Body-Mind Dissociation,Altered States,and Alter Worlds

Sally and the “Lullaby World”

I will start with a clinical example meant to illustrate certain aspects of the structure of dissociation, and how it can express itself clinically. ⁵ I choose this example because it is not an obvious trauma case, nor is the clinical presentation one that on its face indicates obvious dissociative illness. As is typical of the more successfully smooth-functioning, unobtrusive, stable types of dissociative organization (Goldberg 1995), its underlying structure had to be discovered over the course of treatment. These well-adapted “normotic” cases (Bollas 1987) can reveal a great deal about the structure and function of dissociation. In particular I wish to show through this example (1) the role of altered states of consciousness in maintaining a stable pseudo-integration of the dissociated parts; (2) the sophisticated false-self functionality of the protective exoskeletal ego; and (3) the subtle but significant changes that affect both mind and body due to systematic dissociation.

A youthful, agreeable person always attentive to the words of her therapist, Sally was in the second year of a treatment busy with suitable content and interaction and thoughtfulness, but inexplicably lacking in emotional traction. Nothing stuck, and only later did I get the sense that she never stopped to breathe.

I will not recount the variety of interpretive strategies I tried out, which would be familiar to you; but, sensing the impasse, I forswore interpretation, tried to wake myself from the slightly mesmerizing draw of the agreeable content, and began broadening the scope of my attention to take in the psychophysical qualities in the sessions, the prosody and impact of our speech, and the way we “saw” and sensed things in the clinical situation. Soon my attention was drawn to something subtle that I had noticed fleetingly before but had brushed aside—namely, a tendency on her part to become physically dead-still on the couch whenever I spoke and for a second or two before responding in her characteristically engaged and seemingly associative fashion. Initially when I inquired about the pause, she did not seem to know what I was talking about; but, then, soon afterwards, she surprised herself and me by saying, “As you speak, I trace a pattern on the wall”—not only with her eyes, I learned a little later, but with an almost imperceptible movement of her index finger.

As it turned out, Sally would actually continue tracing the pattern even when she began speaking and interacting with me again (the wall was, in fact, rather heavily textured). While she had been oddly aware all along of this shift into a distracted state, it had simply not occurred to her to put it into words, question it, or think about it at all, much less communicate it. But now that her attention had been drawn to it, she became aware of how, as I spoke, she would feel a little “out of it,” and then automatically find herself tracing the patterns on the wall. This, as she put it, clicked her mind into an “automatic pilot” mode, while her body felt under “remote control,” leaving her to float in a “lullaby world.”

It was immediately obvious that this was no simple transient distraction, but a powerful autohypnotic activity that induced (or perhaps more accurately, reinduced) an altered state of consciousness, something like a twilight state in which Sally continued to interact in the relational field, but simultaneously was in an alter world.

A number of things about Sally’s mental functioning and interpersonal presentation led me to conclude that the self-induced trancelike state was dissociative rather than delusional. A comment Sally made in passing captured something about the difference between an autohypnotic state and a delusion: the “lullaby” state, she said, “does not put me out of touch with reality, but makes reality workable my way.” This gets to the essence of how dissociation works—not by means of symbolic or phantasmic modification of the world of objects, but instead by shifting attention and effecting alterations in consciousness. The dissociative process does not put Sally “out of touch with reality,” as we would see in schizoid or psychotic or hysterical states, but—by shifting the degree of embodiment and focus of attention—alters the locus of the self’s response to existing reality. By changing the locus of perception, dissociation reorients our sense of where we are in space and time. This contrasts with the work of repression and splitting, which employ representational and phantasmic strategies (albeit in different ways) to alter reality, to change the meaning of things or the quality of the object as perceived by the subject. In other words, repression and splitting affect the content of perception, while dissociation affects its locus. Because dissociation leaves reality as it is, unmodified, it is indifferent to the injection of meaning or affect into the object relation. But if dissociation operates by shifting the “locus of perception,” how does this take place? What is the psychic mechanism at work here? These are questions I will address.

Not surprisingly, the revelation of Sally’s autohypnotic activity considerably disrupted the locus of my own thinking, my position in the analytic field, and my clinical posture. Despite her having no known history of abuse or cruelty or active neglect, I was forced now to recognize that my voice and my words must constitute a kind of generic threat, signaling a potentially traumatizing event, which activated a barely visible but powerful defensive constellation in the patient. In effect, she was managing a constant repetition of trauma due to our contact, while persisting in her efforts to accommodate herself to the therapy situation. This is typical of dissociative personalities—the ordinary function of the sensorium is appropriated for a special purpose, so that, instead of feeling “what the world is like,” the senses are primed at all times to intercept danger—to sense impending trauma above all else, often to the exclusion of all else. (Bromberg [2003] speaks of the “smoke-detector” orientation that is the legacy of trauma.)

Now I was forced to confront the existence in Sally of a sophisticated and smooth-functioning dissociative organization, with an expertly adapted exterior exoskeleton capable of imitating and mastering social interactions, while her “inner” life (the life of the drives, of the living body, of fantasy, of appetite, and of real-time feeling) remained mute, cut off, absented—“amputated,” as Roussillon (2011) puts it.

From this freshly opened perspective, I could now see some of Sally’s idiosyncrasies in a new light. Previously unnoticed things became visible for the first time—for example, the way Sally never felt hunger, though she knew to eat, and did so according to a meticulous program, maintaining a perfect weight (having skirted around the edges of adolescent anorexia). Likewise, she had never felt at loose ends, having always been relentlessly active. As for her physical presence, she lay like a wooden board on the couch, never feeling the presence of bodily needs or any “body stuff,” but perpetually monitoring and massaging musculoskeletal tightness and sprains. And her mind worked like a ticker tape, reporting things one by one, free of the messy stuff of association. I could see now that her mind had always literally been on “autopilot,” and her body “under remote-control.” Only now had it come to our attention.

As we have seen, Sally’s narcissistic equilibrium was under threat of being disturbed each time I spoke. This threat must have been exacerbated by the way I was speaking, for, up to this point, my mode of speech was generally “interpretive” (i.e., linking manifest and latent content, affect and idea, present to past, and so on). I took for granted an associative capacity in the patient, and so spoke in the wrong way, always implying that she was hiding or resisting something in her feelings or implicit thoughts. This way of speaking reinforces the dissociation: it sharpens the vigilance of the protective exterior layer of the self (the exoskeleton that evolves as the singularly protective executive structure and mutation of the ego in dissociative personalities). The exoskeleton reacts to the threat by reactivating the underlying dissociative structure, and at the same time activating a hypnoid mechanism (the autohypnotic activity of wall-tracing), by which the underlying dislocation is rendered invisible. This dissociative maneuver (underlying detachment plus hypnoid distraction) removes the vulnerable, libidinal aspects of self (in Ferenczi’s terms, the “tender” parts) from contact and engagement with objects, while the exterior discursive self continues in superficially realistic contact with the analyst and the outside world.

