Traditionally, dissociation has been linked to severe pathology, such as multiple personality disorder, psychogenic amnesia and fugue states. Recent research and study about the effects of trauma on the brain and on the developmental process as well as on affect regulation, has broadened our understanding of dissociation. This phenomenon is now more generally seen as a broad spectrum of symptoms ranging from those of the severely pathological through those with less severe manifestations, including depersonalization and derealization, to more benign symptoms, such as daydreaming and “tuning out.” Throughout this spectrum, the central dynamic of dissociation is a disengagement from external reality and a focus on an “internal” world (Perry et al. 1995). Thus, dissociation is now seen as a self-protective process that occurs over a broad spectrum of human behavior with a continuum that ranges from normative, day-to-day dissociation to severe psychopathological dissociation (see Bromberg 1998, 2006; Carroll and Schore 2001; Davies 1996, 1998, 1999, 2004; Davies and Frawley 1994; Howell 2005; Putnam 1989; Schore 2001, 2003; Siegel 1999; Stern 1997).

Detailed material in this paper describes a broad range of dissociation that occurs in the case of a single patient who is in analysis three times a week. Before presenting the case, I discuss concepts from neuroscience that illuminate a clinical process in which attunement to affect states, particularly states of hyperarousal and dissociation, is central. Additionally, I cover concepts from developmental research and from attachment theory that inform a way of working in which attunement to enactments between patient and therapist is essential.

Recent neuroscience has shown that dissociation is integrally linked to hyperarousal, that is, to feelings of anxiety. Proclivities toward extreme states of hyperarousal and dissociation are often linked to attachment disorders, engendering dysregulation that is rooted not only in traumatic events, but also in the on-going developmental relationship between the caregiver and the infant. As many researchers have shown, this early development occurs non-verbally and is not symbolically encoded in the brain. It develops from the non-verbal experience of being with another.

As well, it is now believed that implicit communication in the therapeutic relationship may be as important to “therapeutic change as is insight and understanding” (Levy 2009, personal communication; See Beebe and Lachmann 2002; Lyons-Ruth 1999; Schore 2001, 2003; Stern et al. 1998; Tronick et al. 1998.) Because so much affect dysregulation evolves from affective mis-attunement in developmental relationships, and because the brain has the capacity to change throughout the lifespan, the psychotherapeutic relationship can have a transformative impact in helping patients develop greater affect regulation. Moreover, it is now believed that new patterns of neural organization may be formed through the psychotherapeutic relationship.

This recent research in trauma, in attachment and in neuroscientific theory has reinforced the idea that talk therapy, particularly relational and intersubjective approaches, is especially effective in creating lasting patterns of change including changes in affect regulation. These approaches stress the importance of attunement to the non-verbal aspects of the therapeutic relationship as well as the verbal. That is why Schore, who uses an interdisciplinary approach, calls the therapist a “psychobiological regulator” of the patient (Carroll and Schore 2001; see also Wampold 2001, for data on the importance of the relationship in psychotherapy).

Neuroscience: The Hyperarousal Continuum and The Dissociation Continuum

I became interested in the neuroscience of dissociation after observing that many of my patients experienced both states of high arousal and states of numbness that appeared to be connected. In the work of neuropsychiatrists, including Schore (2003), Siegel (1999), and van der Kolk et al. (1996), I recognized the neurological underpinnings of dissociation and other post-traumatic stress disorder (PTSD) symptoms, including hypervigilance, panic, and somatization. Appreciating the neurobiology of these syndromes enabled me to create more empathic and helpful interventions with my patients.

The psychobiology of dissociation is rooted in a biological model of fight/flight/freeze based on the most basic of animal and human needs—the need to survive. In psychological terms, a threat to survival involves managing fears about survival of the self as well as survival of the body. This survival, or fight/flight/freeze framework, has become a cornerstone of trauma theory (Levine and Frederick 1997; Ogden et al. 2006; Scaer 2001; Schore 2003; Siegel 1999).

Coping mechanisms involving affect regulation are wired in the brain and come on line in the earliest stages of life. These coping mechanisms can, generally, be understood in terms of continuums of hyperarousal and dissociation (Perry et al. 1995). In the event of a threat, be it an event such as a tsunami or a car accident or a developmental interaction such as sexual, physical or emotional abuse, there are two major reactions that occur in the nervous system. One involves the hyperarousal continuum, which includes fight-or-flight responses, and the other involves the dissociation continuum, which includes freeze-and-surrender responses.

