Psychotherapy as the Art of Uncertainty

Preface

This article, by Philip M. Bromberg, is a gem published posthumously as part of this special edition. The origins are worth noting. A student from the Eating Disorders, Compulsions, and Addictions Service (EDCAS) program at the William Alanson White Institute asked me to invite Philip to consider giving a keynote address at the School of Visual Arts (SVA) in New York City. His first response was—as now you may understand—a typical Bromberg response: It went (something like…. rather…. exactly like this,) “No, No, No!…what could I possibly say to students, nonetheless art therapists?” I encouraged him to speak with the EDCAS student, Valerie Sereno, LCAT, and faculty member in the graduate art therapy department at the School of Visual Arts, who was able to deftly convince him. Valerie also provided us the photo with Philip in front of SVA, to which he said—with a big grin—he never thought he’d see his name on a theater marquee. He was truly delighted.

What you see below, was originally presented on September 12, 2014, as the keynote address for SVA’s annual conference of the MPS (Master of Professional Studies) Art Therapy Department. Philip gave a copy to Velleda Ceccoli (this issue), as they shared interest in the crossover of psychoanalysis and art. It feels right to publish it now. The paper is deliberately left in its spoken form (with the addition of footnotes and references), to ensure a felt experience of Philip as you read it. This includes his use of CAPS and italicized words, etc. Many of you would agree, I’m sure, that Philip simply would have had it no other way. Jean Petrucelli, Ph.D.

Thank you, Val, for your generous and warm introduction. When I hear myself described that way, I'm never sure it’s ME, so—just to be on the safe side—I want you to know that HE thanks YOU, too. And the thanks are as much for the magical way you shepherded me through the traditional details and transformed the necessary piece of preliminary “work” into a conversation between friends that became my first introduction to the pleasure I'm feeling right now in being with you all.

In that same spirit, I want to express my deep gratitude to the MPS Art Therapy Department, and the School of Visual Arts for honoring me with this invitation. There is no greater satisfaction than to speak with colleagues whose family of origin differs from mine, but whose sensibility is shared. It’s a cherished opportunity to think TOGETHER about what we each hold most personally valuable, and seeing whether what I call the “negotiation of otherness” expands the joy in being ourselves, by including “other” within it.

When I titled this talk “Psychotherapy as the Art of Uncertainty,” it was because I wanted an EXPERIENTIAL title, and this comes as close as I can get to how I actually experience psychotherapy. I also must confess to another reason I chose the title. I had agreed to submit a title immediately, knowing that it would be months later before I would be able to think about what I wanted to write, so I needed a title that would be not only meaningful to me, but would also sound ambiguous enough to let me go in any direction I chose. This confession may not seem important, but my need to have that much freedom while writing does get me right into the topic of “uncertainty.”

Because of the way I write, a predetermined topic has no linear relationship to what I end up with, which is why I rarely choose a title in advance. For me, a title that clearly defines the topic in advance of the writing is not likely to survive the kind of interpersonal writing process that always takes place between a paper and me once we start to relate to each other. Yes! I do mean that I'm ASKING THE PAPER WHAT IT THINKS I AM WRITING ABOUT! I know that this might feel like an odd concept since—conceptually—I am its creator, but I doubt it will feel experientially unfamiliar to an artist or to an art therapist.

Writing (and in my view, all art) is an interpersonal process between self and other and this paper would be deprived of its input into the title selection, because it had no opportunity to show me—from its own evolving viewpoint—what possible titles feel most alive as we go along. OKAY—you now know my overarching perspective—that a negotiated relational process such as the one I've just described, in whatever domain it takes place, is what most creatively shapes talent into ART. Henry James said the same thing more visually and more movingly. It not only makes him an artist from whom I continue to learn, but why I chose as my subtitle, these lines from his 1893 short story The Middle Years, a piece based on a personal memoir he had “jotted down”¹:

“We work in the dark—we do what we can—we give what we have. Our doubt is our passion and our passion is our task. The rest is the madness of art.” (p. 620)

For Henry James, as well as for me, “the madness of art” speaks to a shared madness that allows safety in the uncertainty of where one’s own self ends, and a different self begins. Those of you who are familiar with my work know that the word “madness” is a complex choice that covers a lot of ground. To immerse oneself in the self/otherness of art, whether its domain is writing, painting, sculpture, or psychotherapy, can indeed be psychologically destabilizing, but the phrase “madness of ART” also describes a never-ending awe of the creative power in a madness that is not true madness but madness of participating in PARADOX.

