetitive violent rape. A shift in ergonomic planning by her company and a move to a new headquarters building completely undid her usual calm at work. Bereft of her familiar office and unable to unconsciously hide and regroup herself emotionally with the new open office glass walls, she became uncharacteristically frightened of going to work. She accumulated some degree of absenteeism before reporting the change to me. Asking her to tell me the details of her experience led (after barely 10 seconds of her effort) this 50-year-old woman in business attire, but now with fear on her face, to draw her knees under her chin while sitting in the chair in my office. Making an apparent effort to wedge herself into the corner of the upholstery, she began to squeal a distress call that was somehow both muffled and also pierced the air between us as a keening that was nearly unbearable to hear. I was confronted with the childlike state space of the past, manifested as a more organized self-state accompanied by flashback-quality experience. Sadly, this is frequently the standard work in the psychotherapy of complex posttraumatic stress disorder and the dissociative disorders. This is not regression; it is a dissociative process in action. Another theoretical approach to the psychology of mental states and “the way we are” is the theory of mentalization (Bateman & Fonagy, 2006; Fonagy, Gergely, Jurist, & Target, 2003; Fonagy & Target, 2007; Gergely, Nadasdy, Csibra, & Biro, 1995; Gergely & Watson, 1996) that is unintentionally supportive of a multiple self-state model of mind while focusing on the importance of mental states. Cognitive-affective-interpersonal schemas (Luyten, Blatt, & Fonagy, 2013) are an extension of the early theory of mentalization, which emphasizes some of the core concerns of a multiple self-state psychology (Chefetz & Bromberg, 2004). The achievement of reflective function and theory of mind arises from the developmental trajectory described by mastering psychic equivalence, pretend, and teleological modes of thinking. This builds on earlier work regarding intentionality and causality (Dennett, 1971) as modes of thinking. The notion of the alien self (Fonagy et al., 2003) is in lockstep with the multiple self-state model but is not noted as such. Achieving a capacity for reflective functioning, the ability to imagine the mental states of others, is predictive of positive outcome in psychotherapy
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(Cologon, Schweitzer, King, & Nolte, 2017). The ability to first imagine and then attune to isolated mental states in one’s own mind is also predictive of positive outcome in the psychotherapy of DID, in my experience.
Some regulatory tasks creating coherent consciousness The psychodynamics of self-states tend to be organized around two unconscious tasks: narrative regulation and affect regulation. When dissociative processes hold sway and go beyond simple pruning to maintain everyday coherent mentation, they act in the service of achieving a counterfeit assimilation or accommodation of a worldview by eliminating memories (amnesias) or distorting the facts of the events (typically denial and disavowal) to change the narrative into a consciously acceptable story (e.g., “I had a normal childhood and a typical family life”) and/or reducing one’s capacity to know feeling (e.g., “That doesn’t mean anything to me, I feel nothing about what happened or who was involved, it just is”). This is typical of complex PTSD (Herman, 1992) or borderline personality disorder (Zanarini et al., 2008). Deflection, dissembling, and grossly misleading statements or actions befuddle and confuse the uneducated therapist. Active or passive neglect in childhood, blunt or developmental trauma, repetitive childhood medical or surgical illness, bullying (Teicher, Samson, Sheu, Polcari, & McGreenery, 2010), parental alcoholic rages, emotionally violent marital discord, traumatic narcissism (Shaw, 2013), and dissociatively held parental trauma (Yehuda et al., 2014) generate these constellations of dissociative adaptation in childhood. Psychodynamics are profoundly influenced by dissociative processes that hide from awareness the underlying meanings of experience, behavior, and motivation. Affect regulation often succumbs to depersonalized numbness, obsessional isolation, secondary alexithymia, and explosive failures to contain the unbearable as it demands expression.
