Bromberg’s Multiplicity of Selves: Dissociation and Eating Disorders

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.

Civil Rights Act of 1964

On this day fifty years ago, the Civil Rights Act of 1964, which outlawed discrimination based on race, sex, color, creed, and national origin, was signed into law by President Lyndon B. Johnson— less than eighteen months after John F. Kennedy called for such a law in his Civil Rights speech on June 11, 1963, a speech given on the heels of the biting police dogs and fire hoses in Birmingham that Spring. This landmark civil rights legislation outlawed racial segregation in schools and at lunch counters where I grew up. It added a richness and breadth to my school day experiences.  

It is the American dream to have the freedom for self determination, not subjugated by predetermination. Neil Altman writes: “Problems arise…when one loses the dialectical relationship between being free and being determined, when one fails to take account both of our human capacity for freedom and the ways in which that freedom is limited.” Foucault reminded us how society, its institutions and history, organizes our thinking around constructed power structures.  Damaging others through subjugation of their capacity for self determination, whether talking sex or race, ought to generate guilt. But operating in the paranoid-schizoid position we split ourselves (good me - bad me) and split others. 

Separating ourselves is antithetical to healing, whether done from within— through dissociation, disavowal, projection, and denial— or from without— through racism, misogyny, contempt for others. To address our dis-integration by these mechanisms we must first acknowledge our participation in them. Once acknowledged, a public (that is, explicit) dialogue can happen. Traumatic experience otherwise remains split off, unspoken. The Fourteenth and Nineteenth Amendments, and subsequent Civil Rights legislation, came about through dialogue, sometimes waging.

We organize ourselves not merely around drives, but more over around attachment and belonging.  When excluded and left out we feel ashamed. 

There is security in finding others like ourselves, but there is joy in finding like-mindedness amongst difference.

Happy Independence Day, USA.

100 years ago today -a little historical perspective

What is and what is true depends on one’s perspective. One hundred years ago today, the assassinations in Sarajevo of Archduke Franz Ferdinand, the heir to the throne of the Austro-Hungarian Empire, and his pregnant wife Sophie by the young Serbian nationalist Gavrilo Princip propelled humanity into the bloodiest century ever, almost 17 million deaths in WWI, and, after German humiliation contributing to the later rise of fascism, over 80 million in WWII. 

Differing perspectives? In Sarajevo today, Princip is seen by Serbians, not as an assassin but as a liberation hero for his stand against the occupation and aggression of the Austro-Hungarian Empire, while non-Serb Bosnians see Princip as the forerunner of the Serbians who bombed Sarajevo in the 1990’s and, in ethnic cleansing, killed so many of its citizens. After WWI, Christian Yogoslavians  claimed this atheist revolutionary  as a martyr, and, after WWII, Communist Yugoslavia praised him as pan-Yugoslav patriot. 

So we hold our theories and truths very lightly as we re-write, rather, re-configure with patients' their histories. New neuronal connections allow for an increasingly expanded repertoire from which to construct 'truth' about what has been, but the negotiation of relationship on an ever shifting foundation can give motion sickness to its participants. Today the contemporary analyst has given up her perch as the arbitrator of truth and struggles to welcome in a kaleidoscope of emerging and ever changing points of view found within both her patient and herself. This poses its difficulties for patients who need a definitive answer on what is and what was. Likewise, it poses difficulty for the analyst who finds uncertainty anxiety provoking.  

   

                       

Countertransference and Disclosure

Another interesting paper on countertransference is by Zachrisson who sees countertransference as “the analyst’s participation in the relationship.” He writes, “Countertransference refers to something happening in the analyst. …Something takes place in the analyst threatening to bring him or her out of analytic position.” In other words, it may threaten the analytic frame by vitiating the therapist’s analytic attitude. It may seem that Zachrisson has the old fashioned view of seeing countertransference as something to be avoided, but instead he writes “An essential aspect of analytic attitude is precisely this: to allow the expression of what is in the patient's psyche, irrespective of which feelings or thoughts are there, and regardless of what feelings these may evoke in the analyst.” These feelings are to be borne and reflected upon by the analyst, and I would add, reflected upon by both participants. If, as Lachmann intimates, co-construction includes countertransference, then would it not follow that exploration which situates both participants in its construction ought to be part of a necessary negotiation?