I described the paradox years ago when I wrote that “Health is the ability to stand in the spaces between realities without losing any of them. It is what self-acceptance means and what creativity is all about—the capacity to feel like oneself while being many” (Bromberg, 1996, p. 186). The longer I do this work, the greater is my awe. It is no longer just a concept. As a therapist, I increasingly live it as a shared event with my patients—the recognition that unitary selfhood is real, but also a necessary illusion that protects us from the potentially destabilizing awareness that even while we are always staying the same, we are always changing—a shifting panorama of self-state configurations—some of which are available to the experience of conflict and some because they exist as “not-me” can only be enacted.

I am saying that because otherness is an intrinsic component of selfhood, “not-me” self-states continue to demand a VOICE even though the voice is unspeakable within the verbal self/other context the therapist offers, which is what makes psychotherapy an art that is filled with the madness of uncertainty. I could have chosen as my title, “Psychotherapy as the Art of Negotiating Otherness,” but even though I didn’t choose it, I hope that I will make it clear that when I speak of The Art of Uncertainty, I am speaking of “art” as a process in which the “other” is not an “object” of art—but an active co-participant in its creation.

I am not an artist, but many years ago I did a clever thing. I married one. Although my analytic sensibility had been bridging art and psychoanalysis unromantically before we met, the inauguration of the bridge was the publication of my paper titled “Artist and Analyst” (Bromberg, 1991) which, several years later, became a chapter in the book Standing in the Spaces (1998). I know that some of you may have read it, but I want to share a few paragraphs of it with you because its theme is especially relevant to everything I will be saying today.

I began by conceptually describing my experience of uncertainty, and the non-rational mystery of what was taking place as my wife painted. During this talk I will be quoting passages from several of my published papers and book chapters, and I want you to know in advance that in some places I have changed a few words and phrases, or added a sentence that makes what I wrote then closer to how I would say it now. In the interest of time and internal coherence, this talk will not reference the changes.

The thought that invariably crosses my mind is how she ever came to be able to do this thing which to me seems beyond comprehension, even though I'm watching it occur and can see the technical process going on in front of my eyes. I know her art background; I know with whom she studied, in which countries she was trained, what painters most influenced her, and even many of the basic principles that guide her, but the sum total of this knowledge, except at some superficial level, does not account for what emerges as she works, either in the moment-to-moment process or at any phase or stage along the way. (1991, p. 289)

As I moved away from my inner world of ideas and the need to “understand,” I moved closer to being with her in the here-and-now and wrote some notes to myself as to what I perceived as I watched my wife. What I PERCEIVED as I watched my wife, was that she was participating in an interactive process through which her vision of what she wanted to create and how it was to be created, changed as it was expressed TO the painting. Little by little, I became aware that every painting she undertook possessed an evolving IDENTITY of its own as it was being painted and, through this evolving identity, it was informing her as to how it did and did not wish to be painted. I could perceive its identity evolving through an interaction in which her participation as a painter was being informed not only by the talent she brought with her to the painting, but by her openness to the interpersonal learning process that shaped the evolving use of her talent during the act of making art, and her personal evolution in being an artist.

I've now gotten one step closer to the main point that brings me here today—that every creative activity, including psychotherapy, is mediated by an interpersonal learning process that evolves perceptually for both partners. If one partner shuts down, both partners will shut down, and the relationship will more than likely lose its personal aliveness and will shift to concepts and away from perception. For a writer, there is nothing more painful than what is called “writer’s block”—the desperate search for the “right words” that will hopefully free the relationship and turn empty language into felt creativity. I'm intentionally nudging us closer and closer to the subject of PERCEPTION, because here lies what I feel may be the most important and least examined source of our commonality as therapists, and a foundational reason that those of you who have read my writing chose me as your speaker.