What was striking in this description of being in a “lullaby world” was the revelation not only that Sally was forced to take radical defensive measures, but that these worked so seamlessly, drawing a minimum of attention to themselves. Even more surprising was the unveiling of an entire dissociative organization, one that kept Sally in a previously unrecognized prison of self-alienation. The way this underlying dissociative structure came to light illustrates another characteristic feature of “successful” dissociative organizations: namely, that the dissociative activity is not kept secret or repressed, or disguised, but simply remains unnoticed. This odd presentation of a seemingly coherent personality that is suddenly revealed as resting on a dissociative foundation is by no means unusual. In my experience, this is precisely how the “discovery” is usually made: no guilt or conflict over its revelation, just surprise, and often shame at being exposed as clueless about oneself or as defective.

This is quite consistent with the fact that the mechanism of dissociation operates not by repression of a wish or by splitting off a fantasy, nor by concealment of hidden ideas or disguise of drive derivatives, but by a reflexive self-detachment ⁶ accompanied by the deployment of hypnoid techniques. The psychic action of dissociation does not depend on processes of mental representation or symbolization (the way projection, for example, is concretely carried out by a fantasy of expulsion, vomiting, intruding, etc.), but employs a refocusing of attention. In health, this contributes to perceptual mobility, a capacity to see things in different ways, from multiple vertices (as Bion puts it), while in its pathological formation the dissociative mechanism is employed to opposite ends—toward a compulsory narrowing and fixity of perception, forcing attention away from real-time experience, until finally one is living more or less permanently in an alter world, in a distracted state, in suspended animation, in a twilight zone.

It is important to clarify that activation of a hypnoid mechanism and the accompanying alteration in state of consciousness is not the agent of dissociation, but rather is its consequence and corollary: Sally’s autohypnotic activity does not cause the dissociation to take place, but is, rather, a specific psychic response to the primary reflexive mind-body dissociation. The importance of hypnoid techniques (distraction, autohypnosis, etc.) lies in their function of maintaining the smooth operation of stable dissociative structures: they shift attention away from the rift in the self, masking its disunity, allowing the underlying dissociation to pass unnoticed. By thus averting the threat of loss of self-coherence, the shift into altered states makes it possible to simulate a normal relation to the world, thus guaranteeing a degree of stable social identity. It is when the hypnoid mechanism fails to perform its function of adroitly bringing about a shift in attention—fails thereby to smoothly and unobtrusively usher in an altered state—that we see the underlying dissociative condition manifest itself more blatantly in the form of extreme states of depersonalization, fugue, deadness, amnesia, apathy, or certain kinds of somatic illness.

The Defensive Function of Body-Mind Dissociation

Insofar as it serves as a defense, dissociation instantly rescues the self from impingement, and does this by shifting the perception of self-experience away from its locus in the body. In the face of excessive stimulation, pain, or existential threat, dissociation effects a degree of detachment from corporeal reality. It provides a way of more or less removing oneself, at a moment’s notice, from the embodied domain, the place where we feel pain.

Seen from this point of view, the mechanism of dissociation is constantly at work both in everyday life and in the clinical situation. Continual modifications and adjustments in the body-mind relation serve to fine-tune the sense of viability and safety, thereby regulating exposure of the vulnerable self to impingement.

Impingement implies cognition of an alterior reality that threatens to encroach on and overwhelm the self. It entails a perception of an actuality that lies outside one’s physical or psychic control, beyond the ego’s power to influence or modify by the means at its disposal (e.g., by means of affective or symbolic modes of communication, or through imagination, fantasy, thought, or action). Sustained loss of a sense of influence over the world of objects means erosion of the necessary feeling of omnipotence (Winnicott 1971), and results in the disappearance of the sense of being accompanied, of what Alvarez (1992) calls “live company.” There is a loss of the sense of being woven into the world. This falling away of the enveloping presence of the holding and containing environment may occur precipitously, threatening breakdown, or might take place gradually and invisibly, hidden by the adaptive ego’s accruing skills. In either case, the result is a feeling of powerlessness to animate or enliven the world, and with it a feeling of being alone. The accompanying proclivity to despair and unmitigated death anxiety may break out into the open, but tends to remain hidden and quite obscure in more “successful” and organized dissociative personalities.

It is under these circumstances of helplessness and feelings of abandonment, when the world’s implacable actuality is felt too keenly, that the dissociative mechanism can provide a highly adaptive mode of self-preservation—a specific strategy to escape or ameliorate impingement. When unmitigated, the experience of impingement activates this reflexive tendency to dissociate—to dissociate, first and foremost, from an embodied locus of perception. This has the effect of removing the self from the immediacy of lived experience, and thereby inducing, at least momentarily, a transcendent state of disembodiment—of living beyond the temporal and physical limitations of corporeal existence.

Insofar as this reflexive detachment immediately saves the self from impingement, it becomes psychologically valuable, and will naturally be recruited into the organized defensive structures of the personality so that it can be deployed more systematically, rather than simply reflexively. In this way, we unconsciously learn to rely on dissociation alongside other mechanisms of defense. And because it is so vital in regulating the impact of the world’s alterity, the activation of dissociated states takes on great ritual and symbolic significance in individual and cultural life (e.g., in the form of trance rituals and innumerable culturally curated forms of induction into altered states).

For present purposes, I would like to step back from the prevalent idea that personal trauma causes dissociation and suggest instead that trauma activates a certain use (and, in the case of persistent and extreme trauma, a pathological overuse) of a dissociative mechanism that is already constantly at work. In fact a wide range of circumstances involving existential threat or impingement—a discrete surprise event, a current threatening situation, the repetition of a past trauma, or even a more distant impersonal threat like war or climate change—are capable of activating the reflexive dissociative mechanism, silently dismantling the associative connection of mind and psyche-soma, unlinking thought and perception from embodied experience. The important variable is whether the automatic dissociative reaction to traumatic threat is transient, and thereby capable of being re-presented in other psychic registers of affect, fantasy, symbolic thought, and memory, or whether the dissociative reaction takes the form of a fixed structure of body-mind detachment.

