Dissociation Then and Now
by Pat Ogden
(This article was first published in the Newsletter for the International Society for the Study of Trauma and Dissociation, 2011, revised 2015)
Trauma-related disorders have long been characterized by dissociation--a vacillation between intrusive reliving of past trauma and numb avoidance of traumatic reminders. But in the early 1970s at the short-term inpatient psychiatric hospital where I worked, no one talked about dissociation. The diagnosis of PTSD was not yet included in the DSM. In retrospect, it is obvious that many hospitalized patients experienced internal parts of themselves that were full of terror, rage and suspicion, often frightening to the staff and other patients. Doctors’ instructed the staff to point out “inappropriate” behavior, request that the patient only use “appropriate” behavior, and revoke privileges like receiving visitors or going on outings if the patient did not comply. Non-compliance was grounds to lock a patient in a padded isolation room administer heavy anti psychotic medication, often forcefully, that had severe side effects. Sometimes behavior was demanded that seemed traumatic in and of itself: for example, one patient who for periods of time could not speak was forced to scrub the floor with a toothbrush until she talked. Doctors and nurses were baffled and frustrated at the ineffectiveness of these interventions, and no one seemed to understand why patients got better or worse.
Steve was admitted at dusk one evening, screaming a frantic warning that the Vietcong were about to attack. In his early 20s, he was a short, muscular blond-headed boy/man with wide blue eyes haunted by what he had seen in foreign jungles. I watched helplessly night after night as his reality slowly shifted from the safety of talking with me about his hopes for the future to apparently reliving the war. One of the first signs was a desperate look in his eyes as they clung to mine, seeming to seek safety in our contact. His body became increasingly tense and agitated and his shoulders more and more hunched. It seemed like his physical movements contradicted each other: he was leaning towards me, eyes desperately seeking mine, while his arms and shoulders tightened, and he fidgeted in his chair. Despite my best attempts to keep him engaged with me, his eyes gradually lost contact with mine, and instead darted around the room searching for the enemy. Talking with him about current safety or appropriate behavior did nothing to quell his panic and only and left him without an ally to accompany him into his terrifying world. Steve spent many an evening in the isolation room. Watching him through the small glass window, alone in the corner, cowering and shaking, had me in tears. I felt somehow that I had failed him and I questioned whether the field of psychology was a good fit for me.
I was fortunate to work along side a Korean nurse who saw things very differently from the rest of the staff and who had the courage to surreptitiously go against doctors’ orders in minor ways when she thought she could help. On patient, Ellen, who professed loudly to anyone who would listen that she was a queen, refused to eat. Doctors finally ordered intravenous feeding. The night before the feedings were to begin, This nurse told me she thought she could get Ellen to eat. I was doubtful; we had been trying for three days. However, she went to Ellen’s room, bowed, and said, “Oh, Queen, I’ve come to fix your dinner. What would you like?” Doctors and nurses were mystified that after all their failed attempts, Ellen suddenly began eating. The feedings never happened.
The next evening, I found Steve quaking in fright, hiding behind his bed. As I entered his room, he yelled, “Get down! You’re going to get killed! They’re everywhere!” Looking up and down the hall to make sure no staff member could witness what I was about to do, I closed the door and dove behind the bed to join him. He pushed me closer to the floor for safety from the imaginary attackers, and after a few minutes his terror subsided. “I think they’re gone,” he said. “Great,” I replied, relieved that Steve didn’t have to go to the isolation room, and also that I had avoided being discovered by someone who might report my own “inappropriate” behavior of joining Steve. His body morphed back into his daytime self—still guarded, but much calmer and more at ease. The terror was gone from his face, his shoulders let down, the tension in his arms relaxed, and he could see what was actually in his room. His eyes were no longer desperate as they met mine, nor was he pulling away or becoming tense. His body appeared more integrated overall. For the rest of the evening, his behavior was “appropriate.” Doctors and nurses wondered aloud what has caused this change.
Years later, as I learned about dissociative disorders, I began to try to help patients use the movement and gestures of their bodies to both prevent reliving and integrate various parts. Julie presented with a mixture of symptoms: terror, panic, and hyper-alertness that alternated with feelings of shame and shutting down. She often experienced time loss and distortions, and said she sometimes felt so dead that she wanted people to hit her so that she could “come back.” She reported feeling “flat” and “just going through the motions” when she wasn’t terrified.