When a threat occurs, an alarm reaction is activated. It is characterized by a sense of hypervigilance, with an increased heart rate, increased blood pressure, and increased respiration rate. There is a release of complex hormones from the adrenal glands and of stored sugar with an increase in muscle tone readying the body to fight or to flee (Perry et al. 1995).

Dissociation is currently thought to occur in one of two ways. It may occur as a direct response to a significant threat, whereby the subject does not immediately move into a fight or flight mode, but rather goes into a freeze and surrender mode. However, more commonly, dissociation occurs less directly. For example, children and victims of abuse are physically overpowered by those who threaten them, so they are not well-positioned to fight or to flee. If they try to fight or call for help and it is to no avail, they may continue along the hyperarousal continuum, becoming more and more agitated and aroused. But, eventually they will tire and move into a freeze or surrender response (Perry et al. 1995).

Schore (2003) likens these survival processes to Bowlby’s (1969) protest and despair responses to attachment ruptures. Bowlby’s terms are derived from observations of 15 to 38 month old children who have been separated from their mothers in hospital and residential treatment centers. At first the child cries loudly and shakes his crib in hopes that his mother will appear. This phase is succeeded by one in which the child becomes inactive and withdrawn. He appears to be in a deep state of mourning. The underlying stress is not visibly evident. Here, hope has given way to quiet hopelessness.

Similarly, Schore (2003) notes that traumatized infants in other settings can be observed to be staring into space with their eyes glazed over which he believes to be states of dissociation. Such states involve avoidance, numbing and restricted affect. “As a result, during times of traumatic dissociation, the major motivational systems that are programmed to actively cope with the external social environment are switched off.” (Schore 2003, p. 67, 136; see also Siegel 1999, pp. 258–259)

In such states of dissociation, internal resources are not developed. Emotional adaptation and development are curtailed. If dissociation becomes habitual, the development of adaptive thought, in which the individual builds on a capacity to think through problems, fails to occur. Instead of being able to weigh the pros and cons of a given situation, there is a kind of dead zone.

The consequences of sustaining such dead zones are far-reaching. These areas are generally cut off from other areas of consciousness so that the individual has islands of unintegrated parts of the self. These split-off parts of the self may manifest themselves in somatic symptoms, intrusive thoughts, such as flashbacks and nightmares, as well as in a host of other psychopathological symptoms. Two aspects of dissociation are emphasized here: (a) the connection between a state of being overwhelmed and then shutting down, and (b) the idea that unprocessed or dissociated states do not get metabolized. Instead, these dead zones remain unverbalized and out of awareness. Thoughts, feelings, and memories stay frozen in time and are not processed. They become aspects of the self that are not integrated into the personality, as they are separate and distinct from other aspects of the individual.

Psychoanalytic Models and Nonverbal Communication

The recent research in trauma, attachment, and neuroscientific theory described above have had a profound effect on psychoanalytic theory. There has been a convergence of data from these fields, data that points to the centrality of the therapist–patient relationship in promoting therapeutic change. Among the concepts that have emerged from this paradigm as a central focus of psychoanalytic research and writing are the following, all of which are related: (a) the ubiquity of bi-directionality in the analyst-patient relationship, (b) the importance of self- and interactive-regulation, and (c) the important role of implicit communication in the analytic dyad.

Whereas explicit communication—meaning-making, symbolization and verbalization—has been the domain of analytic investigation for over a century, implicit communication has only relatively recently become a major area of interest. To quickly review these terms, procedural or implicit knowing has to do with knowing how to do something, such as riding a bike, encoded nonverbally in the mind. Explicit memory entails facts, figures, images, etc., that can be consciously recalled and recounted (Lyons-Ruth 1999). Since dissociation, by its very nature, is nonverbalized, the importance of the analyst’s being attuned to implicit communication cannot be overstated.

