NARRATIVE, DIALOGUE, AND DISSOCIATION Paul M. Gedo This paper explores dissociative phenomena as disruptions of dialogue between persons, and disruptions of internal narratives. A dissociating patient temporarily loses ability to convey his or her inner experience to the therapist. The disconnection between dialogue and internal experience can mislead both participants, or distract them from underlying connotations. Dissociation also disrupts the patient’s sense of internal coherence and internal conversation. Dissociation represents a regression to an early, preverbal mode of (internal and external) communication. The challenge for the dyad is to restore dialogue and then to discern the multiply determined meanings of the dissociative communication. This therapeutic work allows the patient to achieve a more coherent sense of self and of his or her life course.
Each of us needs to develop and sustain a coherent narrative (a form of self-organization, which includes self-representations) of his or her life course. Disruptions in this narrative correlate with subjective discomfort, anxiety, and a sense of inner disorganization (Carney & Cohler, 1993; Cohler, 1980). Rather than viewing psychological maladaptations as the equivalent of a physical disease, one could relate them to the inability to sustain inner equilibrium and coherence. As I defined it in an earlier publication (Gedo, 2000a), “dissociation involves entering an altered state of consciousness in which one is partially or wholly unaware of one’s surroundings, thoughts or actions” (p. 609). It is sometimes the result of actual
An earlier version of this paper was presented at a conference honoring Bertram J. Cohler, Ph.D., Committee on Human Development, University of Chicago, June, 2013. Psychoanalytic Review, 101(1), February 2014
© 2014 N.P.A.P.
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traumatization. At other times, it represents a defense, a form of flight, in the face of overwhelming affects. One lens through which to view dissociative phenomena—an aspect of what Donnell Stern (1997) calls “unformulated experience”—is that dissociation disrupts the person’s sense of internal coherence. It interrupts internal narratives as well as the person’s ability to convey his or her experience to another via discursive language. That is, because the person’s self-organization and self- representation have become disrupted, he or she temporarily lacks the capacity to describe his or her internal state to the therapist. Paradoxically, although it obscures both narrative and dialogue, dissociation nevertheless can sometimes convey important aspects of inner experience. However, these moments or memories are not encoded in words; this challenges the dyad’s capacities to discern meaning via somatic expression and by considering the timing and functions of dissociative defenses. As the therapeutic dyad is able to consider the patient’s disavowal and dissociative functioning, the therapist and patient gain a sense of the sorts of early interpersonal and affective experiences that overwhelmed the patient’s ability to sustain integrated experience. Trying to cope with abuse or severe neglect; feelings of murderous rage, profound isolation, and loneliness; and wishes for affiliation or sexual desire may overcome the person’s ability to process and name his or her wishes or emotions (Gedo, 2013). Partially through co-constructed experiences within the therapy, which allow the patient to reexperience these old affects with an empathic witness, there is an opportunity for an “after- education” (Freud, 1916–1917, p. 451). The dyad begins to include their new understanding of previously wordless interactions in their co-constructed narratives of the therapy, of the patient’s affective reactions, and of the ways he or she habitually managed or warded off intense emotional moments. This in turn provides ways to reconsider early experience. Chronic use of dissociative defenses is related to external or internal challenges that overwhelmed the child’s immature coping capacities. Disavowed splitting off of painful experience represented an early adaptive maneuver which has become embedded in the person’s character.