Odgen makes use of countertransference and “the subjective contribution of the analyst,” Zachrisson writes, and advocates “analysis of this intersubjective construction” to aid the analyst in accessing “the patient’s inner states.” Because “[s]ubjectivity is present ubiquitously” Zachrisson uses Ogden’s concept of the analytic third to help ‘contain’ both “the subjectivity of the analyst” and “the ubiquity of counter transference.” Furthermore, Zachrisson takes Aron’s ideas about the analytic endeavor being both mutual and asymmetric, the latter making expressions by the analyst “both important and complicated” and reminds the analyst that “such openness must be conscious, clear, and contemplated.”  Here I would interject that this would be the ideal, and as such, unattainable, for enactments, sometimes through spontaneous disclosures, are inevitable. Where the analyst can be more easily mindful is in the attitude to allow everything in from the patient, including the painful explication of the effect on the patient of the analyst’s missteps.  As Zachrisson puts it, “In the intersubjective perspective, the analyst’s relationship to the patient is marked by a high degree of mutual subjectivity.”

Zachrisson cautions, “It is decisive to differentiate the case where the analyst enacts his own needs from the case where the primary aim is to communicate an understanding of the patient’s inner world or of the actual relationship. … If he manages to keep his reflecting stance, the countertransference can be useful. If he loses it, the countertransference becomes disturbing.”

Zachrisson, A. (2009). Countertransference and Changes in the Conception of the Psychoanalytic Relationship. Int. Forum Psychoanal., 18:177-188.  

Countertransference?

Can candidates in training, or even seasoned analysts, ever tire of discussing our ‘countertransference’ and the importance of our self reflection? At TBIPS we include the analyst’s contribution— inadvertent or deliberate, explicit or implicit— in our discussions throughout the training, and in every course. Heimann extended the Freudian concept of countertransference (the analyst’s neurotic transference to the patient) to include all feelings and reactions to the patient, acknowledging that countertransference provided useful information about the patient, even positing that the patient created the countertransference. Thus, countertransference was not to be eschewed but, instead, utilized. Lachmann poses the question of whether we are ready to dispense with the term ‘countertransference’ altogether.

Lachmann, from his Self Psychology approach, advocates that the analyst provide (ideally, always) a self object experience for the patient. He gives a clinical example of how he welcomed in Cecilia’s inexhaustible talk about her favorite soap opera. One TBIPS candidate, Stavros Charalambides, noted that Lachmann missed an opportunity for negotiation when he did not pose to Cecilia whether she wanted the analyst to continue listening to the lives of her soap opera characters or whether she wanted to consider if something else might also be worthy of their attention. My Relational bias wonders, too, whether it does a disservice to a patient when we deprive them of knowing their impact on us. I greatly admire Lachmann’s work and often assign his papers, but I, too, was left wanting more from the clinical vignette in his paper. Perhaps Cecelia, over time, goes further than the connection to her mother merely through a soap opera. Maybe Cecilia’s mother can offer nothing more, but how sad if this remains their only connection. Maybe Cecilia’s father can never connect to her except when she does for him, like compiling a book about him. Maybe Cecilia’s acceptance of what little her parents are capable of offering was great progress. But what if an inadvertent outcome for Cecilia was that she had become a self object experience for her parents just as Lachman was for Cecilia, and that she never learns to negotiate to include her own needs?

Lachmann is a great fan of co-construction, now termed co-creation, and wrote with Beebe a wonderful paper on mutual regulation between infant and mother, but I had some questions about why Lachmann does not extend co-construction to include countertransference when he writes “…even if I had felt angry, that would not indicate to me that Cecilia's motivation was to make me angry.” Lachmann, I suppose, is considering other motivations of Celia’s, such as the attempt to make a connection, or an attempt to know her analyst’s mind, for example, which only as a by-product might make her analyst angry. Because Lachmann sees co-construction as “understood,” he does not tell us where the analyst’s contribution is to the Self psychologist’s two dimensions of transference:  the self object dimension and the representational dimension.  Sometimes, I need it made explicit, as may the patient.

Heimann, P. (1950). On counter transference. Int. J. Psycho-Anal., 31, 81. 

Lachmann, F.M. (2001). A Farewell to Countertransference. Int. Forum Psychoanal., 10:242-246.

