Encompassing the Multitude,Animating the Contradictions,and Building Bridges: Reply to Commentaries

Theoretical Strain

As Sandler (1983) has reminded us, theoretical strain, most especially between theoretical concepts and practice, is constantly being generated. As we can observe even among well-trained and highly competent psychoanalysts, the human mind is incapable of holding a multiplicity of inconsistent ideas and concepts all at once; consequently, I approach my interlocutors with some equanimity; we are all engaged in the difficult task of trying to encompass the multitude with its inevitable contradictions and overlays. We should keep in mind, however, that the common ground for analysts working in different theoretical and technical frameworks resides in overlapping concurrences of clinical material, and not in higher-order metapsychology or reified concepts (see Bernardi [2014] on the findings from clinical groups developed by the IPA’s Clinical Observation Committee).

Terminology

Confusion inescapably arises from the lack of agreed-upon meanings of certain terms and the concepts to which they refer, particularly when words are used idiosyncratically or imprecisely. Terminology frequently becomes highly charged based on one’s psychoanalytic culture and prevailing model of the mind, and potentially evokes reductive and stereotyped (mis)understandings. For instance, consider the multiple meanings of terms I employ in my article, including integration, interpretation, conflict, defense, repression, fantasy, regression, representation, active, automatic, hypnoid state, transference, and even trauma itself. The commentators’ varied understandings raise the question of what these terms mean across differing schools or ideologies and how they might be distorted or misunderstood.

Integration

Both Purcell and Stern note something that can easily lead to misunderstanding—namely, my use of the word integrate to bring trauma theory more in line with conflict theory. What I mean by integration is closer to what Purcell refers to as encompassing. The more inclusive yet distinctive usage of integrate here contrasts with the prevalent connotation of simply blending into a unified whole. I visualize psychoanalytic epistemology—like the mind-body itself—largely in a spatial sense, a containing envelope in which many diverse, contradictory, and paradoxical elements reside while preserving their uniqueness (though not all are necessarily accessible, for a variety of reasons). To mix metaphors, I don’t think this container is anything like a melting pot in which diverse elements dissolve together into a smooth and easily digestible (but perhaps less interesting) soup. Rather, I prefer what Hawaiian Islanders refer to as a cultural salad or Creoles call a jambalaya—both of which contain various unique and diverse ingredients that, while held together in a larger vessel, preserve their distinct identities and bear the tensions of differentiation. In using the word integration, I intend to convey the diversity and heterogeneity of pluralism rather than a smoothing-out creating the semblance of homogeneity. Failing to make this distinction explicit often leads to the need to bifurcate in order to preserve identities and theoretical differentiations.

Widening Scope

Again, my aim is to create a larger containing envelope for understanding and treating the unique yet overlapping aspects of trauma, dissociation, and repression. Consequently, I offer an inclusive perspective that encompasses the intermingling of both dissociated, segregated self states and repressed, conflict-based material in a nuanced, dialectical, and less binary clinical model that attempts to locate the patient’s unique subjectivity and dynamic history in an interpsychic field of patient-and-analyst. Given that I address trauma and the associated defenses more generally, I recognize, in retrospect, that I could have made the importance of differential diagnostic considerations more explicit; after all, dissociative functioning is employed in divergent ways depending on a number of factors, including the developmental level at which the original traumatic experience(s) occurred, and whether the patient who now presents in the consulting room functions in ways that might be characterized as neurotic, severely character-disordered, borderline, or psychotic.

Caution and Transference

The commentaries highlight the need for caution in working with traumatized patients, whom both Stern and Purcell view as particularly fragile and easily retraumatized in a malignant way. Taking a different tack, Lombardi cautions against thwarting these “seriously ill” patients’ development. Moreover, all three seem troubled by the use of transference interpretations (which they view, rather reductively, as stemming from “mainstream psychoanalysis” and focused on repetition compulsion, past object relations, and/or unconscious fantasy); conceptualizing and interpreting dissociation as defense; and, by the presumption of clumsy and invasive attempts to introduce possible fantasy and conflictual material (misrepresented as always symbolically accessible). These interpretive activities are basically viewed as evoking malignant forms of regression that must be avoided. Consequently, the discrepant clinical data suggesting the facilitative value of working in the regressive transference is either ignored (Stern), selectively disregarded (Purcell), or considered to slow down mutative work (Lombardi). In contrast, however, Lombardi does address the pertinent clinical data while offering a differing focus on internal functioning that privileges the body.

