From “It's Not Me” to “It Was Me,After All”: A Case Presentation of a Patient Diagnosed with Dissociative Identity Disorder

In cases of extreme childhood trauma associated with abuse and neglect, one's sense of self is seriously compromised. Attachment patterns, symptoms, defensive operations, and character formation will differ depending upon the level of interference and impingement. When repeated trauma occurs in early childhood, the dissociative response may become the first line of defense for the person to rely upon. In its most severe form, patients are diagnosed with Dissociative Identity Disorder (DID). This paper addresses the case of a woman diagnosed with DID. It describes the restoration of a cohesive sense of self from the eight parts of a dissociated and fragmented self in the course of therapy. The clinical case material presented is that of the child part of her, known as Lucy. Her treatment resulted in the integration of the “it's not me!” self to the patient's knowledge that “it was me, after all.”     

Working Through Countertransference: Navigating Between Safety and Paranoia for a Client With Complex Trauma History and Borderline Personality Organization

The aftermath of complex trauma deeply impacts one's self-organization and interpersonal relationships, often resulting in clients who present to therapy with borderline characteristics and are typically labeled as difficult to treat. Further clinical complications with paranoid features may quickly place the therapist at a loss with respect to managing perceived and/or actual threats to client safety. Using psychodynamic theories, especially Kleinian understandings of psychosis and Winnicottian approaches to early disturbance and its impact on the emergence of self, this article provides a detailed case illustration that explores how a critical reflection of countertransference as “enactment,” “communication,” and “imagination” can help the therapist to understand the client's unconscious symbolic psychic struggles and to guide treatment selections in the therapy process.     

Self psychology and projective identification—whither shall they meet? a reply to the editors (1995)

The concept of projective identification continues to be viewed as alien, even dangerous, by self psychologists. Six aspects of self‐psychology/intersubjectivity theory are explored in an attempt to understand the presumed incompatibility of self psychology and projective identification: 1) the empathic vantage point; 2) the focus on subjective reality; 3) the emphasis on the analyst's personal contribution; 4) the focus on selfobject experience; 5) the disruption—restoration process; and 6) the defining of transference and countertransference as “organizing activity.”; The self‐psychological/intersubjective concepts that come closest to describing the phenomenon of projective identification—that is, empathic immersion, affect resonance, and reciprocal mutual influence—fail to capture at least three of its essential elements 1) the patient's persistent, unconscious intent to communicate certain unformulated aspects of self through the other; 2) the analyst's sense of being “taken over”; by the patient's experience; and 3) the intensely visceral quality of the analyst's experience. It is argued that self psychology ignores this important form of patient communication to its own detriment and that the concept of projective identification needs to be reformulated in terms that are more experience near to self psychologists. It is suggested that there exists a normal, developmental need, a selfobject need, to communicate intolerable, unsymbolized affective experience through the other's experience—a need that remains more pervasive and intense in some of us than in others—and that the longed‐for selfobject response is to have one's communication received, contained, and given back in such a way that one knows the other has “gotten”; it from the inside out.     

Crash: What We Do When We Cannot Touch: Commentary on Paper by Meira Likierman

This commentary aims to show the congruence and difference between Likierman's position on recognizing otherness and working with enactment and her relational, intersubjective position. Differences in my reading of the case include stressing the repetition of early attachment trauma, the level of implicit procedural relating, and the patient's contribution to the shared third of rupture and repair. I try to show that enactments arise not merely because the patient is able to pull the patient into forbidden behavior but because the dissociated parts of the patient pull the analyst into dissociation even when the analyst is acting “properly.” The rupture or collision—the “crash”—that the patient helps to formulate represents an opportunity to see the life-giving element in what we, analysts along with patients, inevitably also experience as frightening and even life-threatening.     

Hope When There Is No Hope: Discussion of Jill Scharff's Case Presentation

Jill Scharff's case material is viewed and discussed here from the vantage point of the two partners being an interpenetrating unit held in the grip of an “enactment”—a coconstructed event in which the analyst's participation sometimes becomes so enmeshed with the patient's in an ongoing way that analyst and patient seem to be trapped together in a narrow and concrete tunnel of reality from which they cannot find an escape, gradually making the treatment feel more and more hopeless because it is immune to interpretation of internal conflict. In the language of enactment, analyst and patient are held conjointly in the grasp of a shared dynamic that is a central hallmark of dissociation—an intrapsychic phenomenon that is played out interpersonally. The relationship between trauma, dissociation, shame, and affect regulation is explored in the context of impasse, repair, and psychoanalytic “technique.”     