NARRATIVE, DIALOGUE, DISSOCIATION73
Bill, an eleven-year-old, angry, impulsive child, discussed a recent dispute with his brother. As we considered the ways he felt his brother had provoked him, his intense internal anger, and his escalating behavioral reaction, Bill became distracted. He looked out the window—his face became impassive and blank—and he seemed to stare into space. The tension in the room, generated by our focusing on his hatred and rage, instantly dissipated. I called him back; he eventually reoriented, looked at me, and asked, “What were we talking about?” His affects, our communications, and the therapeutic moment had all been dispelled. A dissociating patient temporarily loses ability to convey his or her inner world to the therapist. The therapist’s subsequent attempts to reach the patient may exacerbate the patient’s confusion (Gedo, 2000a). Even in less severe dissociative states, gaps may appear in the patient’s narrative, leaving the therapist bewildered. The patient may become mute, or speak while losing touch with his or her inner experience, so that the words convey little lexical meaning (Gedo, 2000b; Hadley, 1989). Such disconnects between dialogue and internal experience can mislead both participants or distract them from underlying connotations (J. Gedo, 1996). The therapist may also fail to grasp why the patient dissociates at this particular time. This further complicates any dyadic communication; with his or her ego capacities severely compromised, the patient is not aware of his or her underlying motivations and is in a poor position to introspect or to collaborate toward establishing better understanding. If the patient is in touch with his or her own bewilderment, he or she is unable to convey this lexically, because the more adaptive cortical capacities are temporarily overwhelmed. Traumatized persons also resort to disavowal—a split in consciousness (Freud, 1940), which leads them simultaneously to acknowledge and deny painful realities (Gedo, 2000b, 2009). This creates incoherence in their narrative, as the patient asserts mutually contradictory “realities” with no awareness of this paradox. For example, a traumatized patient, Ms. Q, was very dependent on her abusive parents and clung to her conscious belief that they were loving and good. She believed herself to be bad and therefore deserving to die; this protected her from recognizing and
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having to integrate her profound underlying disillusionment and rage over their neglect (Fairbairn, 1952). At the same time, her chronic suicidality expressed her split-off hostility toward the parents (by taunting them that they could not prevent her impending demise). She was usually unaware of her rage at them, but whenever she got in touch with her anger, she lost access to her usual positive image of her caretakers. Ms. Q made repeated near- lethal suicide attempts and was determined to die. After repeated hospitalizations, her insurance company demanded that she transfer to a facility which emphasized ambulatory care treatment, with very brief hospitalizations if necessary, and announced this would be their last time supporting her. Ms. Q immediately became active and creative in pursuing this opportunity. She did not feel suicidal, and she thoughtfully helped to create a treatment situation that would maximize her chances to recover. Her sudden fight to live superseded her previous determination to die; she was unaware that both wishes were present, responding first to one and then the other. Disavowal also creates internal incoherence, as the person is only aware of one conscious belief or the other, but cannot simultaneously consider them both or recognize that she is living out a contradiction. She wards off awareness of the paradoxes underlying her motivation and behavior, because integrating her ambivalent wishes would entail recognizing and “owning” feelings and internal experiences that threaten her with affective flooding, an overwhelming sense of badness, and fears of abandonment. She therefore adheres to alternative sets of thoughts, memories, and expectations, which she walls off as separate experiences (Klein, 1946). In this manner, she feels safe to experience and acknowledge both sets, but not at the same time. Her sense of experience is fractured, and she constantly lacks access to crucial “data,” which would permit a coherent sense of her past and herself. The therapist may experience a parallel incoherence, finding it difficult to account for the paradoxical aspects of the patient or to keep a clear and consistent sense of her in mind. The therapist must establish an atmosphere of safety (Sandler, 1987), within which he or she can draw the patient’s attention to her mutually contradictory beliefs (such as feeling intense love and hatred for
NARRATIVE, DIALOGUE, DISSOCIATION75
the same person, wanting both to live and to die, recognizing realities yet magically expecting that normal human limits do not apply to her). Dissociation disrupts the patient’s internal narrative, or sense of coherence. He can lose touch with his own thoughts, bodily sensations, affects, and memories. He may no longer recall what he just said. He may temporarily lose the capacity to attend to discursive language and thus miss, or misunderstand, the therapist’s contributions. At an extreme—for instance, during a flashback— the patient may lose touch with physical and temporal reality. He begins affectively to relive previous traumatic experiences, believing himself to be currently existing in the time, place, and company of those with whom the original experience took place. These phenomena disrupt internal monologue, robbing it of coherence and temporal stability. The patient becomes incapable of introspection or self-observation, and loses touch with his feelings or internal experiences. He may feel that he is outside of his own body or that he is watching