Profound bias of psychodynamics by dissociative processes A 35-year-old man with DID, who had been in twice-weekly psychotherapy for 10 years, was increasingly disturbed by tension with his wife and his awareness of his deep love for her simultaneous with his wish to not be touched and his frequent, but entirely intermittent, fascination with the bodies of men. As his psychotherapy progressed, he became aware of a self-state oriented to about age 4 who occupied an internal transitional space (Chefetz, 2015a) complete with the subjective experience of being on a raft. Being touched interrupted the reverie of the emotional isolation contingent with being on the raft and put him at risk of emotional overload. Fascination with the bodies of men began with an experience during his teenage years that left him and others wondering whether he was homosexual. His profound depersonalization, of which he had earlier been unaware, and his lack of being able
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to feel himself alive in his body produced a longing to know what it felt like to be an alive man, a man with a body. Consciousness of these dynamics and a deep discussion directly with the isolated self-states of the patient (Kluft, 2006) led to resolution of his need to keep at a physical distance from his wife and to the rekindling of their sexual relationship. Preoccupations with men’s bodies dissolved as his depersonalization grossly decreased. Without an understanding of dissociative processes, an unknowing clinician might simply have found these problems unresolvable or assumed that the patient was more interested in being with men than with women. Dissociative processes distort psychodynamics and are essential to our understanding of our humanity in the wake of developmental or frank traumatic experience.
Conclusion In the study of being human it is often true that extremes teach us much about what is in the middle. Dissociative processes are normal. When they are provoked to a higher level of activation and persist long after their utility has expired, they distort subjective experience and psychodynamics. The clinician who is interested in cases that don’t improve after much effort should take a good look at dissociative experience and how those processes guide psychodynamics. If it doesn’t help a particular person now, this new knowledge and curiosity will likely not wait for long before it is rewarded with growth in another human being.
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Richard A. Chefetz1,2 1 Washington Baltimore Center for Psychoanalysis, Washington, DC, United States, 2 Institute of Contemporary Psychotherapy & Psychoanalysis, Washington, DC, United States
A dear friend of mine was recovering from a cardiac valve replacement in the home of his girlfriend, who was away on travel. They had become increasingly close to each other and had been dating for several years. I asked him, “So how are things going with her?” He replied, “Oh, she’s just been totally wonderful. She was so present and responsive after my surgery. I wish she were here now. It feels funny being in her home without her.” “You must miss her a lot,” I observed. “Oh, I do,” he said. “You know, I just thought about something as you asked me about her, but I hadn’t put things together. She has this odd habit of eating several crackers before she comes to bed. I always tell her to keep the crackers on her side of the bed. I don’t want to sleep on cracker crumbs. When we’re at my place, I won’t even let her in the bedroom with her crackers. What I thought of when you said I must miss her is that ever since I started staying here without her, I find myself taking several crackers to bed with me and eating them before I go to sleep!” How did my friend not know what he was doing when he was doing it and then develop awareness of it only when we talked about his loving feelings for his girlfriend? Direct infant observation (Bick, 1968; Bowlby, 1958) eventually led to an appreciation of the impact of environmental disturbances on the developing mind in contrast to metapsychological drives gone awry (Bacciagaluppi, 1994; Rayner, 1991). Similarly, a multiple self-state model of mind (Bromberg, 1998; Federn, 1940; Ferenczi, 1955; Mitchell, 1991; Stern, 1997) was a paradigm-shifting embrace of interpersonal trauma guiding the formation of mind, whether that be developmental (parental preoccupation, dismissiveness, or alternating frightening and nonfrightening behavior) or blunt trauma (rape, bullying, beating). Dissociative processes are on an equal footing with associative processes in the achievement of a coherent mind (Chefetz, 2015a; Howell, 2005). We ignore dissociative processes at our personal and clinical peril. They provide parsimonious explanations for some seemingly insoluble clinical problems: Contemporary Psychodynamic Psychotherapy. DOI: https://doi.org/10.1016/B978-0-12-813373-6.00020-9 © 2019 Elsevier Inc. All rights reserved.