The Adaptive-Creative Function of Body-Mind Dissociation

The universal function of dissociation can be seen not only in its defensive deployment, where it regulates the traumatic potential of impingement, but, also—and crucially—in the way it facilitates engagement with the world of objects. In mediating and constantly modifying the mind-body relation, dissociation serves the adaptive function of allowing us to adjust the angle of perception, to find a quality of embodiment suitable to perceiving and “feeling” the presence of objects, without being overwhelmed by them. ⁷

Alterations in the body-mind link also aid in necessary everyday state-transitions—those regular alterations, expansions, and contractions in consciousness that constitute a normal variability in states of attention and embodied perception (alertness, concentration, distraction, engagement, relaxation, rest, reverie, fantasying, daydreaming, sleep, emotional arousal, detachment, motility, somatic absorption, and so on). The ability to transition successfully between states can be considered essential to psychosomatic viability, and the normal functioning of dissociation is indispensable to this.

From this point of view, dissociation can be seen as playing a central role in facilitating new possibilities of engaging the world of objects, affording the opportunity for fresh versions of self-experience beyond the confines of established mind-body links. Through shifts in the degree of embodiment and adjustments in locus of perception, transient states of dissociation allow us to move temporarily beyond the ego’s constraints on individual consciousness. This makes it possible to encounter anew the actuality of things in the world, and—most important—to reenter the shared domain of sensory experience and communal perception (Goldberg 2012) beyond our individual narcissistic constructions, thereby gaining transitory access to fresh ways of feeling and being,

In summary, I wish to highlight the ways in which everyday deployment of dissociation serves both defensive and facilitative purposes: how it mediates our experience of objects both in their impinging and their vitalizing potential; how it is instrumental both in the letting-go of and the refinding of the world of objects; how it thereby facilitates participation in the cultural field of shared experience, beyond the boundaries of the self, and hence enables innovation in the habitus, the lived experience of being-in-the-world; and how it aids in setting up the tempo and rhythm of everyday state-transitions and expansions of consciousness. All of this would naturally invite questions about the role of dissociative processes in the clinical situation, and their place in our clinical models.

Pathological Mutation of Dissociative Structures

But normal, everyday dissociation—whether deployed defensively or adaptively—is capable of mutating into something more rigid and pathological. Its function as an essential regulatory and defense mechanism can be recruited and perverted to a more totalitarian purpose—the establishment of a fixed dissociative structure, armoring the personality against impingement through a regime of self-regulation and control over the body, but thereby also fortifying the personality against any new engagement with the world of objects. In these cases, regulation of the mind-body relation is employed to maintain—at all costs—a systematic and rigid arrangement of mind-body detachment.

Here we begin to see the makings of a permanent alienation from the life of the body, and the emergence of a pathological dissociative structure—what might be designated a dissociative personality—that then dominates psychic life. Under these circumstances, dissociation tends to become the sole means of coping with psychic distress. In place of symbolic communication with internal and external objects, or intersubjective communication through projection and introjection, the dissociative personality instead establishes a noncommunicative regime of regulatory control over the living body—control by means of hypnoid mechanisms rather than fantasy structures or imagoes. Systematic detachment from the somato-psychical quality of inhabiting and living in a body lends the dissociative personality its peculiar ethos of self-contained survivalism.

The consequences of this more systematic kind of dissociative structure are far-reaching in a number of ways. First, the life of the body—its idiomatic needs, its claim as a locus of perception, its drive-based, wishful presence in unconscious psychic life—is effaced and its voice in the life of the mind silenced. This means a constant struggle with psychic devitalization, depersonalization, deadness, and the inevitable travails of pseudo-vitality—the compulsive, manic, and addictive striving for aliveness—that characterize these cases (Goldberg 1995).

Second, because the prime strategy of the dissociative personality is disavowal and control of the life of the body, there is little tolerance for the fluid transitions and shifts in states of embodiment that characterize the broad-band variability of everyday consciousness. Transitions themselves become the enemy, and normal alterations in body-mind states lose their transient quality and give way, instead, to fixed and unyielding altered states, taking on the character of alter worlds in which the self is trapped in one way or another—distracted, sedated, mesmerized, disoriented, devitalized, perpetually overstimulated. In more extreme cases, the inescapable power of these alter worlds may be quite visible to the analyst, in the form of persistent repetitiveness, disconnectedness, somatization, and so on. More commonly, though, these alter worlds persevere in seamless or barely noticeable ways, maintained by an array of institutionalized mental activities like compulsory daydreaming, autostimulation, chronic distraction, and self-hypnotic rituals. These activities are typically accompanied by a subtle underlying sensation of suspended animation; of chronic semidetachment; of feeling subtly sealed off or removed from the world; or of chronic emotional disengagement.

Here we are no longer dealing with the ordinary functions and processes of dissociation, but with pathological dissociative structures occurring across a spectrum from well-adapted “successful” or “normotic” false-self personalities to brittle, more clearly disturbed kinds of post-traumatic personality organization. ⁸

Absent a systematic comparison of dissociative illness with other types of disturbance, one difference is worth noting: whereas the schizoid mechanism in psychotic and borderline conditions works to deny the existence of psychic and social reality (Bion 1959), the individual’s use of dissociation is, by contrast, predicated on a vigilant apprehension of reality. Indeed, the dissociator lives in a world that is all too real, cannot be evaded or modified through dreaming, imagining, or fantasy projections, but must be monitored and controlled in all its immutable actuality—controlled, that is, by changing the locus of perception and alteration of consciousness, rather than projection of fantasy structures or symbolic action in the world. From this standpoint, “dissociation” denotes not a defect in associative or symbolizing capacities, but instead a distinct and effective mode of mental functioning, one in which shifts in attention and control over perception are deployed to regulate psychic states.

Especially when deployed excessively, psychosomatic dissociation carries with it the particular threat of depersonalization. In providing an instant reprieve from impending trauma by removing us from the place where we feel things most immediately—the place of embodied experience—dissociation removes us also from the corporeal housing where we most literally exist and feel alive. So it is not the neurotic anxiety of guilt and punishment, nor the persecutory anxiety of the “bad object” that is spawned by dissociation, but the anxiety of depersonalization—of becoming disembodied, unanchored, lost at sea, losing the feeling of being real (Winnicott 1963).

