[bubniakz]

The Psychoanalytic Quarterly, 2015
Volume LXXXIV, Number 4

"I HEAR MY VOICE, BUT WHO IS TALKING?": UNDERSTANDING DEPERSONALIZATION / BY JACQUELINE HAFT

Depersonalization is the frightening experience of being a shut-inside, ghostlike, "true" self that observes another part of the self interacting in the outside world. The "true" self hides safely within, while the "participating" self holds all affects and impulses. This split in the ego is created via internal projective identification in the face of overwhelming affect, unavailability of adequate identifications, and insufficient support for psychic cohesion. As the transference develops, the powerful entrapping cocoon of depersonalization can be projected onto the now-entrapping analyst, where it can be addressed. A clinical vignette illustrates these points.

Keywords: Depersonalization, derealization, fantasy, child abuse, negative transference, psychic retreat, core self, identification, identity formation.

http://onlinelibrary.wiley.com/doi/10.1002/psaq.12041/abstract

If you want full article in pdf, send me email: [email protected]

SNIPPETS:

"She brought back her projected affects and ego functions increasingly, painstakingly, into her core identity. She very gradually felt that her participating self, the self that lived out odd enactments, or that acted as if she were loving, as if she were angry, as if she felt guilty, and so on, without any emotional connection to the experience, was actually expressing affect and wishes from her real, core self."

"When Ms. T approached the end of her analysis, she spoke of her disappointment at not feeling as she had expected to when her chronic depersonalization lifted. She had anticipated feeling hyperaware and present, like someone who was never fatigued, distracted, or uneasy. Instead,
she found her attunement to herself and her emotional experience to be layered and fluid, and though her feelings were now largely accessible and felt to be her own, it took a great deal of focus and effort for her to contemplate her emotional states."

"Ms. T now recognized that she had a mind that held and processed her thoughts. The defensive ego split of the buried core self that watched her public self acting in the outside world was no longer an inevitable construct, as Ms. T felt safer with her wishes and feelings and was able to develop an accessible self-representation with an identity of her own. She said she felt more alive when she recognized her attachment to her analyst and to the work we had done together, and she now felt more attuned to a rich emotional life belonging to her core self."

"The work that Ms. T did in her treatment was a testament to her ego strength, which allowed her to use the analyst to help her courageously and persistently come into contact with the terrifying wishes, feelings, and confusions within her."

 

[inferentialpolice]

I did not like the paper referenced in this thread. Here are my responses posted to a dissociation discussion board:

> Rich says:
> I believe Haft actually agrees with you, Peter, regarding personalized and
> depersonalized self as she writes about true and participating self,
respectively:
> "Depersonalization is the frightening experience of being a shut-inside,
ghostlike, "true" self that > observes another part of the self
interacting in
> the outside world. The "true" self hides safely within, while the
"participating" self holds all affects
> and impulses. This split in the ego
> is created via internal projective identification in the face of
overwhelming affect, unavailability
> of adequate identifications, and insufficient support for psychic cohesion.

I am not sure there is agreement -- I can accept the poetic sentiment that
the "true" self hides safely within, but I don't regard the
"participating" self as holding ALL affects and impulses, rather I would
say the very fact of disconnection from self means, importantly for
purposes of therapy, that the participating self holds a REDUCED set of
affects and impulses, those being ones curated to facilitate
safely/survival within an adverse set of circumstances.

> language more familiar to a modern Kleinian perspective and filled with
understanding through
> the term projective identification, the attribution of
> core aspects of self to another. This process is unconscious to the
patient,
> and emerges in the analyst as a disturbance which once conscious requires
> that the analyst "metabolize" the projections/attributions and "feed" them
> back to the patient in a palatable form through which the patient can then
> take them in and repopulate their inner experience of self.

Here below is what the paper says about the projective identification
dynamic you mention above, but first a bit of setting up the presentation:

Prior psychotherapy worked with what had been recurrent depression and
"other issues", but Ms. T still had chronic depersonalization. Here is
the presenting complaint as described in the paper:

"I'm not here," she stated; "I don't feel present." She complained of
listening to her voice as if it were coming from someone else. She
wondered who was talking when she spoke and where she was if it was not
she who was speaking.

Here is the mentioned trauma history:

"volatile parents", parents divorced, mother had frequent depressions,
molested by step-brother, witnessed beatings of step-brother, reports
feeling numbed during the years of shared custody, since the time of her
first year of life, parents were never with her at the same time.

So far this sounds quite familiar as a presentation of a patient with an
undiagnosed dissociative disorder, possibly with a better prognosis than
most seeing how she was not completely treatment refractory under
psychotherapy with respect to depression and "other issues".

Patient begins psychoanalysis, four-times-weekly.