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sadomasochism, addictions, treatment-resistant depression, somatization disorders, unremitting posttraumatic stress disorder, bulimia, anorexia, chronic depersonalization, fugue, and multiple personality disorder, now known as dissociative identity disorder (DID). In DID there is an inability to maintain a single, coherent, whole sense of self; the sense of self is in disarray, and a person with DID is often at a loss as to explain his or her subjective experience: “How is it that I can be so competent at work one day and then with just the slightest emotional strain end up feeling like a child who wants to hide under the desk rather than tell the boss the additional merits of my project that I just told her about yesterday?” For the bulimic patient the lament sounds like this: “I was doing so well, and then for reasons I don’t understand, when 10 p.m. came around, I became fretful, and the next thing I knew, I had ordered a pizza. My belly hurt so badly by the time I finished stuffing my mouth that I ended up hugging the toilet bowl again; and that’s the last thing I remember before waking up this morning on the bathroom floor.” It’s not that all the conditions listed above always have underlying active dissociative processes, and it’s also true that dissociative processes gone awry are common enough that the therapist should remain open to the possibility of noticing something that could be life-changing for some individuals. For example, about 40% or more of people with borderline personality disorder have a dissociative disorder, and 40% or more of people with DID have borderline personality disorder (Brand & Lanius, 2014). Dissociative symptoms in borderline personality disorder are exceedingly important in regard to recalcitrance (Korzekwa, Dell, & Pain, 2009; Kleindienst et al., 2011; Zanarini, Frankenburg, Jager-Hyman, Reich, & Fitzmaurice, 2008; Zanarini, Ruser, Frankenburg, & Hennen, 2000). Parsing the differences between dissociative and borderline adaptations to living is critical to an effective approach to psychotherapy.
A delicate balance between associative and dissociative processes Heuristically, as perception evolves, there is an unconscious sorting of mental content for salience, linking together felt experience with the ongoing narrative of the moment, and, ideally, creation of an intellectually honest and coherent appraisal. While an associative process establishes higher relevance, a dissociative process does the opposite, pruning from awareness what a mind unconsciously and automatically assesses doesn’t fit. The dissociative process also protects a mind from overload, facilitating focused attention by removing the extraneous from perception (e.g., the feeling of eyeglasses sitting on a nose), and can be actively enlisted via conscious intent (e.g., “I’m not going to think about that now, I don’t have time for it”) (Loewenstein, 1991). When our worldview can neither assimilate painful new experience nor enlarge itself to accommodate perceived danger (Horowitz, 1986), association may be halted (“I can’t think, it’s too upsetting!”), and dissociation may hold sway.
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Dissociation truncates destabilizing perception (e.g., “When the attack started, there was this odd calm that took me over, and my mind stayed clear while my body wasn’t in the picture. I didn’t notice I was bleeding until it was all over.”). Persistent, intensified, dissociative processes create a problem (e.g., “There’s never been a time in my life when I felt any different even though I knew other people had reactions I wasn’t having, and I don’t think I’m normal.”). Dissociation is normal, just like association. However, too much dissociation distorts and robs us of coherent reality, just as too much association is characteristic of obsessional styles of thinking (Chefetz, 2015a) and may become an obsessional plague of isolated affect, denial, and undoing (S. Freud, 1909).
Some specific bias of unconscious activity by dissociative processes Dissociative processes are multidimensional: psychological, psychophysiological, neurobiological, and somatic. The more intense, sustained, and persistent dissociative processes wreak havoc upon perception and readily decontextualize painful experience into colorless, meaningless pablum. For example, psychic pain is enormous when a sadistic perpetrator physically or sexually brutalizes somebody and then softens the approach: “I can see you’re really hurting. I can see you’re really mad. I understand. I know you want to hit me. It’s okay. You can do it. It’ll be alright. Come on. Do it. You’ll feel a whole lot better if you just let go and hit me. I know you want to, don’t you?” Even a flicker of recognition in the victim that he or she wishes to lash out produces the perpetrator’s desired effect. If there is no flicker, the wish is correctly assumed: “See, you’re such a coward. You don’t have the guts to even try and protect yourself. The fact is, I know you like what I did to you. It’s just that you’re even more pathetic than I thought you were. You can’t even say it, you’re just pond scum and nothing more. If you were even a shadow of a person, you’d already have hit me, but you are nothing. You don’t even deserve to live. You’d do the world a favor if you just killed yourself. I’d do it, but you’re not worth the effort.”1 A child or adult mind crumbles under this onslaught. The shame of even existing predominates and cements in place a complex mix of selfhatred, fear, loathing, humiliation, and rage—none of which can be expressed outwardly, since the perpetrator then follows the diatribe with “The only thing you’re good for is to be hurt, just the way you like it.” And then the perpetrator hurts the target person yet again. Clinicians often write about anxiety or fear but rarely about terror. Intensity on the level of terror or profound shame can evoke a dissociative response. Anxiety 1
To read about the sequence of grooming efforts for pedophilic manipulation, see http://www.wvva.com/ story/16007807/penn-state-scandal-view-the-sandusky-grand-jury-transcript, the grand jury report on the activities of Jerry Sandusky at Pennsylvania State University.