himself, as though he were a character in a movie. Ms. Q, who had suffered neglect and abuse within her family, was vulnerable to severe dissociative episodes inside and outside of her therapy sessions. On several occasions, she suffered flashbacks during her hours. This involved a dissociative state in which she became disoriented about where she was and confused about my identity, and seemed to reexperience some traumatic moments, as though she were back at home. Her facial expressions and body language conveyed intense terror. She could barely talk but muttered that she “saw a picture.” She moved her head in a startle response, or perhaps an effort to “shake” the images she saw. After she regained consensual speech, she could not describe this experience, though she sometimes drew images that portrayed sexual intrusions (Gedo, 2000b). These wordless experiences were frightening and evocative for us both. Within a safe therapeutic environment, in an intense psychodynamic treatment, the patient begins to reexperience the shifting “realities” of affective states in the transference relationship. For instance, Sam, the only child of a single mother, missed months of school due to severe diarrhea; after a thorough medi-
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cal work-up was benign, his internist referred him to me. After considerable exploration of his enmeshed relationship with his mother, Sam himself interpreted his symptom as having represented his discomfort with moving away from her. This allowed him to integrate his experience into his narrative, as he began to effect a psychological separation from her. The ways these discontinuities disrupt dialogue and narrative may obscure ways in which dissociation and disavowal paradoxically also constitute a crucial form of internal and potential interpersonal communication. The central difficulty is that the meanings are not conveyed in dialogue, since they are not encoded lexically. There is not even consensus regarding whether communication has taken place, because the patient is unaware of the significance of what he or she has conveyed nonverbally or via paraverbal cues (such as voice tone, pitch, rate, cadence). One crucial aspect of the therapy involves helping the patient learn to note his or her own behaviors and to “read” these episodes as signals (Gedo, 2000a), which therefore convey meaning (e.g., “When I space out, I may be feeling threatened”). From one perspective, dissociation signals a temporary breakdown in the capacity for consensual speech. That is, it represents a regression to an early, preverbal mode of communication. The brain is organized hierarchically to integrate later learning with earlier experiences; the latter remain present as possible adaptations whenever later, more sophisticated modes of functioning are unavailable or seem ineffective (Wilson & J. Gedo, 1993). When the patient dissociates, it signals that trauma or overwhelming affects have so disorganized him or her, that he or she has no uncompromised ego functioning available. We therefore need another model of the mind, based on the entire self-organization (J. Gedo, 1993) to account for these phenomena, and to address them therapeutically. Because the patient is repeating wordless experiences, dissociation creates the potential for the patient to reimmerse himself or herself, and to immerse the therapist, in whatever affective state prevailed during earlier trauma. The experience is enormously evocative and can even create milder, parallel disruptions within the therapist’s consciousness (Gedo, 2000b).
NARRATIVE, DIALOGUE, DISSOCIATION77
These difficulties challenge the therapist’s capacity to contain the experience (Bion, 1962) and to discern its meaning accurately, including the reasons the patient regressed at the time and in the manner that he or she did and the multiple psychic functions that the dissociation may serve (Gedo, 2000b). The therapist must immerse himself or herself in the patient’s and his or her own intense affective experiences. The therapist must then “read” his or her own affects to begin to understand what the patient unconsciously intends to convey. That is, the therapist must reestablish a comprehensible internal monologue that translates his or her affective experience into a lexical context. The therapist may choose to share this understanding, or use it to reestablish his or her “evenly suspended attention” (Freud, 1912, p. 111). For example, I felt bewilderment, anxiety, fear, and sense of helpless incompetence in the face of Ms. Q’s flashbacks. These feelings offered important clues to her experiences as an abused and neglected child, including her sense of utter confusion and intense terror. Indeed, as her parents had maintained that their cruel behaviors had constituted reasonable treatment, Ms. Q had experienced a “confusion of tongues” and was uncertain whether she had been mistreated at all (Ferenczi, 1933). The flashbacks engendered mutual confusion about what was really going on in Ms. Q and myself, thus echoing her earlier uncertainties. My challenge was to tune in to my own confusion, fear, and anger, and to consider whether these feelings constituted a concordant countertransference (Racker, 1968), versus my own transference to some aspect of Ms. Q’s character or current presentation (e.g., a personal reaction to someone who presents as extremely helpless). Ms. Q’s experience of the “confusion of tongues” had made language itself conflictual for her. Verbal communication had lost its autonomous function (Hartmann, 1939), and she had come to view lexically encoded messages with suspicion and confusion, as they often had not synchronized with her childhood internal emotional experiences. She encoded key experiences and affects nonlexically, as somatic sensations or procedural memories; these were not unconscious, but were not part of her internal narrative because they had never been encoded verbally.