The Boston Change Process Study Group, including parent–infant researchers Daniel Stern, Karlen Lyons-Ruth, and Edward Tronick, discusses implicit communication extensively. A principal element that has evolved from their developmental research has been the idea that implicit communication is as important to creating transformative changes in psychotherapy as is explicit communication. Both individually and together, these analysts and others have been working to develop a language for talking about implicit communication and its role in the process of change (see Stern et al. 1998; Tronick et al. 1998). Lyons-Ruth (1999) summarizes their central ideas:

(1)…much of our relational experience is represented in an implicit procedural or enactive form that is unconscious,…; (2)…in both development and psychoanalysis, the increasing integration and articulation of new enactive “procedures for being with” destabilize existing enactive organization and serve as a primary engine of change; and (3)…enactive procedures become more articulated and integrated through participation in more coherent and collaborative forms of intersubjective interaction. Put another way, at the level of unconscious enactive procedures, the medium is the message; that is, the organization of meaning is implicit in the organization of the enacted relational dialogue and does not require reflective thought or verbalization to be, in some sense, known. In accord with infant observers such as Beebe and Lachmann (2002), enactive representation is viewed here as the earliest medium through which the “shadow of the object” becomes part of the “unthought known” of the infant’s early experience (Bollas 1987). (p. 578)

Developmentally, dissociation occurs when the child’s basic goals and needs are foreclosed by the caretaker. Then implicit procedural representations will be “segregated, fragmented or contradictory” (Lyons-Ruth 1999, pp. 607–608). As new developmental opportunities arise there will be limited capacity to expand, develop, and build on coherent procedural representations—a coherent sense of self as well as a coherent and trustworthy representation of self and other—because they are already fragmented and dissociated.

For example, for an abused child whose basic needs and wishes are overridden by physical or sexual abuse, cutting off or shutting down may be the only way to cope. Splitting, which entails segregating aspects of the mind from other aspects of the mind, becomes the only recourse for a child who cannot understand why the one who takes care of her also hurts her. The double-bind she faces causes confusion and the tendency to withdraw into dissociation, with all the physiological, mental, and emotional ramifications that that entails. Because dissociation involves surrender from cognitive and emotional mental processing, a great deal remains implicit. In therapy, greater awareness of what is experienced implicitly, whether through enactment or through greater sensitivity to nonverbal cues, such as tone of voice, posture, and facial expression in both therapist and patient, can help deepen and expand the therapeutic process. The experience of being together in that process is as important as the explicit elaboration of thoughts and feelings.

Moreover, when the analytic patient is in a state of trauma, either overly activated or dissociated, she cannot think. When the nervous system is overaroused, the patient is unable to reflect and absorb. Without this capacity she is not able to internalize insights or the relational matrix. Without this capacity, helping patients integrate dissociated parts of themselves is especially difficult. Establishing a sense of safety to calm the patient from the fears that have triggered the hyper- or hypo-arousal state is essential. Safety is primarily established through the interpersonal connection between the therapist and the patient. When there is a positive emotional connection, the patient feels less alone and less afraid. This contributes to the internalization of greater calm which, in turn, contributes to enhanced affect regulation. Additionally, in trauma work, many extra-analytic techniques such as psycho-education, resourcing, grounding, visualization and relaxation techniques are useful. These techniques may be successfully integrated into a psychoanalytic model.

Madge—Enacting Abandonment

Madge began treatment 8 years ago. After being downsized from a high-pressured job, and receiving a good severance package, she felt this was an opportune time to begin analytic work, something she had always wanted. The downsizing was a shock to Madge. She entered treatment in a state of anger and anxiety.

Though Madge was strongly motivated to begin treatment, she was also extremely fearful of it. In her first session she told me that she had felt panicked about coming. Her anxiety was palpable. She sat on the edge of the chair facing me, body rigid and with a piercing, wary stare. She seemed ready, at any moment, to bolt from her seat if necessary.

History

Madge was the first of seven children. Father was physically abusive with Mother as well as with many of the children, particularly the boys. Consequently, Madge’s home life was chaotic and unpredictable. When she was 6 years old Madge was sent to boarding school, where she stayed until she was 13. As Madge describes it, she was taken on a ride with her father and ended up in a convent-like school run by nuns. There was no preparation for this event. From this time on, Madge had no contact with her parents, not even through letters or phone calls, except on holidays. She would return home in the summer, but she always felt like an outsider at home. Sometimes she wasn’t even recognized by her very young siblings, who would ask “Mommy, who is she?”

Madge has frequently described the trauma of her first night in the school. She lay in a dark room, in terror, not knowing where she was and not having anyone to comfort her or even to talk to her. At this point there were no other children at the school, as Madge remembers being the first one to arrive. With this history of trauma and abandonment, it is easy to see how, as a 6-year-old girl, and probably even earlier, dissociation became a major coping mechanism.