Model of Mind

Lombardi and I share a model of mind in which clinical technique can be used to address more primitive mental operations, including dissociative functioning. We agree that the mind operates in different ways (which I frame as dual-track functioning) and, particularly when the patient’s mind operates in a deficit-based register that forecloses verbalizable symbolizing (though perhaps more weakly representing), the analyst is called on to become more aware of, and more receptive to, somatic/bodily experience and reverie. Lombardi recognizes the mind’s ongoing conflictual dynamics but cautions against overprivileging these when working at what he considers the “deeper” layer, where primary process reigns supreme. I agree with the necessity of tracking the accessible levels of the mind, but I would repeat here that dissociative states are not necessarily ruled by primary process; instead, both primary and secondary processes are involved (as in neurotic pathology), and it would be a mistake to describe dissociative functioning as inescapably reflective of the “psychotic,” nonrepresentational part of the mind.

Lombardi is influenced by Matte Blanco, who views the unconscious as consisting of two logics: generalizing (i.e., symmetrizing in primary-process forms) and making distinctions (i.e., asymmetrizing, as in secondary processing). I find this conceptualization problematic because there is little or no dynamic relationship between the two, despite the analyst’s goal being to create “bi-logic” through facilitating points of contact. Regardless, both modes of logic are clinically apparent in secondary forms of dissociation in which deep feeling states (symmetry) and discursive thinking (asymmetry) intermingle. In effect, then, Matte Blanco’s model leads one to state simply that the patient is generalizing in psychotic fashion at a given moment and then, at another moment, is differentiating. Consequently, Lombardi falls into a nominalist fallacy in which labeling determines rather than explains.

In contrast, I think of the mind—as well as dissociation, repression, and trauma itself—more in terms of a continuum characterized by degrees, interpenetrations, and oscillations in mental functioning. Thus, it evinces not an either/or binary quality but an intermingling of functions, recognition of which depends largely on the viewer’s position. Moreover, as both Freud and Bion advocate, it is through the analyst’s presence as other that the traces or elements of the primordial mind can reach the workable psychic realm (Scarfone 2013).

Dissociation

Lombardi has contributed substantially to our understanding of the body’s primacy; consequently, he tends to be more circumspect about intrapsychic fantasy and transference interpretation. His thinking is interesting and provocative, though, as I have noted, his distinctive model is applied generally to traumatized patients, including dissociative ones like Ms. A., who had access to more developed secondary, asymmetrical processing even in dissociated states. Lombardi and I most significantly diverge in how we understand dissociation. I do not see it primarily in topographical terms (i.e., arranged in “layers,” some deeper than others), but rather as a set of segregated units or self states that comprise “deeper,” more primitive mental processes—as well as internal structures and objects that also have considerable access to secondary processes pertaining to unconscious fantasy, drive derivatives (including the body and affect), and conflict.

Lombardi seems to recognize the plausible “hypnotic underpinnings” to our divergent views of dissociation, and our differing experiences in working with trance states may have led to contrasting ways of approaching dissociation in the analytic dyad. (I will make this clearer in discussing Purcell’s bifurcation of hypnoid phenomena and dissociation.)

Mutative Change

Lombardi suggests that therapeutic benefit can be achieved more rapidly when “confronting body-mind dissociation” (p. 885). This may be true in certain cases, and while I agree that the “primacy of otherness” (p. 885) can be problematic, transformative work cannot be reduced to its action on a single dissociative (or conflictual) mechanism; instead, it can be determined only through the experiential discovery of the uniqueness of each dissociative patient’s multitudinous unconscious, which typically comes alive in the analytic field—as seen in the case of Ms. A.

Response to Clinical Material

Lombardi respectfully shares his way of looking at the clinical data presented and, perhaps in an effort to find evidence for his theoretical view, offers his reinterpretation of my interventions. For instance, he describes Ms. A. as hating her body and herself (linked to her self-cutting), without offering any supporting evidence. He does not indicate where he gets the clinical material to arrive at this postulation, especially since he says it is not related to the trauma. He notes that she is conflicted between wanting to protect her body and hating it, and because this is “the most urgent level” (p. 882) of her communication, she needs to be able to become conscious of the conflict—though, rather in the way in which I see her defending against experiencing conflict, he views her as dissociating to avoid experiencing the pain such knowledge may bring.