The Nonrepresented, Noncommunicative, Nonrelational Character of Dissociative States

What distinguishes dissociation from other modes of defensive organization is the specific way it regulates danger and anxiety by modifying sensory perception and altering the body-mind relation. In contrast to repression and splitting, dissociation makes no use of mental representation or fantasy or action in the world, nor does it deploy memory or symbolization in order to do its work (though its effects will commonly be represented, retrospectively, in thought and memory). This has significant theoretical and clinical implications: (1) The action of dissociation will not show itself directly in the transference, or through the mechanisms of identification and counteridentification. (2) Dissociation declines to influence or change the object, or to attempt control over the relation to the object, whether in actuality or in fantasy, but rather works to recalibrate the level of primary body-mind detachment within the self. ⁹ (3) The effects of dissociation are not meant to be communicated: It is, in essence, a kind of detachment-readiness, designed to temporarily evade existential peril or overwhelming pain; as such, it works best when operating below the radar. (4) Since it makes no direct use of the representational functions of the mind, dissociation manifests itself less as a defense whose intent can be analyzed, and more as a reflex (Purcell 2019). Its purposes cannot be comprehended and interpreted with reference to unconscious meaning, desire, and conflict. But it is capable of being experienced and noticed in the context of shared perception—the consensual field of perception in the clinical situation.

For all of these reasons, it is easy to see how the action of dissociation might escape familiar clinical detection and psychoanalytic articulation. If dissociation does not announce itself, but remains largely unseen, it is precisely because of how it does its work—by subtracting from meaning, undoing connection, dissolving links, ¹⁰ cutting the associative threads that would link the mind to the experience of living within the constraints of the mortal body. (It may be taken as a dictum that when dissociating, we are not associating.) Dissociation leaves none of the usual traces: like dark matter, nothing is there to see, no signifiers. We cannot “know” dissociation, but can only sense it.

Because its modus operandi entails reflexive detachment from oneself, rather than turning to others or to objects in the internal world (for aid or comfort, for fusional or projective identification), the life of the dissociator is typically rather solitary and noncommunicative. The world of objects has lost reliability and value. This does not mean that the existence of others is denied or foreclosed, but that engagement with the object remains merely tactical and superficial, and there is an indifference to the qualities of the object. The sole concern is vigilance about the potentially disruptive impact of the object. There is a profound disinvestment in the potential of others to serve as transformational objects (Bollas 1979) or agents of containment (Bion 1970). This is the fate of the dissociated subject, who is resigned to accept and deal with the actuality of others, while having to cope with psychic needs utterly alone.

A range of countertransference reactions occur in response to dissociation in the patient, including—quite obviously—the activation of dissociative tendencies in the analyst (i.e., being induced into escapist or docile altered states), which can easily result in a collusive detachment and false-self treatment situations. On the other hand, the analyst might unconsciously attempt—in vain—to inject vitality, aliveness, meaning, action, and stimulation into the proceedings, so as to counteract the grip of depersonalization lying beneath the pseudo-normal encounter. Whatever form they might take, these countertransference reactions should not be assumed to reflect the patient’s unconscious emotional life, and should not therefore be treated as actual communications of repressed contents or fantasy structures. The countertransference in these cases should more accurately be seen as the analyst’s singular and lonely response to deprivation of “true self” contact with the systematically dissociated patient. Accurate recognition of what is prompting these countertransference patterns—the fact that one cannot count on intersubjective and intrapsychic modes of communication—may in fact be a crucial element in realizing the existence of underlying dissociative processes.

Cohesive (“Successful”) vs. Unstable (Post-Traumatic) Dissociative Organizations

What distinguishes someone less obviously traumatized, like Sally, from a more clearly post-traumatic patient is that, in the latter, the fear of being impinged upon, disrupted, or harmed is often discernible in a brittle guardedness on the surface and a tendency to become disorganized or to fragment when threatened by retraumatization. In these more vulnerable cases, the surface cohesion that is typical of more highly organized “successful” dissociative personalities is susceptible to disruption: the post-traumatic patient has had to sacrifice a degree of cohesion and stability of identity in order to avoid retraumatization, and does this by compartmentalization or separation of self states.

The resulting post-traumatic clinical picture has been portrayed by Bromberg (2010) and others in terms of a model of self states that must be kept dissociated from one another so as to avert the recurrence of trauma. These post-traumatic cases tend to be inherently unstable and vulnerable to acute interruptions in ego functioning, whenever compartmentalization of self states can no longer be maintained. Indeed, the clinical encounter itself can be seen as a constant incitement: the therapeutic task of integrating the personality threatens retraumatization at every turn. Here the clinical picture might begin to resemble PTSD, or something like a multiple personality disorder. ¹¹

By contrast, patients like Sally, who are not so obviously affected by trauma, are often able to retain a highly coherent exterior, which involves a sophisticated capacity to master social codes and the relational patterns of interaction with others. What I have called the “successful” dissociative personality is characterized by a functionally cohesive and effective exterior false-self organization that obviates the disruptive compartmentalization of self states evident in post-traumatic personalities.

Living on the Surface: Psychic Disembodiment, the Exoskeletal Self, and Pseudo-Relatedness

Maintenance of a “successful” dissociative organization will rest on how well the exoskeletal ego is able to mold itself seamlessly to the patterns of the external world. This depends on the effective deployment of a particular set of mimetic skills—involving simulation, mimicry, and what might be called contact identification (instant identifications based not on the internalization of the object but on momentary perceptualidentities)—all of which aid in constructing a collated assemblage of self that strives, above all, to retain an exterior coherence, and by which the personality seeks to shape itself to the world around it, without in fact involving the core of the self in object relationships. It is these very skills, however, that keep a primary mind-body dissociation in force beyond reach of recognition and communication. To the degree that, by these means, a successful exo-self is constructed, it accomplishes a “normotic” strategy of identity formation (Bollas 1987), bestowing on the individual the invaluable semblance of a social identity. But the more effective this achievement of pseudo-normality, the more readily we may be blinded to the potential of a dissociative structure deeply institutionalized in the personality, that is operating alongside—but on principles entirely different from— repression and splitting.

While the successful exo-self, due to its skills in mimicry, does appear in many guises, it would nevertheless be a mistake to interpret this kind of false-self construction as a means of disguising or hiding conflicted wishes or repressed mental contents. These exoskeletal strategies are not so much disguises as moldings of self, exterior fabrications of identity shaped to the demands of the outside world. Where dissociation reigns, the “inner” domain—of the drives, of desire, of internal objects—does not take the form of something hidden, waiting to be revealed (through analysis of its derivatives, associative links, dreams, parapraxes, transferences, projective identifications), but is instead kept systematically segregated, both alienated and divorced from self-experience.

Under the hegemony of psyche-soma dissociation, it is not only the unconscious wellspring of the drives (along with any generative elaboration in fantasy and action) that is obstructed; what is also sacrificed, and then gradually eroded and lost to self-experience, is the sense of being alive, which carries with it the sense of realness of self in the world (Winnicott 1963). This is a quality that can be found only through embodiment—through the ordinary needs of a body that gets hungry, wants to move and sense things, and elicits the imaginative work and curiosity of a mind that itself wants to engage the world for pleasure. One can exist psychologically in a dissociated state, but one struggles to feel real and engaged in life.