I LOVE being a therapist, and something makes me feel that this is true of most art therapists. It is by no means something I feel about therapists in general. I want to explore the role of visual perception as a way of being with patients, and how certain choices we make (such as for you, using art—and for me, working with enactments) are made, because they empower a perceptual context as our most fundamental way of being a therapist—a way that makes our “work” come alive because we love being who we are while being therapists. So, how does visual perception make the time we spend with our patients come to mean so much to us personally? Yeah, we all have answers that we more or less settle for, but I'm proposing one that is worth thinking about in addition to the others. I ask: What is the thing about visual perception that makes a creative relationship between artist and painting so inescapably personal, and makes a creative relationship between patient and therapist equally inescapable as personal?

Visual Art is PERCEPTUAL. So too is Psychoanalysis. It is only derivatively about speaking and words. In postclassical psychoanalysis, analysts who are most free to engage in active participations are fostering MUTUALITY of activity because mutual participation is perceptual. Psychoanalysis is most robustly and enduringly psychotherapeutic when it is perceptual. The patient/therapist relationship becomes an ACTIVITY that shapes an ongoing and evolving dialectic between SEEING AND BEING SEEN, rather than an ideational process of one person being seen “INTO” by another. Over the course of many years, psychoanalytic clinicians have found out the hard way, that when you try to see INTO someone, what you get back is one or another of your patient’s SELF-NARRATIVES. A person’s collection of self-narratives is what they use to STAY THE SAME. Self-narrative is what gives everyone something solid to hold onto while their self-states are shifting. It is also what prevents psychoanalysis from being a “talking cure,” as Breuer hopefully called it in his treatment of Anna O. But if it isn’t a talking cure, why NOT, and IF not, what IS it?

What I want to do now, is cobble together some ruminations and see if I end up with a decent argument that perception is what makes the interpersonal/relational field personal, and is thereby the source of its power to be therapeutic.

Let’s go back to self-narratives. EVERYONE has their individual set of personal narratives that one tells oneself over and over in order to believe they know who they REALLY are, no matter which self-state they are inhabiting. I am not talking about the concept of “unconscious fantasy.” Personal narratives, although never completely conscious as a coherent story, are not fantasy. They are found in the ongoing INTERNAL dialogue that everyone lives all the time. We are always talking to ourselves. What we don’t realize is that we are always talking to ourselves the same way. My favorite description of this was written by Carlos Castenada (1971):

Whenever we finish talking to ourselves the world is always as it should be. We renew it, we kindle it with life, we uphold it with our internal talk. Not only that, but we also choose our paths as we talk to ourselves. Thus, we repeat the same choices over and over until the day we die, because we keep on repeating the same internal talk over and over until the day we die. (p. 218)

We are complacently caught in our particular view of the world, which compels us to feel and act as if we know everything about the world. Personal narrative cannot be edited simply by more accurate VERBAL INPUT. This is especially frustrating to therapists. Psychotherapy, most simply put, must provide an experience that is perceivably (not just conceptually) different from the patient’s pre-established self-narratives. A successful therapeutic process is one that bridges the space between a patient’s fixed set of narratives about who they “REALLY” are, and the experience of oneself while the self-narrative is being PERCEPTUALLY altered in the here-and-now of the analytic relationship.

It is in this way that effective psychotherapy breaks down the old narrative frame (the patient’s “truths”) by evoking, through a process of self/other negotiation, perceptual experience that doesn’t quite fit it. In this last sentence I may have given my answer to the two questions I just posed about psychoanalysis—If it isn’t a talking cure, why NOT, and IF not, what IS it? On the other hand, since I hate to be pinned down to something I sound certain about, I'll probably have other answers as I look at it from other angles.