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Fall Semester 2014

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Developmental Issues: Narcissism and the Development of Shame Throughout the Life Cycle

(16 weeks) Wednesdays  8:00am-9:15am   This course offers a contemporary understanding of narcissism, both its developmentally appropriate and pathological aspects, with an emphasis on its primary affect shame, and helping the clinician to avoid engendering shame in the therapeutic situation.  It includes discussion of envy and rage and deficits in mentalization. We emphasize recognition, containment, empathy and mirroring. Instructor: Lycia Alexander-Guerra

Clinical Case Conference (16weeks) Wednesdays 9:30am-10:45pm    This course is designed to support the clinician’s work and offers opportunity to integrate clinical material with psychoanalytic concepts, including ethics, and ways to deepen the psychoanalytic process, with a focus on the therapist’s self reflection, the clinical relationship, and ways to facilitate what is mutative for the patient. Attendees are encouraged to present case material.  Instructor: Lauren Levine

Relational Concepts and Methodology I (16 weeks) Wednesdays 11:00am-12:15am This course is designed to elucidate some of the differences between classical and postclassical psychoanalytic thinking. We will compare assumptions about the mind, compare ideas about clinical process, and consider how relationship is built, maintained, and repaired. With an emphasis on the analyst’s self reflection we will explore how we locate ourselves in the therapeutic process. Instructor: Susan Horky

                     

Psychosoma  I (16 weeks) Wednesdays  11:00am-12:15pm We view hypochondriacal and psychosomatic symptoms as communication of past trauma. This course focuses on helping clinicians with patients who are alexythymic, i.e. have no words for experience—a population often confounding and daunting for  the therapist—and instead express their experience through physical symptoms. We will review an historical perspective and the current psychoanalytic literature on psychosomatic thought. We discuss how embodied experience represents an expansion of the analyst’s work in both transferential and countertransferential. Some specific  organ systems (pulmonary, reproductive, skin, etc) are highlighted. Instructor: Lycia Alexander-Guerra

Hate, Envy, and Destructiveness in the Clinical Situation (16 weeks) Wednesdays 12:30 pm -1:45pm Working with the affectively dysregulated patient presents increased challenges for the clinician, including the need to survive (i.e., neither withdraw from nor retaliate against the patient). Negotiating intersubjective space will be discussed, as will contributions from object relations and how understanding trauma informs our interpersonal interactions. Fee: $250 for a single course; $200 if enrolled in full semester.   Instructor:  Lorrie Gold      

                                         

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_______ Clinical Case Conference  (16 weeks) Wednesdays 9:30am-10:45pm  Sep 17, 2014 – Jan 28, 2015. Fee: $250 for a single course;   $200 if enrolled in 3 or more courses.       

              

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The Third: Moving from Complementarity to Triangular Space

Aron enumerates various ways we conceive of "something beyond the dyad” called the [analytic] third:  “a context within which we emerge, … an emergent property of dyadic interaction and … a dyadic achievement that creates the psychic space necessary for reflexive self-awareness and mentalization" (the understanding that the other has contents of mind, as well, and different from one’s own—an important and necessary component for mutual recognition of relational intersubjectivity). What a recognition of paradox regarding the third: that we emerge from it, as well as it from us, and it is something we create and utilize.

What makes the analytic third so useful? Aron, and Benjamin, state that “thirdness…allows the analyst to restore a process of identification with the patient’s position without losing her own perspective.” This is a refreshing experience of learning negotiation procedurally for a patient raised in an environment of negation (“where the acceptance of one person’s subjectivity meant an obliteration of the other’s”).  Learned complementarity— your way or my way, no in between— can ensue, and play out in the transference-countertransference dialectic, and  an analytic impasse may result. Aron tells us that this impasse can sometimes be averted by opening the intersubjective space to create an analytic third where the analyst is open to the patient’s multiple and contradictory identifications.

Benjamin delineates two types of the third: The ‘one-in-the-third’ (the rhythmic third) — where oneness is experienced in a rhythmic pattern between two such as reciprocal speech or eye gaze, is dyadic and exists early (pre-oedipal) in relationship— and the ‘third-in-the-one’ – where the conflict within the mind of one can act as a third position.  For some, like Britton, where the ‘triangular’ space is created in the analyst’s mind, the mother's mind creates the third position. For Benjamin, the rhythmic third emerges, not from one mind, but from within the dyad. Her third-in-the-one (the intentional third), on the other hand, says Aron, "creates a space for differentiation" [from oneness], much like 'marking' (described by Gergely when the mother gives her version of the infant's response, differentiating her response as a reflective mirroring rather than one generated from within her. The infant has the capacity to see the mother's response as separate from its own.) Marking, then, is not a perfect match, but a reflection, as well, of otherness, a kind of mirroring that "is a dyadic phenomenon, functioning as a differentiating third point emerging between" two people and, as such, does not require a third person to separate the infant from the mother. Marking creates the third-in-the-one [in the one dyad]. We can have both the connection, in the one-in-the-third, and difference, in the third-in-the-one.