During one of our early sessions, as she described a bit of her history, Julie’s eyes locked onto mine as if her life depended on our maintaining eye contact, much as Steve’s had so many years before. But this time, my response was different: I asked her to put the images and content of her history aside for the moment and only be aware of what happened inside her as we maintained eye contact. She reported feeling safer and able to take a deeper breath. I explained to her that eye contact between us could be a relational “resource,” something we could use consciously to help her to stay engaged with me and feel safer.
Different parts will typically experience different reactions to a given intervention, as well as different transferences to the therapist. An intervention or resource that is helpful for one internal part may not be helpful for another. Julie’s eyes locking on to mine represented an internal part seeking protection, but I suspected that another part became frightened by connection and proximity and also needed attention. I tried to track Julie’s responses to my physical proximity in the initial stages of treatment to assess whether there were signals that different internal parts had different reactions to proximity. I noticed that, when our eyes met, her body pulled back, when I took a step towards her, she consistently took a little step back, and when I leaned forward in my chair, she moved back in hers. She also frequently glanced to the door. Her physical movements and gestures seemed contradictory—she sought contact with her eyes, accompanied by a movement forward of her head, but the rest of her body seemed to pull back. I thought perhaps that one part wanted connection, but another part of her was alarmed by eye contact and proximity and perhaps wanted to escape. Her conflicting movement seemed to represent the simultaneous arousal of both attachment (seeking contact and proximity, probably associated with survival for Julie) and defense (flight) against perceived danger.
In Sensorimotor Psychotherapy, integration of parts of the self includes repeated experiences of well-executed, purposeful and congruent actions in the context of an attuned therapeutic relationship. thIntegration is fostered when present moment connections – cognitive, emotional, and somatic – are made and experienced among dissociative parts. I wanted to foster integration of Julie’s posture and movement because I believe integrated, congruent, and purposeful action both reflects and supports integration of dissociative parts.
When I brought her attention to her body pulling away, Julie said it did not mean anything, and it was “fine” with her to be in eye contact and in close proximity. I was doubtful if all parts agreed, judging by the contradictory physical movements---perhaps she was speaking from yet another part of herself who tried to override feelings of threat in order to engage in normal life activities such as talking with me. I wondered how we might address all three of these parts without alienating or excluding any of them-- the part of her that wanted to flee, the one who needed to cling, and the one who said she was “fine” in an apparent attempt to simply participate in life without the interference of the other more dysregulated parts. I suggested that we explore what might be an optimal distance between us and notice how her body responded.
As I asked Julie to sense what was the “right” distance between us, she again said that where I sat was “fine.” But since this seemed to be the perspective of only one part, I continued to wonder out loud which position felt better. I first moved my chair away and then moved it closer, asking her if she noticed any difference in her reactions. Julie recognized that she felt better when I moved away, and her body relaxed, but her eyes seemed more desperate and clinging. We had met the goals of the part of her that was frightened of proximity, but another part desperately needed me as a safe haven. Eventually Julie recognized that the desperate eye contact and the reaching forward of her head and neck were actions of apart that felt that I had “left her” alone when I moved my chair away from her.
We decided to explore eye contact at the distance at which Julie’s body stopped pulling back. I asked her to notice if she thought I was leaving her energetically or not. She reported that she could see I was not, and I wondered aloud if the fearful part could also recognize that I was not abandoning her. Eventually, the fearful, clinging part of her could sense I was still with her. Her eyes lost some of their fear for the time being and her head and neck rested on her shoulders instead of reaching forward. As we attended to the goals and needs of the various parts, her body as well became more aligned.
But over and over again in the course of treatment, Julie and I were faced with the complicated, difficult and sometimes discouraging task of trying to attend simultaneously to the goals of all Julie’s different parts, which we learned to recognize in the contradictory movements and postures of her body. Gradually, Julie learned somatic skills to foster integration, such as recognizing when two parts were in conflict, and then finding a physical posture or action that integrated both parts.
I have often thought that if I had understood dissociation and how Steve’s eyes and body heralded the terrified part of him slowly emerging, perhaps I could have helped him identify this part without reliving the terror so fully. Perhaps I could have targeted un-integrated physical actions that reflect the division of the self into dissociative parts (e.g., simultaneously or sequentially seeking both proximity and distance by reaching out for contact with the arms, head or eyes as the body pulls away) in order to teach skills that help prevent switching, and promote awareness of and communication between dissociative parts. Perhaps Steve could have been spared the added suffering of the isolation room, and could have experienced understanding and integration rather than punishment. I regret that we did not know enough in the 1970s to better help patients like Steve, and hope that those who are suffering today will benefit from what we have learned over the last 40 years.