But looking at it from this angle, one of the most persuasive and intriguing lines of thinking is the work of Peter Fonagy (see Fonagy & Target, 1996; also Fonagy, 2001), which speaks to what he calls the essential difference between developmental and conflictual psychopathology in the organization of self as it influences the success of what takes place in therapy. He distinguishes between “two aspects of the self”—one that is structural (non-interpretable) and one that is dynamic (interpretable). He then goes on to beautifully describe why the aspect of self that is organized by developmental pathology needs to be related to in a special way in order to enhance the usability of psychodynamic interpretations, and what that entails. To do this as a therapist, he says, requires not simply the accurate mirroring of a patient’s mental states but that the therapist must offer a different, yet experientially appropriate, RE-representation that reflects the therapist’s subjectivity as well as the patient’s. In other words, the analyst must show their representation of the patient’s representation, and to do this the analyst must be themself while being a usable object. In Fonagy’s (see Fonagy & Target, 1996) words, “A transactional relationship exists between the child’s own mental experience of himself and that of his object” (p. 460). Further, in a 1999 paper presented at the American Psychoanalytic Association Meeting, Fonagy elaborated this point: “Unconsciously and pervasively, the caregiver ascribes a mental state to the child with her behavior. This is gradually internalized by the child and lays the foundations of a core sense of mental selfhood.”

The role of the analyst, then, is to enhance a patient’s ability to symbolize not only their emotional experience of events, but also their capacity to symbolize the experience of one’s own mental states—A REPRESENTATION OF A MENTAL REPRESENTATION. This is the underpinning of the so-called “observing ego” that analysts rely upon for interpretations to be a viable mode of communication with a given patient, and whether working with children or with adults, “the greater the unevenness in development,” Fonagy and Moran (1991) write, “the less effective will be a technique which relies solely upon interpretations of conflict, and the greater will be the need to devise strategies of analytic intervention aimed to support and strengthen the … CAPACITY to tolerate conflict” (p. 16).

So! Fonagy et al. are arguing that the analyst must show their own subjectivity as part of the relationship and must be themselves while being a usable object. To put it more directly, the analyst must participate in a way that they are SEEN and seen personally. I, too, cannot overestimate the importance of the analyst being SEEN as an inherent part of the process, and I have been making this point for over twenty years, starting with a paper titled “Speak! That I May See You” (1994)—a line that has been attributed to Socrates. When my final draft of that paper was finished and I was about to send it off, I knew the paper wasn’t happy with the title but that I liked it enough to keep it. So—since I wasn’t about to mess around with Socrates, I negotiated with him. What I did was add a final line at the end, in which I asked him if he would mind my wishing he had said, 'Speak! That We May See Both of Us.'

By doing that, I was underscoring my conviction that when perception is what organizes our way of relating, our patients are freed (though not necessarily yet “free”) to actively do unto us, with equivalent perceptiveness, what we are doing unto them. They are freed to actively engage us as a center of our own subjectivity rather than dissociatively hearing our WORDS without seeing the person who speaks them. Psychotherapy is a process in which cognitive representation comes after personal meaning. The initial existence of personal meaning is not birthed by the “right words,” but by a two-way perceptual context that the words later come to represent.

As therapists, the more closely we examine the essence of what perception IS, the easier it is to see why it is so unique. It begins at the brain level as sensory input, but sensory input is not perception. It is when sensory input to the brain becomes PERSONAL EXPERIENCE TO THE MIND, that the SELF becomes involved. Perceptual experience exists because of what the person’s subjectivity makes out of sensory experience. Registration on the senses does not provide meaning. But when the neurological impact at the brain level is experientially shaped by interaction with the individuality of a given person’s subjective experience, what Jerome Bruner (1993) calls “an act of meaning” takes place. PERCEPTION occurs when the brain’s sensory neurology engages with the mind’s subjectivity. To say this in one line: What makes perception SO special is that it facilitates the increasing development of self-otherness. It is because of perception that what we spend our professional lives doing is PERSONAL. It makes the RELATIONSHIP personal, and I am persuaded, is why we LOVE what we do.

