Abstract
I want to commend Michael J. Diamond’s effort in JAPA 68/5 (“Return of the Repressed: Revisiting Dissociation and the Psychoanalysis of the Traumatized Mind’) to integrate (or encompass) a range of psychoanalytic theories and clinical interventions. As Diamond points out, the responses of the commentators, despite their insight and erudition, are concerning, given the vehemence of their critiques and the suggestion that there is a “right” model and clinical approach for most patients. The responses highlight long-standing schismatic tendencies of various psychoanalytic schools, to the detriment of a treatment that requires further development of its research and scientific base. For those new to the field, these papers could suggest we are in a muddle, with no clear way to determine which of several disparate approaches are most appropriate in a given clinical circumstance. I maintain that an integrated model is more theoretically and clinically sound and enables a more constructive engagement in dialogue among practitioners of different schools.
I have put forward models that attempt to integrate dissociated, unrepresented states and intrapsychic conflict, and have discussed relevant clinical approaches that overlap with those presented by Diamond (Busch 2017). I emphasize, as Diamond and others suggest, that individuals operate on multiple levels and self-states (“a dynamic amalgam of states of mind” [Diamond, p. 912]). Thus, their cognitions, affects, symptoms, and behaviors are simultaneously influenced by unrepresented and dissociative states, as well as by conflict and repression. Some of these states of mind are symbolized and readily accessible to consciousness, whereas others are more dissociated or sequestered. For example, patients with panic disorder can experience self-states in which they are highly aware of angry feelings and fantasies, and others, often related to traumatic developmental experiences, in which they lack any awareness of anger, a lack that contributes to panic symptoms. Access to painful states associated with trauma can be limited by dissociation, repression, and a lack of symbolic representation. Each of these mechanisms can contribute to how symptoms are expressed, and addressing these various factors can aid in identifying, symbolizing, and integrating traumatic states.
For example, a stressor that is traumatic or links with painful or traumatic experience in the past frequently triggers affective and/or bodily arousal. In one pathway (designated Level 1), this arousal can be experienced by the individual as a state of distress or somatic symptom that has no psychological meaning, due to a lack of symbolization. In other instances (Level 2), an affect or somatic state is identified as emotionally meaningful but is dissociated from a triggering stressor or traumatic event; the individual experiences symptoms but does not recognize a meaningful context. In a third pathway (Level 3), the stressor triggers affects and fantasies that create intrapsychic conflict and symptoms. The relevant traumatic experience and conflicted fantasies are repressed and therefore unidentified. These pathways also interact: Unsymbolized affective and somatic states disrupt the capacity to modulate intense emotions, fueling fantasies that heighten intrapsychic conflict. Intrapsychic conflict can trigger defenses that interfere with representational capacities or coopt unsymbolized states. Another defense involves a delinkage between affective/somatic states and precipitating stresses or fantasies, consistent with Diamond’s concept of “secondary dissociation.”
In terms of technique, Diamond and I emphasize that an awareness of both contributory dissociative and unrepresented states and those involving conflict and repression can aid analysts in identifying how the patient’s difficulties manifest on multiple levels. Diamond and the various commentators agree that dissociative and unrepresented states are more likely to be triggered by trauma; enactments are emphasized as a means of accessing these states. Information from the body is also needed to give somatic experiences meaning, and to ameliorate dissociation from the body, as emphasized by Riccardo Lombardi in his commentary on Diamond (2020). Additionally, linking various elements aids in the integration of dissociated states. Interpretation can be used to address defenses and bring relevant intrapsychic fantasies and conflicts into awareness. In a particular clinical circumstance there are more and less relevant or accurate areas of focus, but these may vary even within a single session. If one technique seems to be ineffective, the therapist can switch approaches. As Bjørn Killingmo (1989) has noted, the patient may be knocking on a door on the first floor, but the therapist is answering on the second floor. These approaches help avoid too strong a focus on a specific theory or technique, such as Lombardi’s insistence that Diamond’s patient’s comments are primarily about dissociation from the body, even when the clinical evidence for this appears weak.
With these various approaches in mind, the therapist addresses enactments as they emerge over the course of the session and affirms, links, or interprets, all the while assessing the analysand’s response to these interventions. In his clinical example, Diamond confronts a crisis in the form of the patient’s dissociative state. He attempts a series of interventions, speaking to different levels, addressing the enactment, and interpreting. Some aspects of his approach aid the patient in emerging from a toxic level of regression to being able to recognize elements of her painful traumatic experiences in her paranoid transference to the analyst. We are unable to clearly identify what helped the patient emerge from her distress and make the unthinkable thinkable, but we can hypothesize that reaching out to the patient on several levels allowed the analyst to reconnect with her in a positive, facilitating manner. We need further clinical experience and research to determine what works best in given clinical circumstances, but retreating to our various theoretical and clinical silos will make this process more difficult.