Lombardi goes on to declare that the patient’s asking me to “do it” gives evidence of her bodily based self-hatred. Of course, this action-dominated demand could be considered in various ways—for instance, as the very common turning passive into active or, more likely, within the dissociative bodily realm, as a longing to bring a deadened body to life. Certainly, as Lombardi implies without conceptualizing it in such terms, it is a sadomasochistic request; however, one might ask whether Ms. A. is accusing me of representing her abusive grandfather—namely, an externalized counterpart of her intrapsychic world—and therefore becoming insistent and absolute so as not to have to bear the shock that a good person or good internal object can at any moment, unpredictably, turn into a bad one. Perhaps this is why she cannot depend on me (or on her good internal objects).

While Lombardi provides an interesting way to think about the secondary dissociation, nonetheless, in following up on her experience of “falling apart,” she demonstrates being helped to bear the conflict and, ultimately, working it through. The split does not seem to be primarily between her body and her mind, but rather is more likely to vertically divide her between the part of her that knows and the I-part (ego or self state) that doesn’t want to know. These no longer completely differentiated I’s (or ego structures within self states) are both aspects of a larger, more encompassing, internally functioning mind that without such integration might remain disconnected.

Allegiance to a preferred way of thinking appears when Lombardi arbitrarily reinterprets the dream of the child with no mouth without making reference to the patient’s associations (which for reasons of time and space I did not provide). He claims that his interpretation represents the patient’s developmental level and is unrelated to trauma or some other triggering stimulus because Ms. A. is a high-functioning person who can clearly speak and communicate. In fact, though, Ms. A.’s selective mutism lasted for several months after the onset of the childhood abuse, a detail not mentioned in my article. That the dream has dynamic meaning is quite apparent (though of course the specific content of my interpretation may or may not be correct). Regardless, any analyst could offer a reasonable hypothesis, such as that she wished she didn’t have a mouth because speaking about the trauma to her parents was experienced as fraught with peril, but the proof was in the pudding of the analysis moving forward or not. In this case, given her mother’s own history of being abused and her denial of her daughter’s plight (again not discussed in my article), the dynamic seems to fit!

Transference Interpretation and Regression

Lombardi does not appear to view the body as a dimension of the transference relationship, though he regards the body as the primary object. Nonetheless, I read his comments as implicitly suggesting that this primordial object relationship occurs within the regressive transference (in the context of the patient’s conflictual mind). He goes on to indicate that such an implicit transference focus is the preferred means for working through the pathological logjam of mind-body dissociation. However, contrary to my view of “traumatic” regression as potentially mutative (much like the views of Winnicott, Balint, and others), he categorically declares that “regression, even in the best of cases, greatly slows down . . . analytic development” (p. 879). As a result, his ideas about the value of “traumatic” regression seem confused.

Unlike Ferenczi, Winnicott, and others from past eras who worked with traumatized patients, Lombardi doesn’t seem to appreciate that “relational interpretations” in the wider sense can serve as starting points in which externalizing mechanisms operate, and hence enable us to get to the intrapsychic (including the prepsychic realm of the primordial mind-body). He views the transference focus as at risk for “worsening the patient’s expulsive tendency” (p. 883) and reinforcing “the psychotic aspect” (p. 884), apparently without considering the holding function of the frame or the analyst’s attitude itself (these two factors were influential in Ms. A.’s treatment for over two years). Perhaps this is because he views the intrapsychic as essentially consisting of the mind and the dissociated body. For me, the intrapsychic consists of a multitude of objects (the body being only one) or structures that reflect the relationship with the “self”; one part of the mind may be defending against another (both of which had their precursors in the body—as Freud noted early on, and as Winnicott refers to in his description of the psyche-soma). When these parts are brought together, first in the analyst’s mind and in the intersubjective field (which includes the analyst’s reveries and reflections on his bodily experience), and then communicated to the patient, the patient can more fully experience the feelings of her own body.