Your use of art allows a self without words to symbolize perceptually what only exists as internal experience, without self-agency through which it can be interactively communicated to an “other” as something personal. Bruner (1993), in his extraordinary book, ACTS OF MEANING, puts this point right out there:

The child’s acquisition of language requires far more assistance from and interaction with caregivers than Chomsky (and many others) had suspected. Language is acquired not in the role of spectator but through use. Being “exposed” to a flow of language is not nearly so important as using it in the midst of “doing.” (p. 70)

Bruner then goes on to say something that I believe accounts for ATTACHMENT RELATED TRAUMA, and what makes it especially impossible to communicate the experience of it in words. As you listen to Bruner, keep in mind that during the period of early attachment, the formation of a CORE sense of self is trying to come into being through PROCEDURAL interaction patterns prior to the acquisition of language. Bruner (Ibid) writes:

It is only after some language has been acquired in the formal sense, that one can acquire further language as a “bystander.” Its initial mastery can come only from participation in language as an instrument of communication. (p. 73)

The hallmark of the early attachment period is that there IS no participation in language as an instrument of communication, which means that, by necessity, the initial mastery has to start a bit later. Normally it will, but not always. For some children, the transition from Attachment Reality to verbal self/other negotiation as the first representational expression of who you ARE (not just what you feel or need) can be the beginning of a nightmare, rather than the beginning of a sense of individuality and self-agency. The child needs help in making that transition. But if the attachment period was too infused with the “trauma of non-recognition,” it is already too late. The struggle over “who I am” (and for some, IF I am) is more likely to be negotiated with a therapist—and is no picnic, art or no art.

Trauma is not intense anxiety. Anxiety is something you HAVE. Trauma has YOU. Trauma is a flooding of dysregulated affective experience that, because it cannot be cognitively processed, destabilizes a person’s perceptual experience of one’s personal existence, and creates an escalating dread of depersonalization that must be stopped at any cost. The brain then takes over. To avoid the escalation of what is an indescribable threat to survival, the normally fluid dissociative gaps between self-states are hypnoidally rigidified, making self-reflection—and, in turn, intrapsychic conflict—impossible, not just difficult.

Each self-state now defines not simply a point of view of its own, but a narrative truth of its own that is protected by a dissociative structure whose function is to keep the self-states as unbridgeable islands so that each state can unconflictedly perform its own task by using only its own truth. Part of our work as therapists—sometimes our sole focus during the initial part of treatment—is participating in the restoration of fluidity between the dissociated self-state gaps—what I call, the ability to Stand in the Spaces.

Now feels a natural place for me to get into the topic of attachment trauma more deeply. I want to make it as clear as possible WHY the potential for “standing in the spaces” is much, much more difficult, both in life and in psychotherapy, for patients who have suffered it than for patients whose developmental trauma began later. Let’s start with a look at what happens that leads to the experience called the trauma of non-recognition.

A parent who tells a child verbally about what is disapproved of can be hurtful, but the experience is rarely TRAUMATIC because it allows the child to “SEE” the parent as well as hear them. But IGNORING specific self-states of the child as though they do not exist can become the most powerful means of organizing those self-states into a “not-me” entity that then has no legitimacy in human relationships. This is the developmental trauma that I call:

The Trauma of Non-Recognition

During early attachment, the mother and child are bonded in a cocoon of oneness that is developmentally normal. The word “symbiosis” is not accurate because there is, no matter how early, a physically organized recognition of separateness. But, psychologically, the mental quality of the child’s ongoing experience of reality is close to what Fonagy and Target (1996), in an article entitled Playing with Reality, call the “psychic equivalence mode” (p. 219).² For example: I am that which by your knowing, YOU are. And I am not that, which by your not knowing, YOU are not. The child has no psychological self-experience that is not organized through being the child of this parent. All psychological trauma is fundamentally physical, but attachment trauma is even more-so. It is more physical, because the non-recognition is communicated as procedurally as the rest of the dyadic attachment pattern. The behavioral pattern—the interactive “procedure” that defines the way parent and child ARE together, IS the child’s reality. The best way to turn your child into what you need this child to be is not by telling them what to do but by showing them who they ARE. In the attachment phase, reality does not achieve representational meaning through the words that may be said by the parent, but—as with any procedural communication—the parents’ verbal utterances most certainly achieve affective meaning by how they are said. In the face of non-recognition of their subjective experience, the child’s reality is destabilized. The pattern of relating that allowed the child to feel recognized by their mother as her child disappears at that moment, and—along with it—the subjective reality of one’s own experience at that moment disappears with it. What takes place is an affective destabilization of personal reality that is not subject to thinking. For some children, the affective dysregulation escalates into what adults call a “tantrum,” but is actually the panic of impending annihilation. When it happens too frequently, the brain will not let it happen again. A chronic dissociative self-state structure becomes the child’s fail-safe survival solution. Because self-reflection is not possible at the time the trauma takes place, the child, and thereafter the “child-as-adult,” sequesters a “not-me” part of self, to experientially contain the annihilating experience for which symbolizable mental representation is not possible. It is like living in a haunted house. Trying to think about any of this just makes it worse. WE don’t know how to make it different by talking about it, and neither do our patients.