Madge also felt that going back and forth from the academy to home was traumatic for many reasons, not the least of which was the total contrast between the rigidity of life at the academy and the chaos of life at home.

As an adult, Madge was involved in a long-term romantic relationship that ended painfully. Her feelings of abandonment were further inflamed by an experience with a therapist who, after several years of treatment, told her she could not work with Madge’s anger, and referred her to a different therapist. From our first session together, Madge was fearful I would find a reason to terminate her treatment, as her prior therapist had done. Thus Madge’s history signaled my need for great sensitivity to her fears of loss and abandonment and to states of panic and dissociation.

Treatment

In working with Madge I was frequently struck by the different personas, or selves, she presented to me. There was Madge the insightful, analytically minded woman whose intellectual wit, humor, and curiosity made her a joy to work with. Then there was Madge, the frightened child, entering the room with intense anxiety, telling me how much she had to struggle to get herself to come to the office and how frightened she was to be there. These parts of her self were strikingly distinct from each other and her mood shifts were intertwined with them. They were related to her extensive use of dissociation.

Dissociation

Madge uses dissociation in a variety of ways to deal with overwhelming feelings of anxiety, three of which I will discuss. First, when working at her job, Madge is aware that she sometimes panics in the face of demands that seem too great, and she then “zones out.” Having missed important information, she has to play catch-up and feels at a considerable disadvantage with regard to her performance. Madge perceives this not only as a threat to her ability to work but also as a personal defect.

Second, she often “spaces out” or wanders off in therapy. When an emotion becomes too uncomfortable or anxiety-provoking, Madge abruptly “clicks off,” and focuses on the bookcase in my office, looking at the titles on the shelves. This is soothing for Madge, and we have explored some of its meanings for her, one of them being the love of books that she shares with her father. These states often occur after we have worked through a meaningful issue and there is a feeling of closeness between us. This causes anxiety and flight in Madge, and she has associated it to feelings of closeness with her mother whom she experienced as abandoning during a number of traumatic events in her childhood. Thus, for Madge, a feeling of closeness and connectedness, for which she yearns, is a signal of danger.

A third, much more extreme and complex, way in which Madge dissociates has to do with states of isolation that she imposes on herself. During these times, Madge’s dissociation extends to periods when she detaches from the world, hibernates in her home, and comes out only when she needs more food. These periods of isolation represent a cut-off and an escape from the world. Madge feels unable to come to her sessions or even to call to cancel. By working through these enactments we were able to understand the more extreme feelings of anger, hurt, and helplessness that lay below the dissociation.

As I stated earlier, getting to her sessions was always problematic for Madge. She would frequently start sessions by saying she was angry and that it had been very difficult for her to come—or that she felt she would have to stop therapy because it was so difficult for her. She was more often than not considerably late and rarely used the full session time. Usually, she could not elaborate or verbalize why she felt angry at me. She simply knew it, or felt it, but could not think of any specific reason why she felt this way, which might well have been a consequence of her dissociation. She frequently did phone sessions as an alternative to coming. On the many occasions when she would be unable to come or even to call and cancel, it slowly became clear that Madge was holed up in her house, incommunicado. It seemed that the only way that Madge knew how to regulate her anxiety was through what she experienced as her total cut-offs from the world. She stayed in her house and usually read or watched TV, venturing out only when she was literally without a crust of bread. Her apartment represented a place of safety where she would not be impinged upon by either her own internal disquieting thoughts or by those of others, including me.

When I once called her on such an occasion, she screened the call and would not talk. The communication from her was “I do not want to talk to you. I need my space.” If I called, I would be intruding. As stated earlier, we were meeting three times a week. At least one week, Madge missed all three of her sessions. In most of these instances, she would call leaving a message that she would be doing her session later that day by telephone, and then fail to call during her session time. Needless to say, this was a source of great difficulty and confusion for me. Not only did I feel trapped in my office waiting for her call, and with every passing minute, more and more frustrated and angry, but I was also concerned that Madge was on the verge of ending treatment, as she so often said she would. So when Madge reiterated over and over again her fear that I would terminate her treatment and abandon her for her behavior, she was enacting the very abandonment she feared. During these times, I had to work on my own self-regulation to cope with the heightened anxiety that was provoked. I did this, in part, through discussions with colleagues in a weekly peer group I attended.