On this view, to be chronically dissociated means being divorced from the “language of the body”; it entails living on the surface and perceiving things solely from that vantage point. This results in an objectified (rather than subjectively based) sense of personal existence. This was certainly true of Sally. Trapped on the surface of herself, she experienced her identity as coming entirely from the outside.

This is the logic of the dissociative personality: to protect the self by systematically excluding the living body from the felt identity of self. The “psychology of the body” (its idiomatic patterns of motility, drivenness, and psychosensory way of being in the world) is denied a place or “voice” or agency in the life of the mind. In place of symbolic communications with internal and external objects, or concrete exchanges via projection and introjection, the dissociative personality instead establishes a noncommunicative regime of regulatory control over the living body.

Thus, the dehumanized living body must be coaxed back into the sphere of self-experience. Clinically speaking, it is not a matter of decoding what lies on the surface, in hope of uncovering what lies beneath; rather, what lies on the surface must be infused and brought to life by what lies beneath, if it can be found. This has significant implications for clinical technique and the participation of the analyst—the primacy of interpretation gives way to other forms of engagement of analyst with patient.

Exile of the embodied dimension of self may take any of a number of forms, often involving highly organized regimes of control over the body (e.g., in autostimulation and exercise compulsions or eating disorders), or incarceration in obsessional-compulsive or perverse rituals. Where the ego’s mastery over the body is less effective—where the exo-self is less successful in establishing a regime of pseudo-coherence over the dissociated self—the fault lines of the underlying dissociative setup will become more evident. Alienated from a sense of corporeal meaning and vitality, the individual is prone to feeling chronically dispersed and disoriented, banished from a sense of place in the world, and may be plagued by out-of-body experiences, body dysmorphia, fugue, or depersonalization. ¹²

More commonly, however, where a more organized mind-body dissociation prevails, it does its work out of the limelight, obscured by the adoption of socially endorsed rituals and practices that normalize systematic control over the sensorium (practices that often include a wide range of self-care practices, including diet, exercise, autoerotics, or medication and drug regimes) and obscured as well by secondary processes of mental elaboration (along the lines of what Roussillon [2011] calls secondary symbolization and secondary sexualization), in which there occurs a retrospective overlay of representation and narration that recasts and reshapes the underlying psychosomatic detachment. ¹³ The primary condition of mind-body dissociation is thus taken up by the symbolizing capacities of the mind and thereby rationalized, revised, and masked.

Under these circumstances, relating to objects—others—takes on a different cast: there develops a peculiar type of pseudo-relatedness, something that resembles a kind of static symbiosis (Bleger 1967), which tends to lack the affective and fantasy engagement of a true object relationship. Pseudo-relating is not mere superficiality; it is a complex and often sophisticated form of living in the world as a dissociated subject. As a stable false-self strategy, pseudo-relating often involves the ability to enter into what Roussillon (2011) describes as a narcissistic contract, which lays out the terms by which psychic survival may be assured; one must forfeit one’s agency and need, turn away from one’s idiomatic and embodied way of being, and cleave instead to the formative impact of the object, adapting entirely to the will and drive-force of the other. In return one is given a place to exist, a mimetic identity, and a semblance of attachment, but only on condition of alienating one’s own desire. This is a high price indeed to pay for securing a place for oneself in the world. The cost is measured in the more or less radical disavowal of the drives, and thus the forfeiture of the claims of the body to its rightful place in psychic life.

Clinically, psychic disembodiment demands a change in the analyst’s approach and emphasis, away from defense interpretation and the analysis of interpersonal and transferential phenomena, and toward a more experimental approach, where the emphasis falls on facilitating rather than analyzing, and conditions are created for the patient to discover new forms of embodiment and a new flexibility in states of consciousness (which, of course, means facing all the anxieties that come along with it). Where dissociation dominates psychic life, nothing is more important and consequential than the living body finding its voice in the life of the mind. We can see why Winnicott (1960) placed such emphasis on the “spontaneous gesture” in his work with false-self patients. But the spontaneous gesture is not, as one might imagine, an expression of individuality per se, but (perhaps paradoxically) is more like a revival of the undifferentiated sense of shared sensory perception. In this sense, dissociation is what takes us away from what we share through our senses with others. Emancipation from pathological states of dissociation always involves a struggle over perception and sensation (whether we will be joined or alienated from each other), rather than over symbolic or associational meaning. Put another way, it is a struggle over where one is. From this perspective, the treatment of dissociation involves a reclaiming of perception for the lived embodied self. The clinical task in these cases may boil down to a question of how the patient may begin to see and hear the world, not through the narrow and disembodied prism adopted by the protective exo-self, but through the eyes and ears of an embodied (and hence always a shared) subjectivity.

Limitlessness and Psychic Pain

To have a mind means being able to travel beyond oneself. Longing to transcend the limitations of the embodied self is surely a defining feature of human mental life, ¹⁴ powering the imagination and endlessly finding representation in cultural, religious, and scientific forms, as well as in the fantasy life of individuals. But this desire to go beyond the self can tilt over into a refusal or inability to tolerate living in actual space and time. The degree and intensity of dissociation may be decisive in how this plays out—whether moving beyond oneself is something that occurs transiently and flexibly, or becomes instead an absolute necessity and fundamental requirement for survival, bringing with it a phobic intolerance of living even for a moment within the spatiotemporal constraints of embodiment. Here, moving beyond oneself can become permanent exile. Having to exist beyond the felt reality of the self, trapped in a kind of psychic exile with no way back to real life, is a common feature of life under dissociation; and it is marked by a quite specific kind of psychic pain, one that is not meant to be communicated (in the way that persecutory or hysterical pain readily make themselves evident), but remains mute and largely unrecognized.

Lombardi (2003, 2008), in a series of clinical and conceptual papers, has documented the challenge of helping psychotic patients, lost in an unbounded psychic universe, to return to living within the spatiotemporal precincts of the embodied self. My own focus is less on the problem of limitlessness as expressed in the uncontained “symmetrical frenzy” of psychotic illness (Lombardi 2009) than on the quasi-normalized forms of limitlessness found in organized states of dissociation, where the institutionalization of an altered state provides a form of pseudo-containment (Cartwright 2010)—specifically, it secures a sense of existence and psychic continuity by placing all of life in a state of suspended animation, or what I will describe as an alter world.