Many of our patients have spent their lives tortured by the pain of being ALONE with it—and for you as art therapists, and for me as an interpersonal/relational analyst, their pain is in the AIR we breathe. If it were not, we couldn’t know there was anything there that needed healing. We, LIKE our patients, would go on being all alone, helplessly trying to use words even while knowing they are useless. But we DO know. We know through the relationship itself, and it fuels our desire to continue trying to find an alternative to the falseness of words. Your offer of using ART can make a difference even when not accepted, but if and when it IS accepted, the sequestered part in pain feels less “unreachable.” It takes a step toward being “really real” because the ART that you personally offer your patients begins to “change their minds” as well as change the neural pathways in their brains. And the way it “changes their minds” has many forms, one of which is CHANGING THEIR MINDS ABOUT HUMAN RELATEDNESS.

So, if I look to my TITLE for the answer to what makes psychotherapy therapeutic, I would argue that as long as a therapist can accept uncertainty as a central aspect of everything that transpires, including your use of art and my use of enactments, then that therapist will be most likely to participate as an ALIVE partner. And for that therapist, the “art” of the therapy begins when we first say “Hello.” The perceptual power of the relationship and the perceptual power of the thing we use that we value the most, are synchronous. What makes therapy therapeutic is most far-reaching when the relationship allows singing a duet without words. Then words find their natural place, but most enduringly so, when they become part of the duet.

OKAY. I’m going to shift gears. I've now cobbled together what I hope are enough ideas for me to now get more “GRAPHIC” about the interface of procedural and cognitive reality. I'm going to try and see if I can clinically EVOKE what I've begun to recognize has been my most consistent preoccupation since I first became a therapist, but which I haven’t explicitly addressed in my writing—until now: That the trauma of non-recognition,” when it originates during early attachment, disrupts the organization of core identity SO powerfully that when the interpersonal aspect of the trauma is enacted it can generate certain “not-me” behavior that is more destabilizing to the therapist than that which is experienced with other patients. And that some of this behavior, although unusual, is nonetheless an effort to restore an aborted process of self/other negotiation. Sometimes we tend to not take-in the emotional impact of the strangeness, but the more we can, the less we will dissociate from what is an enacted voice of our patient’s dissociated subjectivity and, simultaneously, an enacted part of the here-and-now relationship itself.

The main material will be from a case of my own, but I'm going to precede it with something that I read about. In both, I'm going to be speaking as an uninvited participant in a world of visual perception that I could not then have imagined—each experience in its own way requiring a somewhat destabilizing encounter with paradox and uncertainty.

About ten years ago in the Sunday New York Times Magazine, there was an article by Chip Brown titled “The Man Who Mistook His Wife for a Deer.” Technically, the article is about a class of sleep disorders called PARASOMNIAS, which are defined as unwanted and involuntary behaviors during sleep. But it’s about more than that; it goes right to what has for many years captured my thinking as a psychoanalyst—self-states and the clinical phenomenon of dissociation. Brown (2003) writes:

Parasomnias are interesting for …what they imply about the scope and nature of the self. They point toward a novel model of the mind that envisions waking, sleeping and dreaming as distinct neurodynamic states that lie along a continuum and are separated by imperfect, sometimes porous boundaries [emphasis added]. States can get ’dissociated’ or mixed together in the way script from one program can hang up in another when you’re shifting between the windows of a buggy computer.