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allows thinking to proceed, but fear or terror truncates that possibility (Davis, Walker, Miles, & Grillon, 2010; LeDoux & Pine, 2016). When a mind registers terror, it’s never just a little bit. There is no such thing as being half-terrified. To be in the grip of terror is to suffer an indignity, a profound sense of shame over loss of efficacy and agency. Rage may flicker to life under such an assault but is then humiliated and welded to the shame (Lewis, 1987). Fear of expressing anger often results. The circuit breaker of a dissociative process ensures emotional numbness, out-of-body experience (depersonalization), perceiving a veil covering what can be seen (derealization), partial or complete amnesia, identity confusion (forgetting one’s name), and identity alteration (e.g., “Who is that poor kid on the floor being raped? Glad I’m up here on the ceiling, safe. I’m Richard, and that kid down there is not me.”). Dissociative processes also include things like denial, isolation of affect, and disavowal. Yes, standard mechanisms of defense (Freud, 1936) have a dissociative engine under the hood. In denial the facts of a situation are kept unlinked from the counterfeit story of the event, while disavowal unlinks the reality of a behavior. In the wake of profound interpersonal trauma and dissociation, self-assertion and relatedness are feared. Anger is neither possible nor bearable. Humiliation is not tolerable. Confrontation and engaging in controversy are outside of the bounds of probability. Think of George and Martha in Who’s Afraid of Virginia Woolf (Albee, 1990) or the family scene in A Delicate Balance (Albee, 1966), or perhaps a Cat on a Hot Tin Roof is more to your illustrative liking (Williams, 2014). The toxicity of these family scenes is well known as the hell of adults. But what if you are 3 years old and in the middle of it all? An intensely activated dissociative process can be merciful at its inception, but it is a devil’s bargain when persistent.
The parsimony of a multiple self-state model of mind An activated dissociative process leads to unintegrated remnants of infancy, childhood, latency, teenage, and early adult years, naturalistically congealing isolated self-states, as if without meaning or relationship, into a disorganized/disoriented arrangement (Main & Morgan, 1996). A model of mind in the clinician’s mind that is a match for the patient’s mind is uplifting for the patient and contributes to the feeling of being understood. A person wrote to me, after a recent consultation at which I administered the Cambridge Depersonalization Scale, “. . . the test you had me do was the first one given to me that actually spoke to me, that came closest to articulating what I am feeling, which is that I feel more fractured and disintegrated of late and it really isn’t fun.” This feeling of the clinician “getting it about me” is worth its weight in gold and then some. The challenge is to have a model that both fits the way people are and is anchored firmly in science. It is our good fortune that clinical science has finally caught up with our humanity. Sophisticated analyses of mother infant interaction show microattunements to nonverbal experience (Beebe et al., 2016) that likely underlie the feeling of being
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understood. The mental states of infancy persist into adulthood as patterned behaviors (Hesse, 1999; George, Kaplan, & Main, 1996; Lyons-Ruth, 2003; Main & Goldwyn, 1985; Ogawa, Sroufe, Weinfield, Carlson, & Egelend, 1997; Van IJzendoorn, 1995). Bowlby’s original descriptions of deactivation, segregated subsystems, and defensive exclusion (all dissociative processes) are part of enduring internal working models of self and the world (self-state formation) elaborated as the patterns of attachment in relation to discrete, repetitive, enduring behavioral states (Bowlby, 1980; Bretherton, 1992). Bowlby noted Anna Freud and Dorothy Burlingham’s observations at the Hampstead clinic: “children will cling even to mothers who are continually cross and sometimes cruel to them. The attachment of the small child to his mother seems to a large degree independent of her personal qualities” (Burlingham & Freud, 1942, p. 47, in Bowlby, 1958, p. 353). Bowlby also observed, “The extent to which the attachment seems to be independent of what is received is very plain in these records.” The child has a social tie to the mother, a way of “being with” the mother. These ways of being are what I observe in my adult dissociative patients who have “different ways of being” for different relational constellations that solidify into “different ways of being me.” The fabric of mind is relational. A multiple self-state model of mind is inclusive of these perspectives. Putnam’s discrete behavioral state model of mind (Putnam, 1997) was based significantly upon the observational work of Peter Wolff (1987) and later advanced that model (Putnam, 2016) to make use of the concept of “state spaces” promulgated by the work of the “baby watchers” in their study of infants and sleep patterns. The organization of self occurs in a naturalistic fashion (Stechler & Kaplan, 1980) that creates a knitting together of multiple states of being to provide the illusion of a unitary self. These are the states of mind that undergird the feeling of having a mind (Siegel, 1999). Wolff’s