To Have and to Hold: Thoughts on Admiration/Envy: Commentary on Paper by Joye Weisel-Barth

Using the author's definition of “envy,” I try to separate out fleeting feelings of envy that lead to “admiration” from very disturbing feelings of envy that have to remain hidden because they are so shameful. I try to explore the reasons why it is so unlikely that analysts will feel envy of their patients no matter how rich and famous they may be. Instead, I try to show that this really is a paper on “admiration” and quote the relevant literature on how to distinguish these two affects. A careful reading of the case material shows that the analyst's admiration of her patient's artwork served a very positive role in the treatment of a severely narcissistic man whose self-esteem had plummeted after suffering several losses. It seemed that by being a “container” and “self-object” for a long period, the analyst was able to rescue pieces of the patient's self that he felt were falling through a “colander.” The case is also used as an example of some of the work that started in the 1970s about how to work with narcissistic and nonclassical cases in a noninterpretative manner.     

Murakami's After the Quake—The Writer as Waking Dreamer and Trauma Analyst

In this paper I explore how Haruki Murakami depicts in profound and original images and nested stories the experience of traumatic dissociation and recovery. Murakami has an uncanny ability as a “waking dreamer” to capture and narratively elaborate core imagery. In his writings, he has examined the significance of imagination and dreaming in a person's bearing the complexity and multiplicity inherent in human existence. In “U.F.O. in Kushiro” the protagonist's reawakens from a numb, frozen state through a provocative encounter with someone who melts his frozen dissociation. There is a parallel to analytic working through of enactments stemming from trauma as described and elaborated by Bromberg.

Immersion in great imaginative literature can serve a restorative and generative purpose for the analyst-reader who so often has to wrestle with, and join, a patient's numbed, haunted adaptation to traumas, of the recent and distant past. Murakami's humor and evocativeness help me recover from the everyday depletion of clinical work on the edge of impasse. Literature and art help us regenerate and expand our capacity for complexity, imagination, and play in our daily practice and lives.     

Moments of Therapeutic Impasse: Commentary on Jody Messler Davies's “Whose Bad Objects Are We Anyway? Repetition and Our Elusive Love Affair with Evil”

Davies contributes to the development of relational theory by formulating and illustrating what occurs during especially difficult moments in an analytic exchange. In understanding enactments, Davies importantly underscores the contribution of both the analyst's and patient's “bad objects.” This author attempts to build bridges between Davies' language and concepts anchored in object relations theory and this author's language and concepts based in contemporary or relational self psychology, including the integration of cognitive psychology. In addition, this author delineates the use of the “empathic,” “othercentered,” and “analyst's self” listening/experiencing perspectives to explicate the case material and to provide alternative understandings and pathways for psychoanalytic work. The thesis set forth is that the use of different listening/experiencing perspectives expands choice for the analyst when working in difficult moments of the clinical exchange.     

Cognitive Factors in Fibromyalgia: The Role of Self-Concept and Identity Related Conflicts

Fibromyalgia is a syndrome characterized by the presence of diffuse and chronic musculoskeletal pain of unknown etiology. Clinical diagnosis and the merely palliative treatments considerably affect the patient's experience and the chronic course of the disease. Therefore, several authors have emphasized the need to explore issues related to self in these patients. The repertory grid technique (RGT), derived from personal construct theory, is a method designed to assess the patient's construction of self and others. A group of women with fibromyalgia (n = 30) and a control group (n = 30) were assessed using RGT. Women with fibromyalgia also completed the Fibromyalgia Impact Questionnaire and a visual-analogue scale for pain, and painful tender points were explored. Results suggest that these women had a higher present self–ideal self discrepancy and a lower perceived adequacy of others, and it was more likely to find implicative dilemmas among them compared to controls. These dilemmas are a type of cognitive conflict in which the symptom is construed as “enmeshed” with positive characteristics of the self. Finally, implications of these results for the psychological treatment of fibromyalgia are suggested to give a more central role to self-identity issues and to the related cognitive conflicts.     