Brown gives several illustrations of parasomnias—patients who were studied in the lab at The Minnesota Regional Sleep Disorders Center. One is the nocturnal behavior of a 19-year-old, known as Cat Boy, from which the following is quoted:

Fifty-three minutes after falling asleep, the teenager gets out of bed and begins crawling on the floor, growling, his hands folded into paws. He seizes a corner of the mattress with his teeth and shakes it. After six and a half minutes, perspiring heavily, he collapses and becomes ‘clinically unresponsive.’ When technicians ask him, he reports that he had been dreaming what he always dreams—he is a large cat following a female zookeeper with a bucket of raw meat. Here’s the strangest thing of all. Parasomnia is not technically a sleep disorder. Throughout the episode, Cat Boy’s EEG reports that his brain is AWAKE [emphasis added].

In fact, the researchers at the Minnesota found that a percentage of their parasomnia cases are nocturnal dissociative disorders and that, in all those cases, the EEG reads AWAKE and the person PERCEIVES an altered state of consciousness as if it were a DREAM. In thinking about how to understand the “Cat Boy,” here’s an additional issue you may wish to consider—the relationship between trauma, dissociation, and dreaming. Listen to what the analyst Charles Rycroft in 1979 wrote about what he called “traumatic dreams.” “Traumatic dreams,” Rycroft said,

…differ from other dreams since the traumatic events they repetitiously reproduce are invasions and intrusions upon the victim’s psychological continuity and are in no sense creations of his own imagination or envisaged consequences of his own actions…. [T]hey are attempts… to assimilate an initially unassimilable experience, to convert an unimaginable event that has nonetheless happened, into a memory [emphasis added]. (pp. 98–99)

And Rycroft isn’t the only analyst to have written something that bridges the gap between traumatic dreams and the altered states of patients with dissociative mental structure. Ira Brenner (1999a; 1999b) commented that “that the mind’s capacity to anthropomorphize altered states of consciousness … may occur during traumatic autohypnotic states [emphasis added]” (p. 347). This seemed clearly the case with a patient of my own who I'm going to talk about next— a man who presented with a childhood history of enuresis, sleepwalking, and night terrors (experiences that are dream-like, except that they continue after you awaken and you can’t easily get them to stop)—three symptoms that, in the context of parasomnias, are attention getters. Why so? Because during the 1970s, Charles Fisher, in his groundbreaking dream research,³ found that those three phenomena—bedwetting, sleepwalking, and night terrors— all take place during Stage IV sleep and that Stage IV sleep is not actually a sleep state, but an altered state of consciousness. The really interesting part, however, is that the EEG associated with stage IV sleep, just like the EEG associated with the parasomnia manifested by the Cat Boy, shows that the brain is in a WAKING state.

I'm going to tell you about a seven-year relationship I had with a man who I saw in analytic treatment many years ago—a man I call Mr. C. Those of you who have read Standing in the Spaces (1998) may remember him as the patient who experienced the Isakower phenomenon while in an analytic session (see also Bromberg, 1984). Although not as dramatic as the behavior of the Cat Boy, what took place in our relationship was transformational in the evolution of how I think about what makes psychoanalysis psychotherapy. I'm going to be saying a great deal more about it as I continue, but I want to enter the topic a bit slowly so as to put it into a richer context. Just to remind anyone who may have forgotten, the Isakower Phenomenon is so named because it was the Austrian analyst Otto Isakower who, in 1938, first reported it. It is what is called an autosymbolic hallucination—a hypnogogic occurrence that occurs in the twilight state of consciousness between sleep and waking. It is characteristically reported or remembered as the visual experience of a soft, doughy, shadowy mass, usually round, that is slowly descending on the person’s face, sometimes threatening to crush them, and sometimes threatening to become a part of the person, obscuring the boundaries between their body and the outside world, blurring one’s sense of self more and more. Often there are feelings of floating or loss of equilibrium. It then gradually becomes smaller and moves farther away.