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This meant that we had to translate her unformulated experiences into lexical meanings, to create a more coherent and comprehensive narrative of the therapy and of her life course. Experiencing the patient’s disavowal and its attendant confusion can also allow the therapist to enter into the chaotic experience of carrying out mutually exclusive aims simultaneously. For example, Ms. Q’s frantic need to ward off potential intrusion, intense anger at her caretakers, and fear of being abandoned contributed to a state which echoed Burnham’s “need-fear dilemma” (Burnham, Gladstone, & Gibson, 1969); this dilemma confused and flooded her. She dealt with these experiences via disavowal. This in turn evoked intense contradictory affects in me, which I struggled to contain and understand. Beyond grasping the meanings of these split-off phenomena, the therapist must teach the patient how to encode these pre viously wordless experiences into discursive language. This is especially challenging because the patient has considered the traumatic events and their attendant feelings to be (literally and figuratively) unspeakable. The process begins with the therapist’s internal communication, or monologue; he or she strives to make sense of his or her experience, to give it a structure and a language. The therapist may then lend these words to the patient. For instance, Ms. Q was acutely sensitive to others’ anger and often asked me whether I was feeling angry, sometimes before I myself became aware of my own irritation. When she was correct, I would acknowledge and describe these feelings, and their connections to the dyadic process when relevant. (If my feelings were unrelated to the therapy, I noted this without telling her what they were about.) While I did not speak in a flat tone, I was careful to modulate the affective tone of these communications. Ms. Q was initially terrified but gradually came to recognize that these feelings were not of themselves dangerous and toxic; this facilitated her describing her own angry feelings without resorting to dissociative defenses. The therapist strives to establish a dialogue, by describing his or her own experience in the session, encouraging the patient to do the same, and suggesting possible themes or meanings to the patient. My description of my own affective experiences in the
NARRATIVE, DIALOGUE, DISSOCIATION79
moment, which I connected to Bill’s experience of his brother’s provocativeness or to Ms. Q’s “confusion of tongues” (Ferenczi, 1933) with her parents, constituted efforts to make nonverbal experiences speakable and to consider their multiple meanings and psychological functions. The therapist must first reestablish his or her inner sense of coherence and an internal narrative, and then engage the patient in a dialogue. Our aim is to assist the patient to develop his or her own coherent narrative, incorporating central and previously nonverbal experiences to which the dissociations and disavowals provide a crucial bridge. The process of talking about these previously wordless experiences gradually extends cortical control and detoxifies previously unbearable affects and experiences around which the patient had developed dissociative defenses. It allows the patient to be mindful of his or her tendency to repeat what had been procedural memories. Bringing these experiences within the patient’s narrative is one version of Freud’s (1914) working through, fostering a sense of competence and self-awareness that is echoed in the increased coherence of the treatment and life narratives.
REFERENCES
Bion, W. (1962). Learning from experience. London: Heinemann. Burnham, D., Gladstone, A., & Gibson, R. (1969). Schizophrenia and the need- fear dilemma. New York: International Universities Press. Carney, J., & Cohler, B. (1993). Developmental continuities and adjustment in adulthood: Social relations, morale, and transformation from middle to late life. In G. Pollock & S. Greenspan, eds., The course of life (vol. 6, pp. 199–226). Madison, Conn.: International Universities Press. Cohler, B. (1980). Adult developmental psychology and reconstruction in psychoanalysis. In S. Greenspan & G. Pollock, eds., The course of life: Psychoanalytic contributions toward understanding personality development (vol. 3, pp. 149–199). Bethesda, Md.: National Institutes of Mental Health. Fairbairn, R. (1952). Psychoanalytic studies of the personality. London: Tavistock. Ferenczi, S. (1933). The confusion of tongues between adults and the child. In M. Balint, ed., The selected papers of Sandor Ferenczi (vol. 3, pp. 156–167). New York: Basic Books. Freud, S. (1912). Recommendations to physicians practicing psycho-analysis. In J. Strachey, ed. and trans., The standard edition of the complete psychological works of Sigmund Freud, 24 vols. London: Hogarth Press, 1953–1974. 12:109– 120. ______ (1914). Remembering, repeating, and working through (Further recom-
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mendations on the technique of psychoanalysis II). Standard ed., 12:145– 156. ______ (1916–1917). Introductory lectures on psycho-analysis. Standard ed., 15, 16:3–463. ______ (1940). Splitting of the ego in the process of defense. Standard ed., 23:273–278. Gedo, J. (1993). Beyond interpretation: Toward a revised theory for psychoanalysis (rev. ed.). Hillside, N.J.: Analytic Press. ______ (1996). The languages of psychoanalysis. Hillside, N.J.: Analytic Press. Gedo, P. (2000a). Symptoms, signals, affects: Psychotherapeutic techniques with dissociative patients. J. Amer. Acad. Psychoanal., 28:609–618. ______ (2000b). To be, and not to be: The concept of multiple function and dissociation. Psychoanal. Inq., 20:194–206. ______ (2009, October). The psychodynamic meanings of delusions of badness. Paper presented at the annual meeting of the International Society for the Psychological Treatments of the Schizophrenias and Other Psychoses, U.S. Chapter, Rockville, Maryland. ______ (2013). Transference- countertransference repetitions of traumatic affects. Bull. Menninger Clin., 77:161–177. Hadley, J. (1989). The neurobiology of motivational systems. In J. Lichtenberg, Psychoanalysis and motivation (pp. 227–372). Hillside, N.J.: Analytic Press. Hartmann, H. (1939). Ego psychology and the problem of adaptation. New York: International Universities Press. Klein, M. (1946). Notes on some schizoid mechanisms. In Envy and gratitude and other works, 1946–1963 (pp. 1–24). New York: Free Press. Racker, H. (1968). Transference and countertransference. New York: International Universities Press. Sandler, J. (1987). From safety to superego. London: Karnac. Stern, D. (1997). Unformulated experience: From dissociation to imagination in psychoanalysis. Hillside, N.J.: Analytic Press. Wilson, A., & Gedo, J., eds. (1993). Hierarchical concepts in psychoanalysis. New York: Guilford Press.