On knowing one's patient inside out: The aesthetics of unconscious communication∗1

“Knowing one's patient inside out” is a metaphor that is intended to capture the paradoxical quality of the intersubjective field that we call the analytic relationship. The interface among trauma, dissociation, and regression is discussed in the context of unconscious communication as a transferential enactment of unsymbolized experience.The view is offered that for certain patients in particular, past experience is not so much unconscious as “frozen in time” and that a key element of the psychoanalytic relationship is bridging dissociated aspects of self through the creation of a dyadic experiential field that is both “inside” and “outside.” The writings of Michael Balint, D. W. Winnicott, and several other British object relational theorists are explored in the context of a contemporary interpersonal psychoanalytic perspective.     

Obituaries

This article reviews the growing contribution of self psychology to group psychotherapy. The basic self-psychological concepts as they are applied to group dynamics and the treatment process are explored. Tranference, countertransference, and self-restitutive patterns are illustrated in a clinical vignette that includes a “difficult” patient's impact upon the interactional and group-as-a-whole processes. Several directions for future investigation are described.     

The Analyst's Necessary Vertigo

The euphemistic phrase “the difficult to reach patient” often refers to work with patients who have serious difficulties relating. The author examines the basic construct of “reach,” its pitfalls, and potentials. In the author's view, often we are talking about patients who do not fully experience their own subjective existence or the existence of others. This requires unusual efforts to “reach” the patient in order for the patient to consolidate a sense of self and other, creating the possibility of reflective relating. In contrast to views that see such psychoanalytic “reach” as associated primarily with the analyst's needs or pathology, the author views the analyst's extraordinary efforts as responsive to the patient's need to move the analyst into the foundations of the analyst's own being.     

Applications,Implications, Complications: Reply to Reviews by Elkind,Gerson, and Levine

The author appreciates the careful reading and thoughtful reviews by Sue Elkind, Sam Gerson, and Howard Levine. Elkind's review particularly captures and articulates many of the key ideas in the book Building Bridges: The Negotiation of Paradox in Psychoanalysis and creatively applies concepts of negotiation, paradox, an inherently multiple “distributed self,” and metaphor in her own work consulting on treatment impasses. Gerson incisively focuses on the core idea of recognizing, accepting, and bridging differences and contradictions in personal, and national, perspectives; he also articulates an understanding of the attempt of relational analytic writers to bridge the intrapsychic and the interpersonal with due recognition of each. The author replies extensively to Levine's comparison of Pizer's work with that of Semrad and other “classical” analysts and challenges Levine's premise that a relational perspective, grounded as it is in a two-person contextual psychology, ignores or devalues interpretation, insight, free association, and autonomous mental functioning. Quoting from clinical material in his book, Pizer presents the outcome of a “relational” analysis in terms of the patient's increased access to internal “potential space,” unconscious experience, curiosity, and reflectiveness about the mental life of self and other, and an increased ability to value personal experience in relationship and in solitude.     

Murakami,Connoisseur of Uncertainty: Commentary on Paper by Thomas Rosbrow

My discussion embroiders around Thomas Rosbrow's view of Murakami as a “trauma analyst.” I highlight the ways in which Murakami's writing reflects his keen sensitivity to existential uncertainty and how he seems to understand trauma, much as I do, as a shattering experience that destroys the certainties that organize psychological life and generates efforts at self restoration. Although I share Rosbrow's view that “After the Quake” depicts a character's awakening from the dissociative manifestations of trauma, I spell out how my perspective on this process differs from his.     