The psychoanalyst describes the early years of treatment in interesting
self-referential terms which I'm guessing is part of the psychoanalytical
model:

"While Ms. T related in a socially appropriate manner, for the most part,
it was apparent that in her inner world, she barely held a concept of me.
If I speculated about her thoughts about me, she said she did not grasp me
as a person and had no feelings toward me. Weekend breaks were painfully
difficult and frightening, as she felt a sense of dread and emotional
isolation. Yet when I suggested that she felt abandoned by me over the
weekends, she said she did not perceive me as someone who was with her and
then left her, so she did not experience being left. I thought I was
defensively banished from her inner world, more intensely when we were not
in a session, which suggested a fragmented sense of reality."

"For long periods, I felt the treatment was proceeding evenly, as she was
nondemanding, self-contained, and pleasant. However, Ms. T's occasional
hostile or odd actions punctuated this experience, so that I was left very
confused. She did not mention blatant changes I had made in the consulting
room, was embarrassed to discover she could not unilaterally change an
appointment time, and never alluded to any curiosity about my life. This
stirred puzzlement in me and then recognition that, as she had told me, I
did not seem fully real or thinkable to her, and her sense of an external
reality (of which I was a part) had to be newly registered in any given
moment.

Since Ms. T experienced her core self as apart from the external world and
from her participating self, she often acted out her instinctual life
without recognizing that action as coming from her core self. She said she
made decisions by "seeing where my feet go." Coming late to sessions,
spending her insurance reimbursement on entertainment in- stead of signing
over checks to me, and sexual behavior at home during what had been a
scheduled session time were examples of a participating self infused with
instinctual life expressed toward the analyst. Meanwhile, her core self
felt painfully numb and removed."

The author then does mention a subjective sense of the patient that I
believe most on this list would immediately work with psychodynamically in
relating to a the psychogenesis of a compartmentalized sense of self:

"A theme in many of Ms. T's memories was of imposing herself upon a social
situation that ended with the burning shame of her not belonging there. ",

though here too in the paper it is discussed in self-referential terms:
"Where did she ever belong, really? One can understand Ms. T's defensive
difficulty in grasping my reality, as I sat physically so close to her
literal reach as she lay upon the analytic couch."

Over the course of treatment, they did work on issues relating to the
psychoanalytical dynamic, for example: "When for the first time she
entered into a promising heterosexual relationship, she worked through a
series of assumptions that she could either be in the relationship with
him or, alternatively, continue her relationship with her analyst."

The paper then describes how, over the next ten years, the patient
develops a more keen awareness of the analyst:

"She increasingly expressed her despair that she was still depersonalized,
for which she aggressively blamed the analyst. She proclaimed with anguish
and rage that I was inadequate, abusive, and "monstrous" for victimizing
her, and she was angry at herself for allowing me to take her time and
money without helping her to be "present" and truly alive.",

which the analyst interprets as follows:

"And now, less depersonalized and with the transference more developed,
she projected this abusive entrapment into the analyst. I became the one
who held all efficacy and who kept her locked in a futile treatment and in
a depriving relationship with me. ... With explosive rage, Ms. T accused
me of "monstrous" and cruel abuse in providing a treatment that could lift
her numbed state only by helping her access her fury over the treatment's
limits. She sobbed with anguish and frustration that she was now trapped
with me after having been so egregiously "duped" into entering a lengthy
psychoanalysis."

The metabolizing that Rich mentioned began, with the analyst withstanding
the onslaught, and resolving as follows:

"At last, she took ownership of her depersonalized mental state. She said:
I have to come out. But then, I ask again, why haven't you helped me do
that? Then I feel like-then, on one hand I feel-maybe that's the point. I
have to get to this point where no one can do this but me; you aren't
going to do it. I have to do it. I understand now that you are not going
to come in and bring me out. Maybe this is the point-no one can do this
but me, you aren't going to do it, I have to do it; I have to step out on
my own."

FINALLY, eleven years into the work, the patient arrives at the
psychodynamic realization that here on the DISSOC list is often expressed
as the core realization in addressing the depersonalization experience:

"We continued to work through her emerging sense of self, and it was only
after another year of treatment-eleven years into the analysis- that Ms. T
grasped and articulated that she had earlier defensively withdrawn into
the numbed state she had created"

-----------------------------

While I certainly see the legitimacy of this technique, particularly given
a positive result, I still am wondering what in this eleven-year
four-times-a-week run is additive beyond that which can be gained using
the sort of psychodynamic techniques that in discussions on this list are
typically advised to be employed, and which seem to be less involved
time-wise, and which from the therapist's perspective, are seemingly less
self-involved!