Aron notes that the Lousanne group’s investigation of triangularity in infancy shows the capacity at an early age to have triadic interactions between two people (e.g., from the mother’s mind emerges a third position) indicating that triangularity can no longer be conceived as the hallmark of the oedipal phase. The child no longer needs the primal scene (relationship of parents which excludes the child) to have experience with the third. Rather, the child is privy to the emerging third position within the mother’s mind. A third point of reference can emerge from the dyad within the mind of one and, when shared, can facilitate self-reflection and mentalization.  

Aron points out how certain self disclosures by the analyst can create thirdness in the analytic dyad. When the analyst lets her  mind be known (when , e.g., she disagrees with herself or is of two minds [e.g. I want to respond to your request for advice, but concerned that, if I do, I would be too much like your controlling, know-it-all father”]— that is, where analysts disclose "aspects of their inner processes"—a thirdness is introduced in the dyad, where the disclosure itself can serve as the strange attractor (from chaos theory, which allows the possibility to shake up linear thinking and have a reconfiguration of elements). Aron writes, “[T]he analyst’s reflexive self-awareness, a dialogue with one’s self, creates a third point.” When made explicit, the patient becomes privy to the analyst’s mind, both its contents and its way of  working. It is this third point of view which allows for the third space, and in this space, both analyst and patient can think together about connection and difference.

See also on this same paper the post of Jan 27, 2013. Compare and contrast it to ideas in Aron’s 1995 paper (in the post of Jun 8, 2014.)

Aron, L. (2006). Analytic Impasse and the Third: Clinical implications of intersubjectivity theory. Int. J. PsychoAnal., 87:349-368

Reconciliation: Film, The Railway Man

The Railway Man (2014), directed by Australian Jonathan Teplizky (Burning Man) and starring Colin Firth as the older, WWII veteran Eric Lomax— who quietly suffered decades with Post Traumatic Stress Disorder (PTSD), aggravated perhaps by the stiff upper lip, nobody talks about such things society — is based on Lomax’s 1995 memoir of his capture in Singapore in 1942, where he was forced to work on building the Thai-Burma railroad, his torture in a Japanese POW camp— younger Lomax portrayed by Jeremy Irvine (War Horse)— and the eventual, decades later, confronting of his torturer Takashi Nagase (Hiroyuki Sanada— 47 Ronin, The Last Samurai); the Young Nagase (Tanroh Ishida). In this role, Firth is a changed man from his usual handsome and sometimes comedic presence. He has the haggard look of the perpetually haunted, the vacant look of the dissociated. Firth had met with Lomax before the latter’s death in 2012, and understood from him some of Lomax's utter exposure,  degradation and the vulnerability experienced at the hands of his torturer.

Like a therapy session where present and past alternate foreground and background, — and, inescapably with PTSD, where the past impinges on the present— Teplitzky’s film moves between the war years and the 1980s. Torture, the most horrendous of ruptures, is somehow miraculously repaired when Lomax, returning to Thailand with the intent to torture or kill his torturer, finds that Nagase is deeply remorseful and has spent his life dedicated to making sure no one forgets the atrocities committed by him and others. What has led Lomax, after decades of debilitating flashbacks and nightmares, to have the capacity to forgive Nagase? If he was aided by the relational home that Lomax’s second wife Patti (Nicole Kidman) provided for him, we see very little of her in this film.  If he was aided, too, by Helen Bamber, his therapist at the Medical Foundation for the Care of Victims of Torture, we see none of her in the film. Perhaps the real life friendship that later developed between Lomax and Nagase was based on that Nagase might be the only person who could truly understand what had happened to Lomax in the horror of that wartime. Regardless, The Railway Man depicts the most tremendous of feats of humanity: to forgive the unforgivable.

