by Henry Markman

In this limited time I’m going talk about my work with traumatized-dissociated patients, particularly those with early relational developmental trauma, and some of the ideas the guide me.

We can’t talk about trauma and dissociation without talking about the body and embodiment—both the patient’s body and the therapist’s body. We also can’t talk about the patient’s trauma and dissociation without taking into account the therapist’s dissociation and possible trauma.

With the provision of an adequate environment, where the primary caretaker regulates the intensity of stimulation and cathects the young child’s body through caressing and handling, there begins to develop an inside and outside via the skin ego (Anzieu).  The caretaker-child interactions create a holding environment, a potential space of play, engagement, emotional sharing and transformations (Bollas).

These provisions are necessary in this very dependent phase of life for the development of self and self-experience, a gradual sense of me and not me, a locus of aliveness. The sense of self and the experience of dwelling in the world emerges from coherent bodily experience. The child has experiences that during maturation become memories, though these experiences are encoded also in the body. The body indicates what is going on emotionally,  and integreated perception-sensation offers the child a world of atmosphere, sensation, perception, in which to live and act, share with others, and  dwell in the world.

What happens if these provisions are seriously lacking or there are traumatic impingements? In traumatic situations things happen to the child but these events are not experienced. There isn’t a coherent self to experience what is going on. The organization of sensory-perceptual experience—i.e. bodily experience—is the root of self-development, self-awareness, cohesion, a sense of existing.  Trauma disrupts this continuity so that the there is a dissociation of mind from body leading to a fractured subjectivity, resultant breakdown and “primitive agonies” so vividly described by Winnicott.

In response to trauma both Ferenczi and Winnicott describe   split-off parts of the self that may became caretaker selves or false self-self holding, or Ferenczi’s idea of orpha, pathological organizations, or invasive objects through identification with the aggressor. The mind is altered and separated off from the body which then becomes the exclusive site and repository of the trauma. This overall response to trauma can be called dissociation of mind-body split but also dissociation within parts of the mind that are cut off from each other in discontinuous self-states. There is no “normal functioning” but a mind that is fractured in an attempt to cure the subject of the trauma, to survive. It has structurally changed (see Shore). These fractured selves can be semi-autonomous, with different modes of regulation, body awareness, subjectivities.

Events that are dissociated are not “forgotten” but grafted onto body actions and behaviors.  The way Ferenczi puts it is that in trauma-dissociated states the subject is haunted by sensations and vague perceptions, not objective memories.

From a clinical point of view if the therapist can provide an atmosphere of safety and presence and attentiveness (Ferenczi warmth and welcoming), dissociated states can make their appearance in the relationship with the therapist in intense or subtle ways and in various forms of enactment.  A therapeutic potential here is that these states might move from hypnoid states and quasi hallucinations to ‘objective memories’..

The therapist’s response is crucial. First—though this is easier said than done—she tries to avoid dissociating herself in order to contain and be with what the patient is experiencing, often for the first time. There is an actuality to the relationship and what is going on. That it is so actual can be intimating and confusing to the therapist.

Even more challenging, the therapist may be implicated by the patient in her suffering. It is tempting to correct the patient and show that her reactions come from her past and not presently with the good-intentioned analyst, but that will not help. What does help is for the therapist to tolerate, even embody the role and position the patient is reacting to. Simply tolerating and  being receptive is helpful. What makes the situation more than simply cathartic  is that the therapist assumes responsibility for what she has done, however subtly and often unconsciously. This discrepancy between the past responses and the analyst’s present one allows for past events to be remembered experienced and integrated..

Traumatic states may emerge dramatically when a patient suddenly enters an altered state. These are startling moments for the therapist, beautifully described in Ferenczi’s classic paper Confusion of Tongues. More subtle manifestations of trauma though equally challenging are those where the patient is in a constant low-level dissociative state that makes her difficult to reach. The dissociation is a protective shield against a repetition of trauma. In these situations, the therapist is called upon to be participate in a more active way.

How does our body come in clinically? The patient communicates dissociated states that are powerful and powerfully affecting in non-verbal ways. The therapist’s bodily responses are crucial markers of what is going on. The medium is the message because it is not in words but words and behaviors as actions, as split off happenings. The problem here is that the therapist is not only a trigger for the patient but may be triggered as well and may dissociate with the patient. This is a template for enactments—unfortunately often an enactment of a dysregulated child and dysregulated ineffective or emotionally absent parent.