Finally, Lombardi misconstrues my working in the transference as emphasizing an external relationship rather than as forming a pathway toward intrapsychic functioning. Throughout his commentary, which invites accessing bi-logic, he seems to indicate a belief in using the transference to suggest to the patient that she has alternative ways of responding that may be more effective than her habitual responses. From this more confrontational, rather authoritative position, he tells the patient what reality is by conveying that she should “keep in contact with her body and her bodily sensations” (p. 884). In contrast, I believe that there are ways of interpreting (as well as not interpreting along more conventional lines, such as recognizing, validating, and naming, along with nonverbal forms of containment) that enable patients to bridge the segregated self units and gradually experience “reality” more directly and autonomously. For Ms. A., this might entail becoming an angel on occasion!

Model of the Dissociative Mind

Because Purcell favors a particular model of the dissociative mind closer to traditional trauma theory and anchored in neuroscience—one in which defense, trauma, representation, and conflict are understood in less nuanced, more binary ways—he seemingly fails to understand the essentials of my theorizing. Consequently, he appears committed to demonstrating the superiority of an alternative perspective, which leads to a search for evidence with which to discredit my clinical data. Though I too value neuroscience (and found it useful to include pertinent findings from that discipline in my article), I regard it to be of a different order than clinical psychoanalysis in that, at least as far as I know, it cannot be used to demonstrate defenses, resistances, or meaning makings, either before or after a traumatic experience.

In a related vein, Purcell addresses trauma without making important distinctions, and as a result we differ most significantly in that I view the mind-body or psyche-soma as always representing experience (though perhaps weakly and in an unformulated way), and, to some extent, as interpreting experience—though not necessarily at the time of the experience itself or in symbolic form. Purcell’s view aligns with earlier trauma theorists’ view that dissociation is a phylogenetically significant aspect of a psychobiological response to catastrophic threat that does not involve the dynamic unconscious. Consequently, the mind and body (psyche-soma)—what he terms “psychic agency” and “neural reflex”—remain split in dualistic, Cartesian fashion.

From my perspective, however, even if dissociation were “just” fundamentally a neural response, the mind may immediately present, represent, or interpret it (though perhaps while also dissociating the part of the self that can do so)—or, more likely, the mind later does so après coup, as is often seen in analysis. The clinical issue when secondary dissociation is involved pertains to the self state that actively makes such meaning (though it might be passively experienced), and how and when (or whether) the borders or contact barriers that maintain such segregation can be bridged.

Agency and “Happening” in Dissociation

Winnicott (1960) conveys my way of thinking about passively experienced, albeit active, unconscious agency in discussing the infant’s experience of trauma despite being linguistically unable to represent the experience:

no trauma . . . is outside the individual’s omnipotence. Everything eventually . . . becomes related to secondary processes. Changes come . . . when the traumatic factors enter the psycho-analytic material in the patient’s own way, and within the patient’s omnipotence. . . . The analyst is prepared to wait a long time . . . to do exactly this kind of work [p. 585].

Work with adults traumatized in childhood requires enormous patience and perseverance of both analyst and patient. The analysis of Ms. A. illustrates the need to wait until late in the second year to address this (and then three more years of work were needed to yield lasting transformation). Of course, when a child suffers abuse, she may be quite aware that she is dissociating (though most likely neither using the term nor understanding the concept). In treatment during adolescence or adulthood, patients may speak about an image remembered from an abusive episode (e.g., playing with a doll, being on the ceiling looking down, going completely numb, and disappearing—or, in Ms. A.’s case, imagining a beautiful angel coming down from a cloud to take her to heaven). Being there and not being there—an important aspect of dissociation—is much more likely to be remembered over time than at the beginning of treatment.

Dissociation as Defense

Purcell does not conceptualize dissociation as a defense because it is automatic; however, that view flies in the face of common clinical experience. Most defenses are in fact automatic, as for instance the defense of repression against an unacceptable impulse (one that might not be linguistically symbolized though present in the form of a nonverbalized sign). In any case, defenses such as dissociation or repression may sometimes occur almost instantly, and at other times may arise over time. Dissociation is not a defense against meaningless affect, but protects against confusing and terrifying helplessness and annihilation. Calling it a neural response rather than a psychological one does not distinguish it from other defenses, which are also neural responses.