Dissociation,the Analyst's Vulnerability,and the Body: Review of Awakening the Dreamer: Clinical Journeys by Philip M. Bromberg

This review praises Bromberg's rich and evocative new book for its clinical and theoretical usefulness and elaborates on three broad themes: the analyst's personal role in traumatic enactments, dissociative/addictive uses of the body, and the distinction between life-threatening and developmental trauma. Extending Bromberg's formulations, the author argues that in successful work with trauma survivors, the analyst must be actually (temporarily) traumatized as actual, personal vulnerabilities of the analyst are necessarily engaged. The analyst's vulnerability serves as an internal contact point, opening up a process of unconscious empathy with the patient and providing crucial validation of the patient's experience. The review also explores how bodily processes are used to further dissociation with eating disordered patients and how they become the source of treatment difficulties. When the patient's states of desire have been “detoured” into the body (where they are ruthlessly controlled or attacked) as well as into the relationship with food (where they are temporarily gratified), they are not as available to be mobilized in the analytic relationship. The review also questions Bromberg's assumption that the underlying dissociative mechanisms are the same for life-threatening trauma (or Posttraumatic Stress Disorder) and developmental (or relational) trauma.     

The paradox of innocence dissociative “adhesive”; states in perpetrators of incest

This paper attempts to develop a phenomenology of the perpetrator's conviction of innocence in a condition of actual guilt. This phenomenology is developed through the investigation of dissociative states in a certain type of incestuous perpetrator: one who is herself a survivor of sexual abuse, physical abuse, or both. Clinical material suggests that certain types of schizoid perpetrators can genuinely experience the incestuous act as not really real not really sex, not really mine. This clinical phenomenon is examined from the perspective of two contemporary theoretical trends: the new view of the self as multiple (Bromberg, 1993; Mitchell, 1993), and the neo‐Kleinian formulation of “adhesive”; (Mitrani, 1994) or “autistic‐contiguous”; (Ogden, 1989, 1990) modes of pseudo‐object relatedness. Incestuous acts are conceived as occurring within a prelinguistic modality, and are therefore not encoded in discursive, autobiographical memory. The coexistence of dissociated, multiple self states and modalities accounts for the contradictory levels of object relatedness, memory, and concern frequently encountered in perpetrators of incest.     

Enactment as Therapeutic Hand Grenade: How Bursts of Emotional Honesty Can Get a Stuck Treatment Moving Again: Discussion of Holly Levenkron's Paper

In my discussion of Levenkron's article, I consider ways of understanding the patient's therapeutic progress that were not highlighted by the author. Adding my own criteria to Levenkron's definition of enactment, I suggest that what the author labels as enactment might be seen as a last-ditch but successful effort to get patient and analyst out of a stuck and painful place. I explore the interplay of confrontational and nonconfrontational interventions in contributing to cure, and I suggest placing a greater emphasis than did the author, on the intersubjective contexts out of which the patient's troublesome behaviors emerged.     

In dialogue with Daniel Stern: A review and discussion of The Present Moment in Psychotherapy and Everyday Life

Abstract

Daniel Stern's concepts of “present moment” and “now moment,” with impending kairos, are described. In the latter, the patient demands the authentic presence of the analyst. If the analyst can open himself to the patient, he proposes that this will result in more profound changes in the patient's implicit knowing than verbal interpretations in the narrative domain would lead to. The value of intersubjectively relating and dwelling more in the phenomenal than in the narrative dimension is highlighted. A similarity to the works of the existential psychoanalyst Harold Kelman is shown. The author agrees with, but also problematises, a tendency to favour the implicit, devaluing verbal understanding and interpretation, which may result in the patient not seeing the primitive levels in his inner life. For this purpose, works from D. W. Winnicott, Jessica Benjamin and Christopher Bollas, as well as others, are used. The author concludes that object relations and intersubjective theory need to complement each other that further, there is a need to give words to the middle-ground between the phenomenal and narrative dimensions.     

THE “AS‐YET SITUATION” IN WINNICOTT'S “FRAGMENT OF AN ANALYSIS”: YOUR FATHER “NEVER DID YOU THE HONOR OF”… YET

The author proposes a new hypothesis in relation to Winnicott's “Fragment of an Analysis”: that as early as 1955, in the case described in this text, Winnicott is creating the paternal function in his patient's psychic functioning by implicitly linking his interpretations regarding the father to the Freudian concept of Nachträglichkeit. The author introduces an original clinical concept, the as‐yet situation, which she has observed in her own clinical work, as well as in Winnicott's analysis of the patient described in “Fragment of an Analysis” (1955).