7 Owens Court Rockville, MD 20850 E-mail: [email protected]
The Psychoanalytic Review Vol. 101, No. 1, February 2014
Each of us needs to develop and sustain a coherent narrative (a form of self-organization, which includes self-representations) of his or her life course. Disruptions in this narrative correlate with subjective discomfort, anxiety, and a sense of inner disorganization (Carney & Cohler, 1993; Cohler, 1980). Rather than viewing psychological maladaptations as the equivalent of a physical disease, one could relate them to the inability to sustain inner equilibrium and coherence. As I defined it in an earlier publication (Gedo, 2000a), “dissociation involves entering an altered state of consciousness in which one is partially or wholly unaware of one’s surroundings, thoughts or actions” (p. 609). It is sometimes the result of actual
An earlier version of this paper was presented at a conference honoring Bertram J. Cohler, Ph.D., Committee on Human Development, University of Chicago, June, 2013. Psychoanalytic Review, 101(1), February 2014
© 2014 N.P.A.P.
72
PAUL M. GEDO
traumatization. At other times, it represents a defense, a form of flight, in the face of overwhelming affects. One lens through which to view dissociative phenomena—an aspect of what Donnell Stern (1997) calls “unformulated experience”—is that dissociation disrupts the person’s sense of internal coherence. It interrupts internal narratives as well as the person’s ability to convey his or her experience to another via discursive language. That is, because the person’s self-organization and self- representation have become disrupted, he or she temporarily lacks the capacity to describe his or her internal state to the therapist. Paradoxically, although it obscures both narrative and dialogue, dissociation nevertheless can sometimes convey important aspects of inner experience. However, these moments or memories are not encoded in words; this challenges the dyad’s capacities to discern meaning via somatic expression and by considering the timing and functions of dissociative defenses. As the therapeutic dyad is able to consider the patient’s disavowal and dissociative functioning, the therapist and patient gain a sense of the sorts of early interpersonal and affective experiences that overwhelmed the patient’s ability to sustain integrated experience. Trying to cope with abuse or severe neglect; feelings of murderous rage, profound isolation, and loneliness; and wishes for affiliation or sexual desire may overcome the person’s ability to process and name his or her wishes or emotions (Gedo, 2013). Partially through co-constructed experiences within the therapy, which allow the patient to reexperience these old affects with an empathic witness, there is an opportunity for an “after- education” (Freud, 1916–1917, p. 451). The dyad begins to include their new understanding of previously wordless interactions in their co-constructed narratives of the therapy, of the patient’s affective reactions, and of the ways he or she habitually managed or warded off intense emotional moments. This in turn provides ways to reconsider early experience. Chronic use of dissociative defenses is related to external or internal challenges that overwhelmed the child’s immature coping capacities. Disavowed splitting off of painful experience represented an early adaptive maneuver which has become embedded in the person’s character.
NARRATIVE, DIALOGUE, DISSOCIATION73
Bill, an eleven-year-old, angry, impulsive child, discussed a recent dispute with his brother. As we considered the ways he felt his brother had provoked him, his intense internal anger, and his escalating behavioral reaction, Bill became distracted. He looked out the window—his face became impassive and blank—and he seemed to stare into space. The tension in the room, generated by our focusing on his hatred and rage, instantly dissipated. I called him back; he eventually reoriented, looked at me, and asked, “What were we talking about?” His affects, our communications, and the therapeutic moment had all been dispelled. A dissociating patient temporarily loses ability to convey his or her inner world to the therapist. The therapist’s subsequent attempts to reach the patient may exacerbate the patient’s confusion (Gedo, 2000a). Even in less severe dissociative states, gaps may appear in the patient’s narrative, leaving the therapist bewildered. The patient may become mute, or speak while losing touch with his or her inner experience, so that the words convey little lexical meaning (Gedo, 2000b; Hadley, 1989). Such disconnects between dialogue and internal experience can mislead both participants or distract them from underlying connotations (J. Gedo, 1996). The therapist may also fail to grasp why the patient dissociates at this particular time. This further complicates any dyadic communication; with his or her ego capacities severely compromised, the patient is not aware of his or her underlying motivations and is in a poor position to introspect or to collaborate toward establishing better understanding. If the patient is in touch with his or her own bewilderment, he or she is unable to convey this lexically, because the more adaptive cortical capacities are temporarily overwhelmed. Traumatized persons also resort to disavowal—a split in consciousness (Freud, 1940), which leads them simultaneously to acknowledge and deny painful realities (Gedo, 2000b, 2009). This creates incoherence in their narrative, as the patient asserts mutually contradictory “realities” with no awareness of this paradox. For example, a traumatized patient, Ms. Q, was very dependent on her abusive parents and clung to her conscious belief that they were loving and good. She believed herself to be bad and therefore deserving to die; this protected her from recognizing and
74
PAUL M. GEDO