Hypnoid States

Purcell and I have a very different understanding of trance states, which he distinguishes from dissociation and conceives as a “reflexive compartmentalization of unrepresented affect accompanied by an alteration of consciousness itself” (p. 891). In preserving his neural conception while basically dismissing the operation of secondary dissociation in the analytic setting, he maintains that dissociation cannot be interpreted as a defense—as if doing so would preclude the recognition of exogenous factors in traumatic pathogenesis.

Arguing that psychoanalysts have conflated dissociation with hypnoid phenomena, Purcell claims that, in contrast to dissociation being viewed as a “right brain” neural response, hypnotic phenomena, like repressive defenses, are considered “left brain,” organized, “intentional manipulation[s] of attention by the ego” (p. 892). Having researched and worked clinically with hypnoid (dissociative) phenomena over many years (much as Stern has in viewing hypnoid states as dissociative phenomena), I must respectfully disagree with Purcell’s characterization, as do virtually all leading researchers in the hypnosis field. ²

Secondary dissociation accesses the altered state that hypnotists refer to as trance (and that early analysts termed hypnoid state), and, despite Purcell’s claim, the evidence is unequivocal that such dissociative mechanisms reflect an adaptive and often protective self-induced hypnoid state. In this respect, Purcell seems to unknowingly buttress a long-standing schism between the field of hypnosis and psychoanalysis—limiting analytic treatment of dissociative states to those viewed solely as “protective and consciousness-altering neural reaction[s]” (p. 892).

Affect

Although he offers several alternative ideas, including those of neuroscience, it seems to me that Purcell is primarily making a plea for clinicians dealing with trauma to be sensitive to how overwhelmed patients can become by very disturbing affect. I fully agree with his concern, especially in view of the affective flooding that can occur in treatment and result in secondarily dissociative, defensive self-protection (even though to Purcell dissociation is not a defense). Perhaps I should make explicit that such flooding, though certainly significant, is not central to a major clinical aspect of my thesis, which rests on the role played by self-protective, internal functioning, as well as by unconscious agency. As a result, Purcell and I differ substantially in how we understand and work with the experience of too muchness. Adopting a neurobehavioral stance, he believes solely in a “neural reflex” that becomes an “imprinted protective strategy” (p. 899) with which to deal with excessive affective stimulation. Much like Janet, he posits that this reflects deficits in brain/mind functions; accordingly, it seems that the buck stops there. For me, however, the “excessive overwhelming affective stimulation” (p. 899), like all aspects of trauma, reflects an interaction between the unconscious psyche and external reality.

Attitude

I read Purcell as elaborating Ferenczi’s classic reminder (1933)—written at a time when conflict theory occupied center stage—of the importance of the analyst’s attitude in working with regressed traumatized patients. Unlike Ferenczi (and later Winnicott), Purcell is quite wary of actively allowing for and welcoming regression in the transference relationship. He blurs his idea of the analyst’s attitude (termed “way of being”) with the analyst’s more specific interventions—including silence, containment, reflection, naming, affirmation, suggestion, confrontation, and/or interpretation proper. This is a misleading way to consider the analyst’s attitude, most evident in the narrow way Purcell discusses interpretation as promoting “nonresponsiveness to the patient’s actual clinical needs” (p. 901) and, more damning, as essentially an “impinging,” invasive action insensitive to the patient’s plight. For me, any action or inaction by the analyst, including nonverbal behavior, silence, word usage, and so on, is inevitably conveyed through the analyst’s “way of being,” and therefore the action, inaction, or intervention may be either facilitating or deleterious.

Words and Language

Purcell and I agree that sensitivity is primary, though I particularly stress that the analyst needs to be in synch with the patient’s state of mind. We also agree that this includes being aware and responsive to the patient’s nonverbal activity. However, because my model of the mind incorporates the dynamic intermingling of dissociative and repressive processes among segregated self states, with their own structural components or internal objects, we diverge in addressing the interpenetrating roles played by dissociation and repression in the analytic dyad. Purcell fears that I fail to “recognize the role of exogenous traumatic experience . . . and reflexive dissociation” (p. 896) and that I promote interpretive techniques that are “ineffective or disruptive” (p. 890) operating “in a world of ‘left hemisphere’ functioning” (p. 902).