careful descriptions of the behavioral islands that infants occupy in one state or another—sleep, active alert, distress, hungry, and so on—easily comport with the notion of the healthy parent who builds bridges between islands as the attuned mother knows when her baby is about to need something. Healthy parents can feel the need before they can even tell you how they know it. Bowlby recognized how parents who never learned to be responsive to the needs of others—who lack bridge-building skills or who oppose building bridges that might threaten their own stability—can have a powerful formative effect on the mind of the child, as psychodynamics take a direct hit and become indelibly biased toward isolating selfstates and favoring discontinuity of self and other perception. Putnam’s borrowed concept of the state space derived from mapping things such as heart rate, respiratory rate, and physical movement in three dimensions allowed computer plotting of behavioral patterns. These patterns repeated as a sequential and somewhat predictable series of state changes that involved movement from states such as active alert to hungry, satiated, sleepy, inactive alert, and so on. Of note was that some state space shifts were unidirectional, for example, from satiated to sleepy; shifts from sleepy to satiated did not occur. It is more challenging to track state-space shifts in adults, but in highly dissociative individuals the switches
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are more obvious, since there may be a change in posture, a change in the person’s fund of knowledge, an abridged life history, a constricted range of affect, time distortion (state-related flashback quality misattributions of year, place, and situation), or elevated adrenalin secondary to anticipation of abuse. Wise clinicians learn to watch a patient’s respiratory rate and depth of respiration, degrees of physical tension, stigmata of rapid heart rate (e.g., venous neck pulsations), and tapping of fingers or foot or leg movement as signs of affective disturbance that may not be conscious for the patient and represent an impending or already completed statespace change that would predict future behavior. These switches are observable as unpredictable or unreliable behaviors and a changeable worldview; discontinuity of experience is the password for understanding such a person’s life and clinical presentation (Chefetz, 2015b). It’s as if two different people, with different sensibilities, take turns speaking while appearing to be one person. It can be confusing. For example, an especially sophisticated upper-level manager in a large corporation had, in her early childhood, hidden in a closet to escape repetitive violent rape. A shift in ergonomic planning by her company and a move to a new headquarters building completely undid her usual calm at work. Bereft of her familiar office and unable to unconsciously hide and regroup herself emotionally with the new open office glass walls, she became uncharacteristically frightened of going to work. She accumulated some degree of absenteeism before reporting the change to me. Asking her to tell me the details of her experience led (after barely 10 seconds of her effort) this 50-year-old woman in business attire, but now with fear on her face, to draw her knees under her chin while sitting in the chair in my office. Making an apparent effort to wedge herself into the corner of the upholstery, she began to squeal a distress call that was somehow both muffled and also pierced the air between us as a keening that was nearly unbearable to hear. I was confronted with the childlike state space of the past, manifested as a more organized self-state accompanied by flashback-quality experience. Sadly, this is frequently the standard work in the psychotherapy of complex posttraumatic stress disorder and the dissociative disorders. This is not regression; it is a dissociative process in action. Another theoretical approach to the psychology of mental states and “the way we are” is the theory of mentalization (Bateman & Fonagy, 2006; Fonagy, Gergely, Jurist, & Target, 2003; Fonagy & Target, 2007; Gergely, Nadasdy, Csibra, & Biro, 1995; Gergely & Watson, 1996) that is unintentionally supportive of a multiple self-state model of mind while focusing on the importance of mental states. Cognitive-affective-interpersonal schemas (Luyten, Blatt, & Fonagy, 2013) are an extension of the early theory of mentalization, which emphasizes some of the core concerns of a multiple self-state psychology (Chefetz & Bromberg, 2004). The achievement of reflective function and theory of mind arises from the developmental trajectory described by mastering psychic equivalence, pretend, and teleological modes of thinking. This builds on earlier work regarding intentionality and causality (Dennett, 1971) as modes of thinking. The notion of the alien self (Fonagy et al., 2003) is in lockstep with the multiple self-state model but is not noted as such. Achieving a capacity for reflective functioning, the ability to imagine the mental states of others, is predictive of positive outcome in psychotherapy
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(Cologon, Schweitzer, King, & Nolte, 2017). The ability to first imagine and then attune to isolated mental states in one’s own mind is also predictive of positive outcome in the psychotherapy of DID, in my experience.