Winnicott (1949) wrote that the psyche may be “seduced” away from the soma and into the mind (p. 247). In pathological dissociation, what is normally a transient altered state (a transient reverie-like daydream, for instance) becomes instead a permanent rift in the self (e.g., a ceaseless compulsion to daydream). There occurs a flight from the mortal and musical body, never to return. Perception now falls under the sole aegis of a detached mind, while the wishful body is doomed to remain forever alien, subject to a never ending regime of control, colonization, or erasure.

Dissociation in Everyday Life

Since dissociation makes no use of mental representation to do its work, it remains essentially undocumented in the mind, leaving no mark in the unconscious, no signification that can be retrieved by the lifting of repression or the retrieval of a split-off phantasm. Dissociation works by removing us from ourselves unknowingly, by transporting us to another place without a trace.

Yet it is also true that having an implicit meta-sense of our state-shifting is integral to our self-perception and sanity. Experiencing as we must the alterations of consciousness that characterize everyday life, and the necessary transitions between these states (for example, moving in and out of states of alertness, reverie, sleep, concentration, emotional arousal, interpersonal engagement, rest, contemplation, aimlessness, and so on), we are implicitly—but intimately—acquainted with a certain malleability of conscious existence, and of how changeable our perceptions are. ¹⁵ Indeed, variations in degree of embodiment, and the accompanying changes in locus of perception, would seem to be the very hallmark of ordinary everyday consciousness. By the same token, the inability to transition between states may serve as a sign and a measure of dissociative illness.

If the ability to transition from one state to another is an essential aspect of sanity, this ability itself rests on an implicit sense of belonging and being in the world—of being woven into a shared perceptual environment, an ambient proprioceptive background, a feeling of being in a shared skin holding us as we transition from one state to another. While it is the function of culture and social organization to provide a communal fabric for the sense of being-held-in-the-world, in the clinical situation this function falls to the function of the analytic frame, which works to establish and maintain an effective spatiotemporal matrix; and which— like a shared living skin and contact barrier—facilitates the movement in and out of altered states. Does the analytic method not, after all, depend on these transitions in state—the shift, for example, from goal-oriented thought to free association, from detached observation to emotional immersion, from present perception to reminiscence? This is why, in the treatment of dislocated and chronically dissociated patients, the restoration or creation of a “living frame” takes precedence over techniques of interpretation and analysis of object relationships (Goldberg 2018).

If being alive to the world is like constantly touching—and being stimulated by—things in fresh ways, this wealth of sensory perception also threatens to be overwhelming. Freud (1915a) ascribes to repression the function of a contact barrier; we cannot possibly be—and should not be—aware of everything we feel and perceive and wish for. Repression, however, is for the long haul. Dissociation, by contrast, works now, providing moment-to-moment regulation of the self in the face of a plethora of perception, sensation, and feeling.

Ordinary everyday dissociative states, the kind that come and go, are thus implicated in what Winnicott (1971) calls “creative living.” Transient alterations in consciousness help us to find space and a place where we can live; removing oneself to “another place” provides an opportunity briefly to shift away from the embodied psychic domicile, to discover new forms of integrating mind-body experience, fresh modes of perception, new ways to “imaginatively elaborate” our bodily and unconscious experience. Transient alterations in consciousness allow us to move beyond ourselves while remaining tethered to our embodiment—without becoming too dislocated—thus averting the threat of depersonalization that haunts those who become too detached.

It is no surprise, then, that we like our dissociated states, seek them out, and cultivate them. But if we have to do it alone, it is a recipe for isolation and illness. We are helped along by our membership in the sensory commons: every culture continually incubates rituals, products, art forms, and communal activities that cater to and facilitate altered states.

When analysts have looked at the motives behind the seeking-out of trancelike experiences and altered states, they have tended to ascribe these to the fulfillment of an unconscious wish, or the reenactment of an unconscious idealized object relationship or attachment, or the acting out of a fantasy. But a purely dissociative factor is often at work, and is potentially decisive: When a certain altered state is induced in the clinical situation (e.g., being indistinct, thoughtless, inattentive, sensorially or somatically preoccupied, daydreamy), the patient may not primarily be attempting to evade a genuine emotional reckoning or a real engagement with the analyst or an internal object; instead of evasion, entry into an altered state might also be an effort at a new embodied engagement with the object world. Along these lines, it could be an attempt to explore and discover a locus of perception that allows for a more creative way of being genuinely embodied; to seek a more fundamental (mutually induced, intercorporeal) way of connecting and communing with the analyst (Goldberg 2012); to find respite, an interlude, a temporary release from the constraints of corporeal reality.

The possibility of a variegated detachment from our selves—a regulated movement in and out of being embodied—accomplished by alterations in states of consciousness, seems as essential to sanity as anything one could think of. It is a way of moving beyond the limitations of our existence, but not so far beyond that we would become disembodied and depersonalized. In their healthy form, transient alterations of consciousness do not put up a permanent wall between mind and body, but allow both mind and body to enter fresh perceptual terrain where new psychic forms may be found and created. In this regard, access to certain alterations in consciousness are probably integral to entering the space of “illusion” (Milner 1952) or transitional phenomena (Winnicott 1951). It is no surprise, then, that rituals that facilitate the elective entry into altered states may be among the most highly valued in cultural life. ¹⁶

Trapped in Alter Worlds: When Altered States Become Pathological Dissociative Organizations

The picture becomes quite different in cases where dissociative states become fixed entities, and alterations of consciousness lose their transient and elective quality. No longer is there freedom of movement in and out of different states, and instead they become compulsory, unchanging, and inescapable, states of mind that one enters and must never leave. The tremendous potential for enjoyment and creativity afforded by voluntary access to special states of attention and sensory perception (e.g., listening to or playing music, reading, daydreaming) is supplanted by addictive dependency on the power of trancelike states to dominate psychic life.

When incessant distraction takes over one’s experience—where, for example, daydreaming is compulsory at all times; where music is playing incessantly through headphones or in one’s head; where relentless mentalizing (solving mathematical formulae, or making to-do lists) accompanies every interpersonal exchange—the altered state no longer functions as a form of mental recreation, a chance to live temporarily beyond the constraints of everyday embodiment and ego-hegemony. Instead of creating a kind of transient “play space,” altered states are now deployed to maintain a permanently dissociated personality structure. Here we observe the mutation of ordinary dissociative states into a fixed organization that dominates the personality, enforcing a permanent alienation between living in the mind and living in the body.