In contrast, I consistently find that the analyst’s use of speech and words—including validation, naming, linking, and even traditional interpretations of what may remain dissociated—can express both sensitivity and emotional resonance, as well as provide the needed containing protection. In this way, a relational act of understanding helps create a potentially transformative opportunity for journeying together into the complexities of the patient’s mind and the frequently hidden, secret self (i.e., the missing I) to which trauma has led. Though not without risk of covering over or constricting the traumatized patient, the language of the analyst’s words, in its many functions and manifestations, can serve to enliven, open up, and move analytic process forward (Vivona 2014).

Interpretation

Perhaps because Purcell is troubled that interpretive technique is originally “derived from conflict theory” (p. 898), he and I seem to have very different ideas about the value of interpretation in its various forms, from affirming or ascribing, validating, and naming to its more traditional, investigative or reclaiming attempt to draw a link with unconscious or split-off material in object-relational or structural form. (When taken together, these broad categories of interpretation reflect what I describe as the dual-track approach to analytic listening and interpreting in both a transformative and an archaeological manner.) In fact, Purcell’s skillful work (2019) with a severely dissociative patient illustrates how his own humble questioning opened up the work to the patient’s dissociative core.

Speech is the principal medium—though not the only one (as both Purcell and Stern suggest)—with which to relate to our patients in a way that inspires an experience of being understood and recognized (Spivak 2014). Spoken words can serve as relational containers that protect the terrified patient, while also serving to articulate transformative meaning, even when working with the archaic, nonthinking aspects of the primordial mind. In the latter case, the analyst’s word presentations help transform “presentational traces” into representations “in the psychic field” (Scarfone 2013, p. 85).

Mutative Action: Interpretation and Beyond

In working with dissociative phenomena, I believe it is important to understand that the patient is searching for another mind to find her “true self” (Winnicott 1954) or even trying to “surrender” in order to be found (Ghent 1990). However, as seen with Ms. A. and in other displays of repetition compulsion, including those of Purcell’s patient John (2019), secondary dissociation in the analytic dyad can express an archaic effort at mastery or growth that reflects a longing for the birth (or rebirth) of the true self. Even when the traumatic repetition takes the form of masochistic submission, as with Ms. A., I find it most useful to appreciate that this repetition represents an active (albeit unconscious) attempt to find in the analyst a containing object capable of making sense of what has remained weakly symbolized and is often expressed somatically. The patient’s eventual understanding that her analyst is trying to make sense is often sufficient to provide such containment.

In short, the dissociation appearing in regressive transferences serves to hide the true I suffering from the traumatic experience. While most patients experience real-life events as happening to them, analytic interpretation in its many forms—ranging from traditional uncovering, to affirmative (Killingmo 1989), to amplifying or ascribing of meaning (Alvarez 2010)—can enable them to experience something they are unconsciously rearranging in their present situation (e.g., the transference) in a way that, though active, typically is weakly symbolized or not fully represented.

Over considerable time, a severely traumatized patient like Ms. A. is often able to experience herself as the agent of the secondary dissociation in an emotionally alive way. Sufficient time is required in order to sensitively receive, hold, metabolize, and contain what is distinctively a quasi-interpretive intervention in the form of naming, in which the analyst supportively handles the patient’s turbulent affect.

Clinical Technique

Surprisingly, it seems as though Purcell fails to understand how the analyst’s use of verbal language, including interpretation, clarification, and, in particular, naming and affirming—especially in acknowledging the patient’s passive experiencing—can result in the patient’s feeling that her deeper and often preconscious experience is recognized. Instead, Purcell postulates that such activities invariably assault the patient’s precarious psychic functioning. In objecting to naming and affirming Ms. A.’s “defensive” need to protect a threatened self, Purcell declares that in her state of mind, “defense interpretation. . . . cannot be grappled with” (p. 904), despite clear evidence that not only does she grapple with it, but also, within several emotionally engaged minutes, she is able to experience herself as both safely contained and sufficiently understood to inhabit her experience.

Purcell persists in defining interpretations very narrowly: as statements in which the analyst leads the patient rather than being with and following her. Consequently, he suggests that I maintain “silence” (which otherwise is apparent while I am quietly engaged in my own bodily/emotional and associative reveries), and he completely misses the patient’s experience of the interaction. Instead, perhaps to argue that I prioritize the “overarching importance of addressing conflict” (p. 900)—he does not acknowledge that my focus is on the intermingling of dissociative and conflict-based mechanisms—he misreads the clinical data and construes the interaction in line with his own theory, bifurcating dissociative and repressive, hypnotic, and conflictual processes, as well as neural mechanisms and psychological defenses.