Some regulatory tasks creating coherent consciousness The psychodynamics of self-states tend to be organized around two unconscious tasks: narrative regulation and affect regulation. When dissociative processes hold sway and go beyond simple pruning to maintain everyday coherent mentation, they act in the service of achieving a counterfeit assimilation or accommodation of a worldview by eliminating memories (amnesias) or distorting the facts of the events (typically denial and disavowal) to change the narrative into a consciously acceptable story (e.g., “I had a normal childhood and a typical family life”) and/or reducing one’s capacity to know feeling (e.g., “That doesn’t mean anything to me, I feel nothing about what happened or who was involved, it just is”). This is typical of complex PTSD (Herman, 1992) or borderline personality disorder (Zanarini et al., 2008). Deflection, dissembling, and grossly misleading statements or actions befuddle and confuse the uneducated therapist. Active or passive neglect in childhood, blunt or developmental trauma, repetitive childhood medical or surgical illness, bullying (Teicher, Samson, Sheu, Polcari, & McGreenery, 2010), parental alcoholic rages, emotionally violent marital discord, traumatic narcissism (Shaw, 2013), and dissociatively held parental trauma (Yehuda et al., 2014) generate these constellations of dissociative adaptation in childhood. Psychodynamics are profoundly influenced by dissociative processes that hide from awareness the underlying meanings of experience, behavior, and motivation. Affect regulation often succumbs to depersonalized numbness, obsessional isolation, secondary alexithymia, and explosive failures to contain the unbearable as it demands expression.
Profound bias of psychodynamics by dissociative processes A 35-year-old man with DID, who had been in twice-weekly psychotherapy for 10 years, was increasingly disturbed by tension with his wife and his awareness of his deep love for her simultaneous with his wish to not be touched and his frequent, but entirely intermittent, fascination with the bodies of men. As his psychotherapy progressed, he became aware of a self-state oriented to about age 4 who occupied an internal transitional space (Chefetz, 2015a) complete with the subjective experience of being on a raft. Being touched interrupted the reverie of the emotional isolation contingent with being on the raft and put him at risk of emotional overload. Fascination with the bodies of men began with an experience during his teenage years that left him and others wondering whether he was homosexual. His profound depersonalization, of which he had earlier been unaware, and his lack of being able
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to feel himself alive in his body produced a longing to know what it felt like to be an alive man, a man with a body. Consciousness of these dynamics and a deep discussion directly with the isolated self-states of the patient (Kluft, 2006) led to resolution of his need to keep at a physical distance from his wife and to the rekindling of their sexual relationship. Preoccupations with men’s bodies dissolved as his depersonalization grossly decreased. Without an understanding of dissociative processes, an unknowing clinician might simply have found these problems unresolvable or assumed that the patient was more interested in being with men than with women. Dissociative processes distort psychodynamics and are essential to our understanding of our humanity in the wake of developmental or frank traumatic experience.
Conclusion In the study of being human it is often true that extremes teach us much about what is in the middle. Dissociative processes are normal. When they are provoked to a higher level of activation and persist long after their utility has expired, they distort subjective experience and psychodynamics. The clinician who is interested in cases that don’t improve after much effort should take a good look at dissociative experience and how those processes guide psychodynamics. If it doesn’t help a particular person now, this new knowledge and curiosity will likely not wait for long before it is rewarded with growth in another human being.
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