Three Principles of Salience and Working with Madge

In my work with Madge I make use of “three principles of salience” to provide a framework for discussing regulation. The three principles are ongoing regulations, disruption and repair of ongoing regulations, and heightened affective moments (Beebe and Lachmann 2002, p. 185). They encompass the range of implicit and explicit interactions that one experiences in psychoanalytic work. They take into account (a) both verbal and nonverbal interactions, (b) the bi-directionality of the analyst-patient interaction, and (c) the great importance of self- and interactive regulations. For these reasons, these principles are especially helpful in working with trauma survivors where a focus on regulation goes a long way in creating an “atmosphere of safety” (Schafer 1983), essential to the work.

Ongoing Regulations

In the first 4–5 years of Madge’s treatment, ongoing regulations were fraught with anxiety. Madge was often palpably terrified that she would do something that would cause me to end her treatment, as her former therapist had done. She was usually late to her treatment, for which she thought she would be punished. She frequently told me that getting to a session was an enormous struggle and she didn’t know how she could keep doing it. Yet, she mostly appeared for her sessions, and, if she missed one, she conscientiously paid for it. As for my role, it was important to maintain a safe holding environment of consistency and continuity, by sticking to the boundaries of starting and ending on time, and sustaining a noncritical, curious, analytic stance. In terms of the countertransference, my anxiety was often raised by Madge’s continually bringing up the possibility that she might leave. In this way, Madge shared her anxiety with me. Thus, we both contributed anxiety to the intersubjective field. Because of this, I had to continuously self-regulate to maintain a calm, nurturing stance.

Disruption and Repair

I return to the periods of isolation described earlier, in which Madge avoided coming to her sessions. These occurred, on and off, during the first 4 or so years of her treatment. As we slowly began to analyze these enactments, it became clear that the isolation had several meanings.

For one thing, Madge felt she needed to cut off or take a breather from the relationship with me. Talking about her feelings and relating in an intimate one-on-one relationship provoked extreme anxiety. In addition, the dissociation or psychic numbing that Madge experienced covered both terror and rage. Her terror had to do with thoughts that I would eventually stop seeing her because she misbehaved. Her rage was about her feeling that I was controlling her by imposing therapy sessions on her. Disruption and repair occurred continuously around these issues. Madge believed her not coming to her sessions would cause me to end her treatment. “How can we go on this way?” she would ask. “Are you still going to allow me to come?” It seemed almost incomprehensible to Madge that I would continue to work with her. For my part, I never wavered in my assertion that, barring being hit by a bus, I would not stop seeing her.

There is a paradoxical nature to this behavior. Madge felt that I would be angry at her for not coming to her sessions and that I would abandon her. She also expressed the feeling that I was controlling her by getting her to come to sessions at all. Her sense of agency with regard to these matters was dissociated: the idea that she initiated treatment and she decided when to come and when not to come did not register in these moments. The paradoxical enactment involved her playing out her fear of abandonment by not coming to her sessions, threatening to leave treatment, and then fearing this would cause me to abandon her. Since I continually reassured her that this would not happen, both explicitly by telling her so and implicitly by remaining steady, analytic, and concerned, we were in a continuous cycle of disruption and repair. It was within these disruption/repair cycles that trust began to build. Each time we worked in these moments of fracture, we explored feelings, we made connections, and, perhaps most importantly, Madge received assurances that she would not be abandoned. Eventually she was able to internalize this new way of thinking.

One of Madge’s dreams captures her ambivalence about wanting to be close and then fleeing. The immediate context for the following process material is that Madge had had a satisfying session in which she felt a strong connection to me. Here is the following session. Derivatives of dissociation are evident in the material.

M::

I had a nightmare last night. I was in a dark place. I looked down and there was a leopard in the room and there were big cats all around me. They were beginning to menace me. They were trying to get me and eat me up. I was trying to escape and being successful and not being successful. It was only a matter of time until I became a victim of these voracious creatures.

S::

What comes to mind about a leopard?

M::

Spots. It’s you. You’re an evil feline figure constantly changing your spots, trying to eat me up and spit me out.

S::

How am I changing my spots?

M::

I think that you’re genuinely trying to help me, but on the other hand I feel you’re out to get me. I get this feeling this is a fiction. I’m making it up as I go along.

S::

Go with it.

M::

It’s difficult for me to believe you’re genuinely trying to help me, that there isn’t a negative side. There has to be an opposite side. You’re trying to dupe me. You’re trying to trip me up. If I just think you’re genuinely interested in helping me then I’m going to get sucked in and then I’ll be suddenly ejected, abandoned. I’ve got to always be on guard for this. Otherwise I won’t be prepared. When I think that way, I become deadened so much that it takes a while until I come out of it.

