Dissociation

Olivia, twenty-two, comes three times a week, but from session to session, I never know who I am going to see. Sometimes we laugh together, as she amuses me with funny stories. Other times, she rages at me, although I am never quite sure what I did that triggered her upset. Other times, she is profoundly sad, but again, I am never clear about the trigger. If I remind her of how different our dynamic feels to me from session to session, she says “I know, but I can’t help it.” Her knowing, at first made me think that this is not dissociative, but over time, I have begun to wonder that as coping with stress can be so difficult, that for some, developing different personality styles is a way of coping, similar to dissociation where, often because of severe trauma, one has to “leave” oneself in order to cope with the devastation. Olivia’s quickly shifting relating styles makes me wonder about her history of trauma where she might have felt the need to have different senses of herself, with little threads of continuity, in order not to process the pain of disappointment in her important relationships with her early caretakers. Dissociation is taking denial one step further. Bringing her personalities together, helping Olivia develop internal continuity is our work. This internal continuity is critical for self-confidence and trust in oneself. Peter Fonagy in London has said this multiple times in his work on mentalization. One must be able to think about oneself in a cohesive way in order to enjoy one’s life and not chronically suffer from painful confusion. Olivia knows she needs help with her confusion. That is a good first step.

Is Trauma Interpersonal?

The baby growing up in a household who is unwanted and ignored is traumatized by lack of attention and responsiveness. Nomi, twenty-five, was born to a teenage mom, who was too ashamed to get an abortion, or so that is what Nomi has come to believe. Nomi was raised by her mom and her grandmother, both of whom, by Nomi’s report, treated her like a burden which they would have rather not had. Nomi clarifies that she was well fed, and all of her medical and dental needs were attended to. Money was not a problem as the grandmother was well-off and she was generous with her money. The problem, as Nomi has come to believe through our work together, is that neither her mother or her grandmother, was excited about her accomplishments-big or little. She went to Ivy League college, and then on to a prestigious law school. She does not remember hearing a “congratulations.” “Gosh, it sounds like you feel that you were very alone in the world, and I wonder if at some level that makes you very angry and scared to engage with other people on a deep level.” I say, highlighting the notion that trauma can be interpersonal, and as with all trauma, the downstream effect is one of constriction and numbness. “I don’t see myself as having rage, but maybe I do,” Nomi reflects. “Mostly, I see myself as lacking confidence,” she continues. “Well, that may also be a downstream result of not having someone who mirrors your developmental progress.” I say, pointing out that lack of mirroring has a multitude of unpleasant and undesirable outcomes, which often include a lack of self-assuredness and rage. ” I don’t know that I will ever get there,” Nomi says in despair. “The fact that we can talk about it is a large step towards metabolizing your rage and developing a greater sense of your own potential.” I say, trying to help her see that being in psychotherapy, particularly in-depth psychotherapy, takes courage to confront very challenging feelings and experiences. ” I still feel despair,” Nomi insists. “I can understand that your feelings of despair alternate with your feelings of hope in our process.” I say, stating that despair is a part of her experience, but our work together, our persistence in trying to understand her emotional interior, also gives her hope that she can learn to feel better about herself. Trauma can be interpersonal. Trauma, all kinds, can also heal.

The Yoga Intervention

http://www.traumacenter.org/about/..\clients\MagInside.Su09.p12-13.pdf

This article, by a well-respected expert, asserts that yoga heals the mind by working with the body. That makes sense to me.

The Car Accident

Louise and her dad come in for their weekly visit with looks on their faces which speaks to a traumatic event. Louise, age six, says “we have been through a lot,” in a way that conveys she does not want to tell me all of her news in one sentence. Although only six, she seems to want me to guess as to what might have happened to her. She is teasing me, in a playful way. Larry, her fifty-year old dad, chimes in, “we had a car accident.” Larry’s tone and body movements are different than usual; he is more tense and uptight. Louise jumps in, “we got to ride in a big truck,” she says with excitement for the novelty of riding in a tow truck. Larry, who is not the focus of the treatment, concerns me in his demeanor. He has the appearance of “shell shock,” I tell him. It is the look of stiffness and detachment. Louise, on the other hand, appears relaxed and happy. Louise has some behavioral problems at school, but through our work together, as Larry tells me, she has calmed down quite a bit. “I have to say I am concerned about you, Larry,” I say, trying to walk the fine line of expressing a clinical judgment to someone who has not consented to be my patient. “Yea, it was pretty scary. I had Louise in the car and I just can’t believe how close we were,” stopping his sentence right before he seemed about to say how close they were to dying. “I can certainly imagine how terrifying that is,” I say, understanding that the motor vehicle accident broke through Larry’s denial about the finite quality to our lives. I know the accident was recent and that with time, Larry is likely to restore his old defense mechanisms, but I want to tell him that if this “shell shock” quality does not go away, then he should seek professional consultation. I am not exactly sure how to say this, so I end up saying, “let’s meet next week without Louise and see where we are.” Traumas are openings for the re-working of internal structure, but first they create a numbness that speaks to future suffering when the numbness wears off. “I am glad Louise is doing better,” I say refocusing our work back to Louise, but still concerned about Larry. “Yea,” Larry says with a flatness that is uncharacteristic for him. We stop on that heavy note of flatness.

Hurt People, Hurt People

Wounded adults become wounded parents who then wound their children and the intergenerational transmission of trauma continues. Psychotherapy hopes to interrupt this pattern and thereby not only help the patient, but future generations to come. Leah, thirty-seven, has a thirteen-year old daughter Sophie, and no husband. Leah is divorced, but her daughter is the product of artificial insemination which occurred after her break-up with her husband. Leah constantly “worries” about Sophie in the same way that Leah’s mom hovered over Leah. Leah understands this, but she feels she can’t help herself. She comes to me with the hope that she will be a better parent than her mom, along with the hope that she will feel more relaxed around Sophie. Together, over many years, Leah and I explore her identification with her mom, along with her inability to separate from her. We also explore Leah’s relationship with me, and particularly how Leah has unconsciously assumed that I am judging and evaluating Leah in the same way that her mom has over the years. “OK, to get psychoanalytic about this,” Leah says, “I think I have always thought of you as my mom and I have always thought that you were judging everything about me: my clothes, my hair, my interpersonal skills. It is only recently that I have come to see that I am assuming that, and that maybe that is not true.” Leah explains to me with a sense of contentment that I rarely see her exhibit. I sit there listening attentively, but feeling no need to respond, as Leah has taken over the work of our psychotherapy/psychoanalysis. She has begun to develop an observing ego such that she can appreciate how her dynamics, her assumptions about other people,  are getting in the way of enjoying her life. “Hurt people, hurt people when they do not develop distance from themselves,” I say, reminding Leah that she is beginning to break the chain.