Model of Mind

Stern makes it clear that he and I operate from different models of mind. Unfortunately, he seems determined to represent my model as “simple and straightforward” (p. 907), arguing that both repression and dissociation are based on early-twentieth-century Freudian ideas, such as Breuer and Freud’s view that “consciousness requires verbal-symbolic representation” (p. 907). In Stern’s polemicized way of proceeding—perhaps a reaction to frequent criticisms from “classical” analysts that his work neglects the conflictual nature of the dynamic unconscious—he, too, misconstrues my model and then argues against it. Such a reading seems to mirror the late-twentieth-century emergence of the largely New York–based relational school, speciously rooting my thinking in “the long-standing tradition of North American psychoanalytic ego psychology” (p. 916).

Repression

Though I believe Stern and I view trauma’s too muchness quite similarly (except in relation to the mind’s unconscious activity), he misrepresents my views on repression and secondary dissociation. He states that I assume the “usual view” of repression that involves “mental contents . . . that have already attained verbal-symbolic form” (p. 907; emphasis added). In contrast, I believe that repression and other defenses, especially secondary dissociation, entail varying gradients of representation, which typically are weakly formulated and often manifest as signs lacking verbal form. Moreover, as noted earlier, I do not agree that repression acts only on symbolized, verbal experiences. Consider the little boy when he first sees his mother’s genitalia: surely he doesn’t really think in language, “Oh my God, this could happen to me!”

Because some of my remarks in response to Purcell’s commentary pertain also to Stern’s comments, I will limit my additional observations here to a few key divergences and misconceptions.

Theoretical Allegiance

While I object to the clear-cut bifurcation of concepts based on their origin in divergent theories of more than a century ago, I nonetheless find aspects of Stern’s theoretical framework useful, and I do not wish to dismiss the clinical value of differing viewpoints. However, Stern makes a number of distinctions that neither add to an understanding of my ideas nor help bridge the schisms that continue to plague our profession; unfortunately, ideological hegemony grounded in identifications and idealizations remains prevalent in psychoanalysis.

Stern apparently feels otherwise in seeking to differentiate himself by replacing established psychoanalytic concepts with contrasting ideas. Thus, he makes no bones about advocating hegemony for the “contemporary interpersonal/relational” viewpoint that he takes it upon himself to speak for (p. 908). Conceivably, it is out of a wish to keep his ideas sequestered from the remnants of classical analytic thinking that he boldly declares that analytic writers from outside his coterie’s distinctive view of dissociation—writers like me—cannot use his work, or Bromberg’s, to “support” their models. Similarly, he professes concern about “sacrificing” his own point of view pertaining to his theory of unformulated experience. Fearing that his model could be denatured, he considers the gaps inherent in conflicting viewpoints incompatible under a larger analytic umbrella—as if the branches of a tall oak are not part of the same tree.

In the irony of parallel processing, a schism is created yet again, where there ought to be simple disagreements, differing emphases, and varying perspectives. Though I understand that Stern feels otherwise, I find this extremism disturbingly unscientific and inconsistent with promoting progress in psychoanalytic theory and practice.

Stern then uses his response to my paper as an “opportunity” to explain why dissociation and repression cannot coexist in his frame of reference. I suppose this is one way to react to a colleague’s work, but I submit that it would be more useful had Stern chosen to write a separate paper on this theme—a topic he notes he is often “asked about.”

Pluralism

It is noteworthy that Stern mischaracterizes my argument for a broader, more inclusive approach as one in which I would view “Freudian theory and relational theory . . . as complementary, not contradictory” (p. 909). By substituting complementary for my term—supplementary—as well as by introducing the term unity (suggesting that I am attempting “to create unity” [p. 909]), Stern preserves a binary structure freed from nuances. Perhaps such distortions arise from his idea that my model is of a unitary mind; consequently, he sees an inevitable (and apparently irreconcilable) clash with his interpersonal/relational view.