having to integrate her profound underlying disillusionment and rage over their neglect (Fairbairn, 1952). At the same time, her chronic suicidality expressed her split-off hostility toward the parents (by taunting them that they could not prevent her impending demise). She was usually unaware of her rage at them, but whenever she got in touch with her anger, she lost access to her usual positive image of her caretakers. Ms. Q made repeated near- lethal suicide attempts and was determined to die. After repeated hospitalizations, her insurance company demanded that she transfer to a facility which emphasized ambulatory care treatment, with very brief hospitalizations if necessary, and announced this would be their last time supporting her. Ms. Q immediately became active and creative in pursuing this opportunity. She did not feel suicidal, and she thoughtfully helped to create a treatment situation that would maximize her chances to recover. Her sudden fight to live superseded her previous determination to die; she was unaware that both wishes were present, responding first to one and then the other. Disavowal also creates internal incoherence, as the person is only aware of one conscious belief or the other, but cannot simultaneously consider them both or recognize that she is living out a contradiction. She wards off awareness of the paradoxes underlying her motivation and behavior, because integrating her ambivalent wishes would entail recognizing and “owning” feelings and internal experiences that threaten her with affective flooding, an overwhelming sense of badness, and fears of abandonment. She therefore adheres to alternative sets of thoughts, memories, and expectations, which she walls off as separate experiences (Klein, 1946). In this manner, she feels safe to experience and acknowledge both sets, but not at the same time. Her sense of experience is fractured, and she constantly lacks access to crucial “data,” which would permit a coherent sense of her past and herself. The therapist may experience a parallel incoherence, finding it difficult to account for the paradoxical aspects of the patient or to keep a clear and consistent sense of her in mind. The therapist must establish an atmosphere of safety (Sandler, 1987), within which he or she can draw the patient’s attention to her mutually contradictory beliefs (such as feeling intense love and hatred for
NARRATIVE, DIALOGUE, DISSOCIATION75
the same person, wanting both to live and to die, recognizing realities yet magically expecting that normal human limits do not apply to her). Dissociation disrupts the patient’s internal narrative, or sense of coherence. He can lose touch with his own thoughts, bodily sensations, affects, and memories. He may no longer recall what he just said. He may temporarily lose the capacity to attend to discursive language and thus miss, or misunderstand, the therapist’s contributions. At an extreme—for instance, during a flashback— the patient may lose touch with physical and temporal reality. He begins affectively to relive previous traumatic experiences, believing himself to be currently existing in the time, place, and company of those with whom the original experience took place. These phenomena disrupt internal monologue, robbing it of coherence and temporal stability. The patient becomes incapable of introspection or self-observation, and loses touch with his feelings or internal experiences. He may feel that he is outside of his own body or that he is watching himself, as though he were a character in a movie. Ms. Q, who had suffered neglect and abuse within her family, was vulnerable to severe dissociative episodes inside and outside of her therapy sessions. On several occasions, she suffered flashbacks during her hours. This involved a dissociative state in which she became disoriented about where she was and confused about my identity, and seemed to reexperience some traumatic moments, as though she were back at home. Her facial expressions and body language conveyed intense terror. She could barely talk but muttered that she “saw a picture.” She moved her head in a startle response, or perhaps an effort to “shake” the images she saw. After she regained consensual speech, she could not describe this experience, though she sometimes drew images that portrayed sexual intrusions (Gedo, 2000b). These wordless experiences were frightening and evocative for us both. Within a safe therapeutic environment, in an intense psychodynamic treatment, the patient begins to reexperience the shifting “realities” of affective states in the transference relationship. For instance, Sam, the only child of a single mother, missed months of school due to severe diarrhea; after a thorough medi-
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cal work-up was benign, his internist referred him to me. After considerable exploration of his enmeshed relationship with his mother, Sam himself interpreted his symptom as having represented his discomfort with moving away from her. This allowed him to integrate his experience into his narrative, as he began to effect a psychological separation from her. The ways these discontinuities disrupt dialogue and narrative may obscure ways in which dissociation and disavowal paradoxically also constitute a crucial form of internal and potential interpersonal communication. The central difficulty is that the meanings are not conveyed in dialogue, since they are not encoded lexically. There is not even consensus regarding whether communication has taken place, because the patient is unaware of the significance of what he or she has conveyed nonverbally or via paraverbal cues (such as voice tone, pitch, rate, cadence). One crucial aspect of the therapy involves helping the patient learn to note his or her own behaviors and to “read” these episodes as signals (Gedo, 2000a), which therefore convey meaning (e.g., “When I space out, I may be feeling threatened”). From one perspective, dissociation signals a temporary breakdown in the capacity for consensual speech. That is, it represents a regression to an early, preverbal mode of communication. The brain is organized hierarchically to integrate later learning with earlier experiences; the latter remain present as possible adaptations whenever later, more sophisticated modes of functioning are unavailable or seem ineffective (Wilson & J. Gedo, 1993). When the patient dissociates, it signals that trauma or overwhelming affects have so disorganized him or her, that he or she has no uncompromised ego functioning available. We therefore need another model of the mind, based on the entire self-organization (J. Gedo, 1993) to account for these phenomena, and to address them therapeutically. Because the patient is repeating wordless experiences, dissociation creates the potential for the patient to reimmerse himself or herself, and to immerse the therapist, in whatever affective state prevailed during earlier trauma. The experience is enormously evocative and can even create milder, parallel disruptions within the therapist’s consciousness (Gedo, 2000b).
