When we think of multiplicity and dissociation we think of Phillip Bromberg who wrote the beautifully rendered Standing in the Spaces (1998), Awakening the Dreamer (2006) and The Shadow of the Tsunami (2011). I deem felicitous everything he puts to pen for Bromberg weaves stories, memoir, and theory into useful relation with clinical practice. Not only does he long emphasize how trauma leads to dysregulation of affect and to dissociation (as well as an inability to contain desire), but he highlights the inevitable dissociation by all of us, including the analyst, as we continually shift our myriad self states from background to foreground. [Bromberg sees the unitary self as illusion, albeit a “developmentally necessary illusion”.] These shifts or dissociations are in response to interpersonal interactions in an almost infinite number of transitory permutations which are co-created between one self state of the patient in conjunction with one of the analyst. Treatment, then,
draws the work into a dialectic between the here and now and the there and then, allowing the mutual construction of a transitional reality in which both the patient's and the analyst's dissociated experience have an opportunity to coexist as a perceived event different enough from the patient's narrative “truth” about relationships to permit internal repair to take place and the patient's reliance on dissociation to be gradually surrendered. To be fully in the moment is to be fully allowing new (as yet unprocessed) experience to interface perceptually with episodic memory, thus optimizing its potential for integration into narrative memory and, ultimately, enriching self-narrative—the goal of any form of treatment.
Dissociation, writes Bromberg, forecloses “the possibility of holding in a single state of consciousness two incompatible modes of relating.” It is the traumatized patients who most require our affective honesty in combination with safety. How are we to be genuine regarding the effect patients have on us while simultaneously avoiding shaming them or, worse, misconstruing their intentions in order to meet our own needs? It is through a secure attachment, with its consistently repeated safe interpersonal interactions, which allows for affect regulation. Disruptions in mutual regulation create a break in intersubjectivity in which the patient or the analyst may— until righting oneself once again in the ability to see the other as an equal subject— disparage, blame, or judge harshly the other.
We cannot undo the trauma that has been inflicted on patients, but Bromberg notes that, instead, we can try “to cure them of what they still do to themselves (and to others) in order to cope with what was done to them in the past.” Bromberg sees most of the symptoms of eating disorders as an outcome of dissociation. It is also thought (Boris, 1986) that dysregulation of desire in infancy is linked to the dysregulation of appetite [and choice] where “[g]reed is a state that attempts to eliminate the potential for traumatic rupture in human relatedness by replacing relationship with food —a solution that is largely self-contained and thus not subject to betrayal by the ‘other’.” Anorexia is the renunciation [through dissociation] of desire, but at its core, Bromberg writes, “is a loss of faith in the reliability of human relatedness” for “Trauma creates the experience of nonreparability…” Dissociation is, then, “not just insularity but regulation.” And the “insularity reflects the necessity to remain ready for danger at all times so it can never—as with the original traumatic experiences—arrive unanticipated.” Binging and purging, also accomplished via dissociation, are an attempt to bound the self, delineate an unfragmented edge.
by ‘noticing,’ through the impact of forced involvement with what the patient needs to call attention to without communicative speech, the dissociated self can start to exist, and a transition begins to take place... But the success of the transition depends on the ability of the patient to destroy successfully the analyst's unilateral experience of ‘what this is “really” all about’... The problem for the analyst, of course, is that his own self-image, which is a part of all this, is also dismantled, and it is this destruction he must ‘survive,’ … [Winnicott (1969)
Bromberg, P.M. (2001). Treating Patients with Symptoms—and Symptoms with Patience: Reflections on Shame, Dissociation, and Eating Disorders. Psychoanal. Dial., 11:891-912.