S::

If you get too overwhelmed, you shut down.

M::

Well, I’ve got to be prepared. I become enraged, but I don’t exactly feel the rage.

S::

So let’s say part of your anger at me is a way of guarding against good feelings you get from our interaction.

M::

That may have a direct bearing on my absenteeism. So I feel good on Monday and don’t come Wednesday. The no-show day is to offset the show day.

Madge’s last remark is particularly important in the session. Madge’s response to my intervention about guarding against the good feelings is to discuss her absenteeism: the show days and the no-show days. Here she is making a new connection and building a bridge between her heretofore dissociated experiences. By bringing them into cognitive awareness, they can be further elaborated.

Madge’s ambivalence towards me is clear in this session. I might have given an example of disruption and repair that occurred on a microlevel, like a negative reaction to an interpretation or a negative reaction to a facial expression of mine or to a tone of voice—all of which have occurred frequently in our work together. However, I prefer to look at the bigger picture. The disruption addressed in this process has to do with the patient’s expectancy that I will turn on her, a fear that causes disruption and the need for repair repeatedly in the treatment. The repeated experience of repair eventually allowed Madge to let go of the expectation that I would end her treatment.

Heightened Affective Moments

The following short excerpts from three sequential sessions occurred approximately 3 years after the session quoted above. It is important to note that these sessions were led up to by many moments of attunement, misattunement, and re-attunement. The theme of closeness and danger is central here. In these sessions I have introduced a component from a trauma model where body sensations are brought into awareness and integrated into the psychoanalytic work. This is a process we experimented with on and off for about a year; though not our primary mode of working, it captures the spirit of much of our work in which heightened moments had a powerfully transformative effect. Other aspects of a trauma model will also be evident.

Excerpt 1

M::

I woke up in terrible dread, panic. It’s like something is attacking me. I become incapable of making it stop.

S::

How does that feel in your body right now?

M::

In my upper chest, I feel such fear and such dread. These volcanic eruptions are becoming more forceful. Having to leave my home is hitting me full force. I’m not sure, but I’m wondering if the last session scared me?

S::

What scared you?

M::

A good feeling—the fear of a good feeling. I felt an emotional connection to you or to something I long for.

S::

What would feel comforting? (Grounding.)

M::

Snow.

S::

Paint it for me.

M::

I can remember a beautiful snowy morning when I was a kid. I woke up and the snow was covering everything. It was pure and soft—all puffy. I went outside with my brother. There was such a feeling of closeness between us. We were so together. There was such warmth between us.

S::

What do you feel in your body?

M::

Energized. Tingling. My heart is on fire. It’s like warmth. It’s ablaze.

S::

Stay with that. Let that blaze move through your body.

M::

My whole body is tingling. (Silence.)

S::

What’s coming up?

M::

The loss of that connection is making me sad. The loss of the connectedness to my family, my siblings—I ended up odd man out.

S::

If you were to envision yourself back in that beautiful landscape, how would that feel? (Grounding. Reinforcing the Positive Feeling.)

M::

A very intimate, wonderful feeling.

Excerpt 2

In the session following the one above, I worked with Madge on re-imagining what she might have liked to happen rather than being sent away to school—the memory at the heart of Madge’s traumatic past.

S::

How would you have wanted it to be?

M::

The first image that comes to mind is me as a little girl and instead of being sent away, my mother prevents me from going. My mom is hugging me and knowing she will not allow me to go. She will save me from this fate and stay close to me as opposed to her pushing me away.

S::

How does that feel in your body?

M::

Tingling in my whole body.

S::

(Very soothingly) Your mother is holding you tight and you are feeling her warmth and love.

M::

It’s almost as if I feel nurtured in such a way as I feel I’ve been saved because she is there hugging and she’s hugging so hard and so close, I feel totally secure. I feel an energized tingling and now there’s warmth and joy and tears, and they’re tears of joy. (Crying).

S::

You’re experiencing something you’ve been yearning for all these years. And you’re no longer alone with those feelings.

Excerpt 3

M::

I had transferred all my feelings from my mother directly to you. It’s had an upsetting effect. Now I feel I have to pull back. This is not something I trust.

S::

That is what you feared. Now it’s more intense than ever.