It follows that when the therapist is attuned to her own body and bodily responses as a daily clinical practice and a form of attention—what I call embodied attunement–this gives her a home base during stormy weather. A lighthouse or beacon we might say. The challenge is that stormy weather is often is associated with fog and in our dissociated dysregulated state we may not have the wherewithal and the distance from what is happening to notice what is happening. We are embedded in enactment. I think this in inevitable in seeing traumatized people, especially if part of the therapist’s aim is for a therapeutic regression.. A crucial way of getting back to ourselves is working through whatever transferences and narcissist resistances (like guilt and withdrawal) so that we can again attune to our bodily states to became open, receive and inhabit the patient’s experience. Perhaps clinicians who are sensitive to both bodies in the room have come to value this sensibility, as I have, from working with people who are dissociated, people who are  able to carry on conversations and associate and receive our interesting interpretations without anything changing, without contacting the core of their suffering.

Here are some brief examples that come from vignettes from my recent book.

With Erin I feel behind a pane of glass, her mouth speaking an incomprehensible language.  I have an eerie haunting feeling surrounded by gauzy film. After several sessions where I am ‘I am gone but I don’t know where’ as Paul Simon sings, I find my body back into the room. I notice my bodies tensions and agitations, sensations of hyperarousal. Often attending to these bodily states embodies me in the session despite the discomfort, and the intensity diminishes as a surrender to it. I have come back to myself.

Now, how can I get beyond the glass pane that protects her from certain horrors of her childhood? And her fear of repeating them with me (fear of breakdown).

I start with the everyday and ordinary, calmly describing what I see of her: her movements and posture, dress, especially her tone of voice, in the hope of bringing consciousness to her bodily experience, her sense of being seen and existing. Erin then begins to notice her own voice and describes a memory of seeing her brother,  her main stable object in childhood, far off on a lake, she left behind on the shore afraid.

Linda suddenly began to hyperventilate and chant “I don’t know. I don’t know… Do something!”. I feel panicky and helpless. These sudden terrifying (for me too) moments sent me into a panic to do something but I did not know what. I tried but it always felt off to me and to Linda, feuled my by my own urgency, which only intensified her panic: “I’m too much for you!”, she cries. I had to bear failing her in these moments and acknowledge that, which actually seemed to help. Only later did I learn we were enacting early periods of profound neglect and abandonment that she “solved” by being a good girl and never asking for anything, especially when she urgently needed them,  because when she did she encountered her parent’s rage or dismissal. Now she was free to make these demands on me.

David describes his life as a movie he watches with detached interest and curiosity. He wants me to share it, sometimes embellishing it with humorous ironic touches. He is completely disembodied. The scenes of his childhood are horrid. When I allowed myself to spontaneously respond to these images with shock, anger, or deep sadness for the “boy in the movie” (we didn’t break the illusion of film watching), he had sort of breakthrough. He began to emotionally identity with the boy in the movie: ”I don’t want those images to be about me…I don’t want that father to be my father”. Gradually over time his past became populated by embodied memories and not movies or stories, and I could sense his mind cohering and there emerged someone in the room with me.

Allen was silent for days and I could feel the room tilting such that I might slip out the window. I wanted to think his silence meant something about her ‘going on being’ yet my body told me otherwise. He wasn’t there. Noticing I had been gone too I was intensely anxious.  Again,  after some time of tolerating these disorienting states,  I came to myself and my body and in the room. In one session I noticed the weather outside as the world and office came into view. “Yes, I’m in the world and here I am”, I said to myself. I started to relay what I saw to Allen: the rain outside and the wind and I asked (this apparently was an important moment and he was seen and thought about ) if he got wet. I wanted to bring us into a shared sensory world together. We started to talk about the weather. He then he shifted the conversation to the office as a haven: the warmth and coziness on this stormy day and the quality of my voice, getting closer to me and more intimate. He said he wanted to touch something in my office whose texture intrigued him.

I often noticed that interventions such as these described in the vignettes may bring the patient’s experiencing self and their body into the room. The person used the office as a potential space, playing with fabric on the wall, walking up to a painting, commenting on my voice or the colors in my office. That is, they used their body to explore the world around them that we both share. Perhaps later I will hear about what happened to them, but I am in no hurry. The important moment here is that they are becoming embodied, and the analyst and office are a potential space for perceptual-sensate-emotional exploration in deepening their sense of a self.

To do this I have to provide a medium (Balint’s metaphor of water). Anzieu noted that traumatized patients come to the analyst to be carried and held, often with our voice and movement and office surround.  This is the offer of holding in an embodied world. They are not coming to be fed…