NARRATIVE, DIALOGUE, DISSOCIATION77
These difficulties challenge the therapist’s capacity to contain the experience (Bion, 1962) and to discern its meaning accurately, including the reasons the patient regressed at the time and in the manner that he or she did and the multiple psychic functions that the dissociation may serve (Gedo, 2000b). The therapist must immerse himself or herself in the patient’s and his or her own intense affective experiences. The therapist must then “read” his or her own affects to begin to understand what the patient unconsciously intends to convey. That is, the therapist must reestablish a comprehensible internal monologue that translates his or her affective experience into a lexical context. The therapist may choose to share this understanding, or use it to reestablish his or her “evenly suspended attention” (Freud, 1912, p. 111). For example, I felt bewilderment, anxiety, fear, and sense of helpless incompetence in the face of Ms. Q’s flashbacks. These feelings offered important clues to her experiences as an abused and neglected child, including her sense of utter confusion and intense terror. Indeed, as her parents had maintained that their cruel behaviors had constituted reasonable treatment, Ms. Q had experienced a “confusion of tongues” and was uncertain whether she had been mistreated at all (Ferenczi, 1933). The flashbacks engendered mutual confusion about what was really going on in Ms. Q and myself, thus echoing her earlier uncertainties. My challenge was to tune in to my own confusion, fear, and anger, and to consider whether these feelings constituted a concordant countertransference (Racker, 1968), versus my own transference to some aspect of Ms. Q’s character or current presentation (e.g., a personal reaction to someone who presents as extremely helpless). Ms. Q’s experience of the “confusion of tongues” had made language itself conflictual for her. Verbal communication had lost its autonomous function (Hartmann, 1939), and she had come to view lexically encoded messages with suspicion and confusion, as they often had not synchronized with her childhood internal emotional experiences. She encoded key experiences and affects nonlexically, as somatic sensations or procedural memories; these were not unconscious, but were not part of her internal narrative because they had never been encoded verbally.
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This meant that we had to translate her unformulated experiences into lexical meanings, to create a more coherent and comprehensive narrative of the therapy and of her life course. Experiencing the patient’s disavowal and its attendant confusion can also allow the therapist to enter into the chaotic experience of carrying out mutually exclusive aims simultaneously. For example, Ms. Q’s frantic need to ward off potential intrusion, intense anger at her caretakers, and fear of being abandoned contributed to a state which echoed Burnham’s “need-fear dilemma” (Burnham, Gladstone, & Gibson, 1969); this dilemma confused and flooded her. She dealt with these experiences via disavowal. This in turn evoked intense contradictory affects in me, which I struggled to contain and understand. Beyond grasping the meanings of these split-off phenomena, the therapist must teach the patient how to encode these pre viously wordless experiences into discursive language. This is especially challenging because the patient has considered the traumatic events and their attendant feelings to be (literally and figuratively) unspeakable. The process begins with the therapist’s internal communication, or monologue; he or she strives to make sense of his or her experience, to give it a structure and a language. The therapist may then lend these words to the patient. For instance, Ms. Q was acutely sensitive to others’ anger and often asked me whether I was feeling angry, sometimes before I myself became aware of my own irritation. When she was correct, I would acknowledge and describe these feelings, and their connections to the dyadic process when relevant. (If my feelings were unrelated to the therapy, I noted this without telling her what they were about.) While I did not speak in a flat tone, I was careful to modulate the affective tone of these communications. Ms. Q was initially terrified but gradually came to recognize that these feelings were not of themselves dangerous and toxic; this facilitated her describing her own angry feelings without resorting to dissociative defenses. The therapist strives to establish a dialogue, by describing his or her own experience in the session, encouraging the patient to do the same, and suggesting possible themes or meanings to the patient. My description of my own affective experiences in the
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moment, which I connected to Bill’s experience of his brother’s provocativeness or to Ms. Q’s “confusion of tongues” (Ferenczi, 1933) with her parents, constituted efforts to make nonverbal experiences speakable and to consider their multiple meanings and psychological functions. The therapist must first reestablish his or her inner sense of coherence and an internal narrative, and then engage the patient in a dialogue. Our aim is to assist the patient to develop his or her own coherent narrative, incorporating central and previously nonverbal experiences to which the dissociations and disavowals provide a crucial bridge. The process of talking about these previously wordless experiences gradually extends cortical control and detoxifies previously unbearable affects and experiences around which the patient had developed dissociative defenses. It allows the patient to be mindful of his or her tendency to repeat what had been procedural memories. Bringing these experiences within the patient’s narrative is one version of Freud’s (1914) working through, fostering a sense of competence and self-awareness that is echoed in the increased coherence of the treatment and life narratives.