In effect, then, the ordinary function of dissociation is perverted to new ends: What was initially a transient altered state takes on the character of a singular alter world, a place to live in completely. This alter world is quite distinctive in its makeup. While it functions psychologically as a total world, encompassing and coloring all of subjective experience (e.g., rendering everything to some degree monotone, or foggy, or feelingless, or pedestrian, or rote, or sinister, or erotogenic, or somatically impinging), the alter world does not interfere with “reality testing,” but operates instead as a facsimile of the world of consensual reality. In contrast to delusional constructions and the “dream furniture” of psychosis (Bion 1957), the alter world entails no modification or distortion of reality through fantasy, projection, provocation, or action; what makes it an alter world is the peculiar state of attenuated perception that is its hallmark. Living in the alter world has the power to appropriate all of perception; the world is seen entirely through the lens of a fixed state of consciousness custom-made to hold in place an unchanging dissociative structure—one that is devoted to preventing the free movement of the living body and mind. Interaction with the world remains intact, and relational skills and other ego skills may be hyperdeveloped. These characteristics of the alter world—a world built not on delusion but on the reproduction and mimicry of reality—make it difficult to comprehend the degree to which the individual’s psychic life has been taken over by a fixed regime that restricts the experience of time, agency, and sensory perception. ¹⁷

The necessity of remaining as far as possible in an unchanging alter world requires the consistent activation of hypnoid techniques (including distraction, autohypnosis, autosuggestion, and autostimulation). Retreat into a stable alter world is a complex psychological strategy designed (1) to camouflage the dissociative division within the self, masking the sense of disconnectedness and incoherence that accompanies the workings of dissociation, and protecting consciousness from awareness of its own disunity, from the lurking threat of depersonalization, and from the despair of emotional isolation; (2) to foreclose the “use of the object” and evade emotional contact by subtly detaching and going “somewhere else” (Winnicott 1971), while at the same time remaining sufficiently engaged at the relational level to maintain a social identity and affiliation; and (3) to provide a relatively stable and coherent identity by effecting a pseudo-integration or illusory unity of the divided self (Goldberg 1995).

I once reported a case (Goldberg 1987) in which certain mundane and unremarkable activities of a patient—fiddling with the heel of a shoe, staring at a spot on the carpet—served as decoy activities that allowed her nominally to stay present in the consulting room, while masking a radical withdrawal. While this patient was prone at times to brief periods of marked dissociative symptomatology, such as frightening flashbacks and disturbing out-of-body experiences, the greater clinical challenge consisted in unveiling a more subtle, extensive, and stable dissociative organization. It became clear that when in her more organized mental state, free of disintegration anxieties and explicit symptoms of dissociation, she was in fact perpetually in a “twilight” state, an alter world in which she was neither fully present nor too markedly absent. In addition to the habitual decoy activities of fiddling and squinting, a number of other facts became discernible, all of them evidencing the structure of a pervasive state of dislocation. These included propensities toward sleepwalking, chronic daydreaming, and a subtle sense of not quite being in her body. ¹⁸

At its most smooth-functioning, the false-self exoskeleton not only learns to mimic the social and technological codes of the external world, but also masters surveillance of the internal world, so as to achieve a simulacrum of affective self-integrity, while maintaining a primary dissociation from the lived body-psyche. The success of this kind of pseudo-integration in affecting an illusion of wholeness and associative vitality is what must have prompted Winnicott (1960) to warn against false analyses. The false self, after all, seeks nothing more than to succeed at the task of being real.

Usually when a “successful” dissociative organization and pseudo-unity of the self is established, the alter worlds are felt to be quite natural and necessary for survival, barely recognized as such or communicated about. Only once the primary dissociation (between mind and psyche-soma) is brought out in analysis do patients begin to notice and report that they have been living in suspended animation, or find themselves feeling that they are always distracted, being in two places at once, or constantly feeling “out of it” and the like. Less “successful” alter worlds, by comparison, are frequently felt as acutely unpleasant, especially in more disturbed cases where stronger underlying fragmenting forces are at work, and the “twilight” state of mind tends to be more powerfully hypnotic, druglike, inescapable. As these states are brought to light in treatment, it is not uncommon for the patient to become increasingly aware of a kind of horror in being trapped in semidetachment, in an unwelcome trance or semi-coma, unable to fully wake up; of being persistently numb, feeling half-alive and perpetually unreal; of living at a remove or like a drone without volition, constrained within a fixed and implacable neo-reality; and so on.

The Disembodied Mind

In the depiction of her mind on “autopilot,” Sally captures something important about the detached “mind-object” (Corrigan and Gordon 1994) that is endemic to entrenched dissociative states. Cut off from the psychology of the living body, the mind tends to take on characteristics of hypermentation, vigilance, and restlessness, developing a type of thinking that has peculiar qualities ¹⁹ that may be summarized in broad terms as follows: (1) a ceaseless kind of mentation that leads nowhere; a way of thinking that immobilizes experience; (2) an underlying lack of agency, despite an often active or overactive exterior; (3) a relation to time that has the quality of suspended animation—i.e., nothing changes; (4) an inability to recall or make sense of subjective emotional events, though often accompanied by a note-taking kind of detailed memorizing (Winnicott 1949), rather than a living-feeling kind of remembering.

Cut off from the living body, the mind becomes a scavenger, looking for something to pattern itself upon, either in the immediate sensorial surroundings (which can take the form of an autistic adhesive strategy), or in an adhesion to social and technological codes, which provide a sense of identity through mimesis, collation, and a kind of contact identification (or perceptual identification) with objects in the outside world. The exoskeletal surface must be constructed as coherently as possible, and maintained at all costs.

Despite the compulsive, over-full, and often overstimulated quality of their thinking, those who must detach themselves from emotional and instinctual life are haunted by emptiness and depersonalization. Because it is not housed in a living, breathing body, the detached mind is highly susceptible to the encroachment of lifelessness and loss of identity. Some otherwise highly functional individuals live under a constant threat of sudden dislocation—of being literally extinguished—which, however, usually resolves quickly enough to remain unreported. ²⁰

The Dissociated Body in Exile

Where the personality has taken on a systematic dissociative cast, one might say that, in order to protect the self, the mind comes to distrust the body and strives to gain control over the senses, seeking to regulate and control perception and to deny the body its legitimate life-giving role in psychic life.

