De-personalization; De-realization; and De-contextualization
The most provocative part of any presentation is, for me, the clinical, which, in addition to who says (left-brain) what to whom, includes relationship, the implicit, and, a lot of right-brain knowing, and not-knowing. For ethical reasons, I can only marginally report on who says what to whom. Still, discussing ideas, not a particular case, excitedly lights up the curious brain.
On October 25, 2008 Richard A. Chefetz, MD, from New Directions in Psychoanalysis at the Washington Psychoanalytic Foundation, and the Advanced Psychoanalytic Training of the Washington School of Psychiatry opened the Trauma Series Workshop of the Tampa Bay Institute for Psychoanalytic Studies, Inc with a paper on Dissociation. Chefetz used Bucci's definition of dissociation: the unlinking of normally associated elements of experience that nonetheless remain unconsciously, implicitly, bound and related. This unlinking is facilitated by failure of the brain to formulate referential connections between different elements of experience, the failure to provide the context necessary to [more]accurately interpret experience.
While dissociation is part of normal mental function, e.g. highway hypnosis, or the fact that the brain selectively allows little, at any one time, into conscious awareness, when the right (amygdala) brain is overwhelmed with emotion, the left brain (Broca's area) is hypoperfused such that the experience cannot be linked to potentially helpful narrative. In fact, during intense emotion, e.g. intense fright, one can be rendered literally speechless (a fact that can be used didactically-cognitively to vitiate the guilt of a survivor who could not protest at the time of the abuse and victimization). Right brain hyperactivity can intensify vulnerability and aggravate trauma by denying it symbolization through narrative. (Likewise, when the left brain is busy, we tend to notice less our painful feelings and bodily sensations.)
Trauma is an experience that changes one's world view, one's self view, one's subjectivity (a person's interpretation of thoughts, feelings, and sensations). The dissociative process protects the self from trauma, from, e.g. the disparate elements of both loving and fearing the unpredictable caretaker. But its fallout includes severely limiting one's affective capacity and it creates incoherence, coherence being necessary for self regulation.
Isolated affect, an attempt at regulation, is dissociation that maintains attachment. A child accommodates to prevent the needed caretaker's withdrawal. Security, i.e. sameness -what is predictable, coherent, familiar- is sought, even if it is painful, creates deadness, or requires the disappearance of the self. Chefetz notes that a therapist, by being helpful, can cause a shift in a patient's self state, from child to adult, but then, the adult, believing only children need (and get) help, paradoxically, goes into a panic.
Dissociative Identity ("multiple personality") Disorder challenges the therapist's idea of a unified, cohesive self. We are likewise challenged to tolerate our own varying self states, and our capacity, as well as the patient's, for anger, rage, sadism, collusion. Can we, for example, explore with the patient her/his request for physical closeness and sexual contact, its meaning, its potential betrayal if acted upon, and can we be trusted to set and maintain appropriate boundaries? Will we deny this capacity in ourselves and insist on being the 'rescuer,' or withdraw, or lose all awareness of the ways we are sadistic?
Chefetz reminds us to be be curious and open about what we are feeling in a given moment, and to remain 'experience near.' I will, on January 10, 2009 in Part II of the Trauma Workshop Series, talk more about dissociation, both in the therapist and patient, how to navigate and how to use it, as well as about how to recognize, after the fact, enactments and their usefulness, when working with adults who have survived severe physical and childhood sexual abuse.