PDW

 

[inferentialpolice]

And here was some more of the exchange from the dissociation board composed mainly of dissociation therapists:

> Dear Peter, I'm not trimming this post since it's so old, but that's the
> price I am paying for having too much on my plate to digest your note
> earlier, and it's complexity.
>
> I believe, when all is said and done your parting sentences hold the
> essence
> of your feelings and understanding about this paper:
>
> "While I certainly see the legitimacy of this technique, particularly
> given
> a positive result, I still am wondering what in this eleven-year
> four-times-a-week run is additive beyond that which can be gained using
> the
> sort of psychodynamic techniques that in discussions on this list are
> typically advised to be employed, and which seem to be less involved
> time-wise, and which from the therapist's perspective, are seemingly less
> self-involved!"
>
> Many people treat folks with DDs for years and don't have a positive
> result.
> An open question is whether a relatively similar result might have
> occurred
> with eleven years of twice or three times weekly meetings. However, it's
> hard to argue with success for this clinical couple. Ten years is not at
> all
> unheard of in some treatments, and certainly not unusual in my casework.
> The
> intensity and depth of the treatment may have been a particular factor for
> helping this particular patient. One size doesn't fit all.
>
> In regard to the self-involved observation, it seemed to me that this
> analyst did a good job of describing what it was like to "work in the
> transference" and make use of that experience. A relational psychoanalytic
> approach, just like a self-psychological perspective, is a two-person
> treatment. In other words, the reactions of the therapist inform the
> treatment, though they need not be disclosed. On the other hand, Bromberg
> writes compellingly that not only is self-disclosure something that
> happens
> in thoughtful treatments where the couple earn that opportunity, but it
> may
> be a necessity. See his last book, The Shadow of the Tsunami. Constance
> Dalenberg has much to say about this kind of thing in her work on
> countertransference.
>
> Psychoanalytic theory has a lot to offer DD treatment, even if you don't
> use
> psychoanalytic technique. Kluft is quick to point out that cognitive
> therapy
> was formulated by Beck, who was trained as a psychoanalyst. Best, Rich

Rich,

These were my main points:

1) The author's analytical model of depersonalization seemed misspecified
as evidenced by her statement that the participating self held all affect
and impulses, whereas I believe we can agree that the sin qua non of
dissociative processes is a participating part with a reduced set of
affect and impulses. As analyst Brenner describes it, a pathognomonic
psychic structure having "disowned intolerable memories, affects, and
drives" To the extent that theory informs practice, the author's
(mis?)conception could affect many variables of the therapeutic endeavor.

2) The author's technique seemed purely one of what Kluft calls "Strategic
Integrationalism", an analytical method seemingly devoid of "Tactical
Integrationalism" which Kluft conceptualizes as adroit therapeutic devices
typically employed to hasten recovery. The author's lack of employment
of techniques that are commonly discussed on the DISSOC list perhaps
contributed to the lengthiness of the endeavor, and while I acknowledge
what you say that some other benefit toward recovery may have resulted
from the authors purist technique, whatever that may be was not developed
within the article, and that was the point of my asking "what is
additive".

As further explication on these points, I've assembled a set of valuable
articles that Kluft and Foote co-edited in the AMERICAN JOURNAL OF
PSYCHOTHERAPY, Vol. 53, No. 3, Summer 1999. There, Brenner presents his
analytical model of DID, Kluft presents a typology of treatment methods,
Fine presents (as you've alluded) a set of cognitive behavioral techniques
serving as an example of tactical technique for DID, and Shusta presents
an example of a tactical technique that brought results in weeks in the
case of DID underlying OCD behavior.

Below is the table of contents of that remarkable issue of Am J
Psychotherapy, and here is the link to access the articles listed there:

http://ge.tt/12xA4MQ2?c

SPECIAL SECTION: DISSOCIATIVE DISORDERS Richard P. Kluft, M.D. and Brad
Foote, M.D. (Guest Editors)

Dissociative Identity Disorder: Recent Developments Richard P. Kluft, M.D.
and Brad Foote, M.D.

An Overview of the Psychotherapy of Dissociative Identity Disorder Richard
P. Kluft, M.D.

Dissociative Identity Disorder and Pseudo-Hysteria Brad Foote, M.D.

Deconstructing DID Ira Brenner, M.D.

The Tactical-Integration Model for the Treatment of Dissociative Identity
Disorder and Allied Dissociative Disorders Catherine G. Fine, Ph.D.

Successful Treatment of Refractory Obsessive-Compulsive Disorder (Case
Study) ShielaghR. Shusta,Ph.D.

PDW

 

[luctor et emergo]

Fascinating. Thanks for posting!

 

[inferentialpolice]

Thanks for your comment Dennis ... You are likely the only one to persevere through the dense reading material -- Perhaps that is suggestive that you'd be a good candidate for a run at psychodynamic treatment of your symptoms!

 

[kamil]

good stuff. i found the article around a week ago, and identified a lot with some passages. it's great that it includes the observations of the psychiatrist about the patient, because most dpdr papers nowadays don't include any insights into the patients.

 

[meekah]

very good post