But to the degree that a stable dissociative regime has been established, it depends not only on the construction of alter worlds, but on the maintenance of a fabricated or phantom body (Goldberg 2004) that is constructed by the mind to take the place of the lived psyche-soma. This is not a delusional distortion of the actual body, but a realistic (often hyperaccurate) apprehension of the workings of the body in order to bring it under the hegemony of a compulsive omniscience. As Sally so aptly put it, the body is placed under “remote control.” “Successful” systematic dissociation effects a kind of colonization of the body, rendering it a thing to be omnipotently controlled—first, to forestall impingement erupting from the direction of the instincts and soma; and, second, so that the mind, detached from body aliveness and thus starved of vitality, can whenever necessary activate somatic aliveness to forestall depersonalization (Goldberg 1995). In this dissociative setup, the mind does not wait, as it were, to receive communications from the body, but preempts and usurps the initiating function of the psyche-soma. The dissociated mind already “knows” (or legislates) the body’s urges, hungers, and reactions. “I am hungry only when I think I am hungry” is the motto of the somatic false self. Pseudo-vitality (Goldberg 1995) is coercively maintained by techniques of autostimulation, autosuggestion, and addictive rituals, as well as fantasying and omnipotence of thought. In these cases, somatic and affective experience is reduced to events that are activated ritually, on command; or, alternately, somatic affects are kept in a constant state of preemptive arousal (often a component of compulsive eroticization, as well as fanatical exercise and dietary regimes). In this way, ordinary patterns of embodied need—and the accompanying rhythms of desiring, waiting, trusting the object, sustaining loss and disappointment, and so on—fail to evolve, leaving the individual prey to the depredations of pseudo-vitality and coercive derepression (Goldberg 1995). ²¹

Where the senses and the instincts are exploited and the body virtually colonized in this way, the psyche-soma is essentially stripped of spontaneity and agency and therefore remains mute even when it is compulsively brought to life. Obsessions with regulation of the body, food intake, exercise addiction, compulsive habits of self-care become implicated in the process of regulating the dissociated emotional and somatic core of the self. This is the ethos of “successful” dissociation: the ability to shift attention, switch channels, alter states, so that authentic need and desire do not assert themselves and lay claim to perception of self-in-the-world. Where dissociation takes on a fixed and superordinate character in the personality, the somatic core of the self—the literal site of need, of the drives, of the sense of aliveness, of hunger and tender feelings that constitutes the embodied locus of self—is cut off, exiled, and refused ingress back into the life of the mind. Here the body becomes alien, a thing to be controlled.

As I have noted, there exists a kind of survivalist strategy that prioritizes self-alienation as a means of self-care and self-cure. This corresponds to Winnicott’s description of the false self formation (1949), where mind takes over the caretaking functions of the environment. Reflected here is the development of a personality based on a profound loss of faith in others to meet the authentic needs of the self.

The Inductive Dimension of the Analyst’s Presence and Engagement

Recognizing this challenge, both Bromberg (2010) and Lombardi (2008) advocate, though in very different ways, the importance of a “structuring” type of interpretive activity, which strengthens patients’ ability to connect cognitive and emotional aspects of their mental functioning. I would like, however, to emphasize the importance of what might be called the inductive dimension of the analyst’s presence and engagement, which emphasizes the work of the analyst in catalyzing an interweaving of therapist-patient engagement at the psychosensorial level, as a first and fundamental aspect of the analyst’s therapeutic activity.

Broadly speaking, as regards psyche-soma dissociation in particular, the clinical task is to heal the dissociative rift within the self, to rediscover the alienated libidinal domain of embodied experience and restore it to self-perception. This involves a clinical approach that differs from the free-associational and interpretive method of uncovering repressed wishes and unconscious defenses, and differs also from the object-relational approach of analyzing split-off aspects of self, and from the relational exploration of mutually dissociated states. Instead, first and foremost, the analyst becomes midwife to the relinking of mind and psyche-soma, ²² and must actively facilitate discovery of live being-in-the-world.

It is clear that where systematic dissociation has alienated the life of the mind from the psychology of the body, symbolic links to unconscious life are sundered, and the power of words to make new links and forge new meanings is impaired. Insofar, then, as dissociation bypasses fantasy structures and dismantles associative links, the psychoanalyst’s most specialized method—the use of interpretation—loses its efficacy. In the face of dissociation, the analyst cannot effectively remain in a purely interpretive posture, nor is it sufficient to take up a position of receptivity and reverie (though these are, of course, crucial in their own domain).

To the extent that entrenched states of dissociation verge on the uninterpretable, it is necessary to go further: the clinical emphasis in working with these patients falls on certain kinds of noninterpretive activity and engagement by the analyst. The analyst’s psycho-physical presence and posture come to the fore. It is essential to cultivate an active posture at the psychosensory level. I have referred to this engagement readiness—in the work done at the level of shared psychosensory experience (sensory symbiosis)—as the inductive dimension of the analyst’s activity (Goldberg 2012). Noticing things, seeing and sensing things together, becomes the basis of a clinical approach to dissociation. Reclamation of the embodied self entails an activation of shared sensoriality, ²³ because our bodily based perception of the world is never a singular isolated activity, but is always a matter of communal perception. We can sense the world only through the sensibility of others. ²⁴

Psychosomatic dissociation challenges us to reverse the usual emphatic direction implied in our clinical theory, whereby we strive always to give representation to what has remained unrepresented, to bring the inarticulate into the realm of words. The dilemma posed by dissociative structures is that words are sundered from unconscious meaning: the representational domain of words remains divorced from the presentation of embodied feeling and desire. In this sense, in order for words to be of any use, they have to go back to being things (Goldberg 2012). The clinical task, then, is not so much to bring the psychic depths to the surface, but to return the surface to the depths (Scarfone 2015)—to return the analyst’s speech to its protosymbolic function of bridging body and mind, feeling and thought (Anzieu 1995; Roussillon 2011).

This means that the analyst must broaden the scope for preverbal or protoverbal exchange and connection at the nonrepresentational level. In a sense, the analyst must learn how to speak anew in the presence of each patient, not in the semantic but in the performative sense of speech. Speaking must first be capable of doing something—conveying an embodied presence—before it can serve its function of representing things, naming and differentiating things, and conveying lexical meaning. In order for the spoken word to work as a symbolic conveyance of meaning, it must first (and always) succeed in effecting a psychosensory bond: words must be felt in the body, in the form of a being-in-the-world together, if they are going to carry significance in the mind. So perhaps it is more accurate to say that we learn to sing anew with each patient, as it were, on the way to finding a way to speak symbolically.

In the case of Sally, the unveiling of the underlying primary dissociation involved my putting aside my interpretive approach and focusing more completely on the sensory surround, sound of voice, rhythm of breathing (it was difficult to tell how there was space for breath between the words). My own words became a commentary on states—in musical performance terms, an accompaniment (see Grossmark 2012)—and my mode of speaking a form of shared psychosensory and affective regulation.