Finding a Third

Coming to terms with being left out can sometimes predominate in an analysis. As children, we do not simply internalize objects (mother, father) but also relationships or patterns of relationships (systems) – including the perceived relationships of our parents, observed or imagined— and exclusion from it can be a narcissistic injury. Aron writes, “The child’s wish to be included represents both a wish for relationship…and an attempt to maintain self esteem.” In finding ourselves excluded from the parental relationship and parental interaction (the primal scene as exclusion of the child from the parental dyad), this exclusion, with its blow to a child’s grandiosity, becomes an organizer which links narcissism and object relations.

Trauma can disrupt the capacity to pretend, play, and move freely between identity and multiplicity, between discontinuity and integration. One cannot enjoy being the object of desire without also having established one’s own subjectivity and agency. When unable to experience self as subject with agency, the analysand or the child operating in the paranoid-schizoid position, in psychic equivalence, fears loss of self and identity.

The up side of recognition of this exclusion is the opportunity to experience the self as both subject and an object, which leads to the possibility of developing the capacity to hold two contrasting ideas simultaneously – that of being both a subject and object—and, ala Winnicott, the ability to allow for paradox to be sustained without the need to push for its resolution.  Aron says this capacity for toleration of contradiction becomes another nidus for regulation of self and object relations, for creativity, mentalization, symbolization, and even multiplicity of gender. The capacity to be both subject and object, participant and observer, allows one to be both subject who desires and object who is desired.

Moreover, experiencing oneself as both subject and object allows for intersubjectivity and, in the treatment situation, the creation of an analytic third. Aron writes that the child first lives in a dyadic world, relating to only one parent a time, until it discovers (in the Oedipal stage) that parents have a relationship of their own from which the child is excluded. In utilizing Britton’s ‘triangular space,’ Aron notes it “allows for the possibility of being a participant in a [dyadic] relationship and observed by a third person and of being an observer of a relationship between two other people.” The child is able to identify with self as object and self as subject, and to identify with other as both subject and object, that is the development of intersubjectivity.  Aron asserts that the experience with this alternating between participation and observation is what allows for becoming an analysand.

Aron, L. (1995). The Internalized Primal Scene. Psychoanal. Dial., 5:195-237.

Retrieving a beloved son, Bergdahl

Bowe Bergdahl, a US Army soldier held captive for almost five years by Taliban forces, was the last and only American POW in Afghanistan to bring home. But there were controversies surrounding his return, the two main ones being his exchange for five Taliban detainees from Guantanamo Bay, and claims that our commander in chief Obama did not have the authority to make such an exchange. Additionally, there are those who are angry at Bergdahl for leaving his post, going AWOL, or possibly deserting, and he may face court martial and prison time. Rumors abound about whether other soldiers died as a direct result of their search for Bergdahl.  One former US Army Sergeant, Josh Korder, for example, denounces Bergdahl, “He chose to take off his gear, put down his weapon, and walk away…” and says what Bergdahl did is “just not forgivable.” 

My two older brothers came of age during the Viet Nam war. This was a time when our country did not whole heartedly “support our troops,” calling them, for one, “baby killers” –there is a rumor that Bergdahl saw an American tank run over an Afghani child. Though I am against military action before diplomacy is exhausted, I am happy that our nation does not now disparage these young men and women upon their return home.  I additionally advocate that we not disparage troops who, for whatever reasons, break or break faith.  The older of my two brothers  joined up in the late sixties, his best childhood friend having ‘been the first on our block to come home in a box’  and the other brother made his plans to relocate to Canada should his draft number come up. My parents supported both their sons’ decisions. Looking back, this support of these two antipodal positions now seems remarkable in this political climate where black and white are so rigidly demarcated. Though both my brothers fare well today, we know too well that not all our soldiers come home unscathed.  Can we not find compassion for the horrific pressures troops are placed under?

I am so proud to be a volunteer clinician for TBIPS’ Veterans Family Initiative which provides pro bono and low fee, long term and intensive psychotherapy services without any significant wait time to veterans and their families. I am so proud, too, that training at TBIPS emphasizes negotiation of paradox where seemingly contradictory positions are, with our understanding of multiple self states, welcomed in, each as a necessary part of the whole. We all strive to be whole and wholly connected. No matter what Bowe Bergdahl has done or did not do, he remains the beloved son of Jani and Bob, and I, with them, welcome him home.