M::

My concern is that it’s stopping me from what I need to get done. I felt so fused with you. Did you feel it or am I hallucinating or something?

S::

(Silent hesitation) I felt it. (Pause) Sometimes you have to go through that feeling of being fused to work it through.

M::

I just want to work it through. How will I do that? I feel numb. I don’t feel uplifted—like a non-entity, as if I’m floating around without a destination. My only refuge is myself, but myself in isolation. My only comforts are inanimate objects. (Pause) I have to remind myself that this is a process. This is so deep. I’m not going to be abandoned by you.

S::

This time you’re not.

M::

Can you call me next week when you’re on vacation?

S::

Yes. We can arrange a time. (I had called B. when I went away for 3 weeks a few months prior to this. It was the first time I had done so and it had a steadying effect on her.)

M::

I think in my infantile mind it’s good for you to call me rather than vice versa. That’s getting something I didn’t get. At boarding school, I so wanted to hear my mother’s voice.

S::

What are you feeling about my going away and not seeing you next week?

M::

I feel that I dealt with this feeling of potential abandonment by thinking about it and asking you to call me.

Case Discussion

In this case, dissociation came to be seen as signaling that the patient felt scared or overwhelmed, and she was withdrawing from the world and from her therapist. This was revealed through close attunement to the patient’s affect states, particularly to alternating states of arousal and disconnection. Over time, the patient became able to identify and articulate these affect states, leading to greater affect regulation.

In the first years of treatment, Madge rarely made connections between one session and the next. The linking of thoughts and feelings occurred primarily within each session. A close monitoring of moment-to-moment feelings in the here and now was especially useful during this phase of treatment. Through this close affect attunement, it was revealed that Madge would cut-off, or, dissociate, suddenly and automatically, right after a moment when she was feeling understood. Closeness triggered fear and flight.

During the second stage of treatment awareness and affect attunement were expanded: Madge and I were able to discuss not only what she experienced during a given session but also what occurred to her between sessions. What was especially powerful was attunement to the dissociative enactments around Madge’s missing her sessions. During these many enactments, enactments in which the patient would frequently tell me she would be calling me for a session and then not call, the intersubjective field was rife with feelings. On Madge’s side there was an obstinate and fearful withdrawal. On my side, as I waited for Madge to call, I believe I experienced the kind of confusion and anger that Madge said she felt but could not articulate. Her actions dysregulated me as they caused disruption in my expectations. Eventually, I found it imperative to communicate to Madge some of what I felt around these enactments. Her enactments were implicit communications that needed to be explored and articulated. As we slowly did this a core dynamic was revealed: the patient used dissociation as a way of protecting herself from intense longings and great fears of closeness, a dynamic that was also seen in the cut-offs in the office. On a deeper level, thoughts of abandonment provoked fear of self-fragmentation and annihilation.

The way we discovered the core dynamic—the patient’s feeling of connection followed by flight—was through attending to the dissociation she experienced both in the moment-to-moment interaction in the office as well as in her dissociative enactments of flight and isolation. Dissociation, by its very nature, is a silent coping mechanism, so it is easily missed. In order to pick it up, the therapist must be attuned to nonverbal, implicit communications and to her own internal responses to these communications. Thus, in working with trauma, attunement to implicit communications and to enactments, on the part of both the patient and the therapist, is essential. In this close state of attunement, this relationship takes on a life of its own, becoming what Ogden (1994) has called “the analytic third.” It is this relationship, with all that it entails, that creates the potential for powerful therapeutic transformation.

As a framework for conceptualizing this case, I chose Beebe and Lachmann’s (2002) three principles of salience because they encompass both the explicit and the implicit dimensions of the intersubjective relationship between the therapist and the patient. A key component of this conceptual framework is the idea that through therapy, expectancies that were structured into the mind at a young age can be restructured. As Lyons-Ruth (1999) puts it, there is “the creation of the new and the reworking of the old simultaneously” (p. 608).

For Madge, the old ways involve many frightening expectations: She will be kicked out of our relationship, or any relationship, because she is a bad, hateful child (a belief she held since being sent to boarding school). She will be punished for having wishes and needs, and then she will be ignored or dismissed. She will anger those around her for expressing her rage and she will be left all alone. In both explicit and implicit ways, these feelings were disconfirmed in the course of our treatment. Much of this work was accomplished by helping Madge to feel safe enough to work through long-dissociated feelings of fear, anger, grief, and joy.