REFERENCES
Bion, W. (1962). Learning from experience. London: Heinemann. Burnham, D., Gladstone, A., & Gibson, R. (1969). Schizophrenia and the need- fear dilemma. New York: International Universities Press. Carney, J., & Cohler, B. (1993). Developmental continuities and adjustment in adulthood: Social relations, morale, and transformation from middle to late life. In G. Pollock & S. Greenspan, eds., The course of life (vol. 6, pp. 199–226). Madison, Conn.: International Universities Press. Cohler, B. (1980). Adult developmental psychology and reconstruction in psychoanalysis. In S. Greenspan & G. Pollock, eds., The course of life: Psychoanalytic contributions toward understanding personality development (vol. 3, pp. 149–199). Bethesda, Md.: National Institutes of Mental Health. Fairbairn, R. (1952). Psychoanalytic studies of the personality. London: Tavistock. Ferenczi, S. (1933). The confusion of tongues between adults and the child. In M. Balint, ed., The selected papers of Sandor Ferenczi (vol. 3, pp. 156–167). New York: Basic Books. Freud, S. (1912). Recommendations to physicians practicing psycho-analysis. In J. Strachey, ed. and trans., The standard edition of the complete psychological works of Sigmund Freud, 24 vols. London: Hogarth Press, 1953–1974. 12:109– 120. ______ (1914). Remembering, repeating, and working through (Further recom-
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mendations on the technique of psychoanalysis II). Standard ed., 12:145– 156. ______ (1916–1917). Introductory lectures on psycho-analysis. Standard ed., 15, 16:3–463. ______ (1940). Splitting of the ego in the process of defense. Standard ed., 23:273–278. Gedo, J. (1993). Beyond interpretation: Toward a revised theory for psychoanalysis (rev. ed.). Hillside, N.J.: Analytic Press. ______ (1996). The languages of psychoanalysis. Hillside, N.J.: Analytic Press. Gedo, P. (2000a). Symptoms, signals, affects: Psychotherapeutic techniques with dissociative patients. J. Amer. Acad. Psychoanal., 28:609–618. ______ (2000b). To be, and not to be: The concept of multiple function and dissociation. Psychoanal. Inq., 20:194–206. ______ (2009, October). The psychodynamic meanings of delusions of badness. Paper presented at the annual meeting of the International Society for the Psychological Treatments of the Schizophrenias and Other Psychoses, U.S. Chapter, Rockville, Maryland. ______ (2013). Transference- countertransference repetitions of traumatic affects. Bull. Menninger Clin., 77:161–177. Hadley, J. (1989). The neurobiology of motivational systems. In J. Lichtenberg, Psychoanalysis and motivation (pp. 227–372). Hillside, N.J.: Analytic Press. Hartmann, H. (1939). Ego psychology and the problem of adaptation. New York: International Universities Press. Klein, M. (1946). Notes on some schizoid mechanisms. In Envy and gratitude and other works, 1946–1963 (pp. 1–24). New York: Free Press. Racker, H. (1968). Transference and countertransference. New York: International Universities Press. Sandler, J. (1987). From safety to superego. London: Karnac. Stern, D. (1997). Unformulated experience: From dissociation to imagination in psychoanalysis. Hillside, N.J.: Analytic Press. Wilson, A., & Gedo, J., eds. (1993). Hierarchical concepts in psychoanalysis. New York: Guilford Press.
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The Psychoanalytic Review Vol. 101, No. 1, February 2014
