Sunday, October 26, 2008


Dissociation: Dis-order of Subjectivity.
Dis-aggregation; and Dis-connection
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.


Anonymous said...

The Tampa psychoanalytic community hosted Lew Aron on Oct 15, who exhorted us to think critically and analyze papers, presentations, etc. Then on Oct 25, the Tampa community hosted Richard Chefetz, speaking about Dissociative Disorders. The attendees made stabs at critical dialogue with the presentor, but Dr. Alexander-Guerra's reporting did not. She seemed more inclined to merely pick salient points. Yet the workshop itself stirred up controversy over whether a clinician badgers/re-traumatizes/coerces with suggestion and authority a patient, or whether arguing with a patient who gets increasingly angry with the therapist facilitates the patient's edgedness, subjectivity, and allows for the practicing of protestation in a safe, consistent, staying-with manner.

And what of the communication a patient makes to the therapist when an alter has the same name as the therapist? What use can be made of that, and is it an enactment?

I think the author here was too oblique and shied away from controversy.

Kim Vaz, Ph.D., LMHC said...

As one in the community of therapists who attended the presentation of Lewis Aron just last Saturday, I was primed to bring my newly sharpened critical perspective to bear on Chefetz’s presentation of trauma and dissociation. Drawing on a vast body of scientific theory and a repository of clinical experience as a primary care doctor, psychiatrist and psychoanalyst and with cognitive therapy techniques, Chefetz’s goal was to offer the listeners a window into the subjective experience of those who dissociate as only they can know it.

Intersubjectivity and relational theory makes us wonder if it is ever possible to understand and or convey the subjective experience of another person unmediated by the therapist’s own subjectivity.

While Chefetz’s presentation was evocative, Aron’s integration of feminist theory into psychoanalytic discourse, highlighted the need for those working in the dissociative field to engage with the debates of power and domination as their patients, esp. women process their lives through a discordant prism of ‘selves’ which are multiply gendered, variously aged, and strategically engaged in one part of the emotional distress to the exclusion of other aspects of the distress.

Even the synthesizing of psychoanalytic with cognitive approaches to therapy with dissociated subjectivity absent of feminist perspectives, leaves us ill-equipped to recognize, work with and even honor a) the “queer” parts of the self; b) the desire not simply for revenge for past abuses and victimizations, but a real thirst for social justice; and c) the women’s liberation actions and feminist thinking of the past 30 years that have set millions of women free to “name” and articulate their own reality, unsullied by imposed medical or even analytic models.

Anonymous said...

As a patient with DID and in therapy for years, please know that the only place where I felt safe and allowed all parts of myself manifest "themselves" with a therapist,one amongst you,who never yelled at me, argued with me, belittled me, but accepted all of "me" gently and quietly while I healed within safe and proper boundaries.