Stern might be surprised to learn that, influenced by the thinking of early psychoanalytic dissociationists (to coin a term)—including Paul Federn and others who wrote in the language of ego states—I basically agree with him in viewing the self as “a dynamic amalgam of states of mind” (p. 912). Unfortunately, he persists in locating me on the problematic side of the polemic (where the mind is considered unitary). Perhaps readers will be best served by my clarifying that I view the phenomenological experience of the self as built upon the “illusion” of unity—as both Bromberg and the Buddhist tradition believe.

Further, as suggested by my epigraph regarding “multitudes” and based on my long-standing clinical observations of dissociated self or ego states, I do not view unity as an apt construction for either the mind or the self. Rather, as illustrated with Ms. A., I advocate technique that addresses dissociative multiplicity in which sequestering states of mind are at play.

Representation and Language

To better understand how Stern and I both diverge and overlap, it is important to say again that both representation and dissociation (as well as trauma) occur in gradients, and that symbolization doesn’t necessarily follow in verbal form. Consequently, as many contemporary analysts propose, it is useful to distinguish perception, affect, presentation, representation, figurability, and symbolization in linguistic form. Moreover, more extreme dissociative experience tends to remain weakly symbolized—or, particularly when relegated to the body, it may persist as unformulated in language-based form, and therefore unrepresented in the symbolic register.

Though Stern does not address my clinical example, in which I illustrate the patient’s movement from concrete, somaticized experience to language-based representation, I make it clear that even when not formulated in symbolic mode, some weaker, nonlinguistically structured representations may remain present. Further, and most important, these weaker representations can become accessible in analysis. This often occurs in the patient’s “traumatic” or retraumatizing regression within an emotionally intense, embodied transference-countertransference. With Ms. A., it is evident that the embodied and overwhelmingly terrifying affective experience, yet to be linguistically represented, came alive, was sufficiently contained, and was eventually transformed in an emotionally engrossing relationship, both in its nonverbal forms and through the analyst’s words. I suspect that Stern (2019) would describe this as the formulation of experience through nonverbal realization and verbal articulation.

Trauma and Activity

To clarify where Stern and I diverge on the unconscious activity accompanying trauma—namely, the I doing the secondary dissociating—I will restate, as I discussed in responding to Purcell, that trauma reflects a disruptive, brutal encounter between external reality and an unconscious fantasy that is rarely accessible to language at the time. I maintain that in trauma, consistent with Winnicott’s (1960) idea, there is always a nascent I or true self (in Stern’s and Bromberg’s view, selves) that, despite initially being unrepresentable in linguistic/symbolic form, eventually achieves representation in language within the regressive transference when it “becomes related to secondary processes . . . in the patient’s own way” (p. 585). This was evident with Ms. A.

Dissociation, Conflict, and Defense

In contrast to Stern’s theory, my clinical observations indicate that repression and secondary dissociation, rather than being alternative defenses, usually work together by intermingling and interpenetrating. Both tend to be experienced passively, and both happen “automatically.” Again, repression—along with other defenses—reflects not only symbolized, verbal experiences. Accordingly, Stern rightfully challenges my explication of splitting; in an effort to distinguish it from secondary dissociation, I may have overstated the case by saying that “splitting operates primarily on what has already been formulated linguistically” (p. 849).

More crucially, however, Stern has difficulty distinguishing primary dissociation from secondary dissociation, which tends to occur in the analytic setting—seemingly because the latter is triggered by unconscious experiences of internal conflict while nonetheless reflecting segregated self states. Though Stern fully understands the operation of segregated, sequestered self states (with their unique dynamics and object relations), he doesn’t acknowledge the intermingling within and across such segregated units in which repression and dissociation may occur simultaneously. For instance, one part (termed an alter in a Dissociative Identity Disorder patient) that is repressed may often remain more traditionally accessible, while another part persists in (secondarily) dissociated form. It bears repeating, then, that the analyst’s challenge is to determine what sort of mind is being dealt with at any point—and as illustrated by the analyst’s determined search to find Ms. A.’s accessible mind (or self state), it is often by means of affirmatively naming the secondarily dissociative processes in the transference that the accompanying (and intermingled) repressed conflicts, internal object relations, bodily experience, and accessible, preconscious fantasies can be brought to light.

As I hope to have made clearer, then, therapeutic action partly resides in an experience of being understood rather than a “rational understanding” of unconscious material, and so this experience of being understood serves as a relational container (what Stern would consider a shift in the interpersonal field [p. 917]) that promotes mutative change.