Certain people experience it passively while others make a determined effort to control it, which is what was found in patients with “Parasomnias” (Cat Boy being one). In other words, among those who attempt to control it, are individuals who are attempting to convert what Rycroft (1979) called “an unimaginable event that has nonetheless happened” (p. 99) into a visual perception of “otherness” that can be RECIPROCALLY engaged. That is to say, the person is not just experiencing the event, but is participating in a SELF-INDUCED (autosymbolic) hallucination that parallels what should be the normal INTERPERSONAL development of self-agency. I find this a fairly good argument that autosymbolic hallucinations and Dreamlike Activity such as the Cat Boy’s can each be usefully explored as self-generated efforts at symbol formation through IMAGES—AN EFFORT TO STRUCTURE AND MASTER EXPERIENCE THAT IS NONLINGUISTIC AND MENTALLY DISORGANIZING IN A WAKING STATE.

Mr. C entered analysis in his late 30 s to try to “cure” what was for him the one thing that felt immediately urgent: sexual dysfunction with a woman he had begun to care for. He was only partly being humorous when he said he wasn’t certain whether his problem was the sexual dysfunction or that he had begun to care for her. Treatment was begun on a three-session-a week basis with Mr. C on the couch (at his own request). Descriptively, he was a verbally gifted unmarried man, unusually tall and—despite an insatiable appetite—was slender to the point of looking undernourished. Thick horn-rimmed eyeglasses he had worn since childhood somewhat masked the tenseness in his face, while giving the impression of his peering down at you through binoculars.

It is almost impossible to describe the trauma of non-recognition during attachment, because words are truly inadequate. But I'm going to try anyway, because being with him enabled me to know it without words. During the period of early attachment, the two most important developmental milestones of that phase were made impossible. The unique and unparalleled pleasure in the normal experience of ONENESS that attachment provides became a threat to sanity. And so too did the normal narcissistic pride a child experiences during their safe transition to authentic individuality When I first met Mr. C, NEITHER self-agency NOR the intoxicating joy of being able to sometimes not care where “my self ends and yours begins,” seemed to exist for him.

As an infant, hungry or not, he had been breast-fed on a rigidly fixed schedule for the first six months of his life simply because it was “time to eat.” In the same way, sleepy or not, he was put to bed on a non-negotiable schedule because it was “time to sleep.” Between ages one and two he was unable to sleep through the night and cried inconsolably. His parents disagreed on how to respond to this behavior, and a pattern emerged in which he was allowed to cry to the point of hysteria (because he must REALLY be sleepy), at which juncture—depending on which parent prevailed—either his mother would carry him around, or his father would come to the side of the crib and shout. If nothing stopped his crying, they would take him into their own bed where, lying between them (and I use the word “lying” in both meanings), he would eventually stop crying and “sort-of” close his eyes, seeming to be (at least to his parents), asleep and contented. He slept in his parents’ bedroom until age six, a situation structured around the same power struggle between the parents as to whether he should be forced to grow up and sleep alone in another room or should be allowed to feel “contented” and be permitted to sleep in their room until he “grew up.”

At the point I entered his life, Mr. C's ongoing mental state each day and every day was that of being endangered by something that couldn’t be avoided and would leave him flooded with shame. “I may step on someone’s feet if I have to go the bathroom while in a theater, so I’d better make sure to sit on the aisle; I may not be able to perform sexually if someone is willing to go to bed with me; I may go into a panic on the subway and might not be able to get out.” The external world and its routine pressures were a preverbal horror that haunted him in dreams, physical symptoms, and affective flooding that appeared in contexts where there was the least verbal and cognitive structuring. Any internal or external experience with the potential to lead to a situation that could not be controlled in a predictably manner was felt as a threat to the stability of his mind, because when affect-REGULATION has not been achieved, then affect-CONTROL becomes the most important priority to assure survival. Something as innocuous as the ticking of a clock, the sound of his own heartbeat, or the falling of raindrops upon him when he did not have an umbrella could be enough to snowball into a state of potentially escalating depersonalization.

At “bedtime,” Mr. C was particularly vulnerable. I am calling it “bedtime” because it was experienced as the time he was supposed to be ready for sleep. Falling asleep, normally a pleasurable transitional state in which waking consciousness is surrendered gradually, was replaced by an elaborate pre-sleep ritual through which he MADE sleep take place. He would eat until he felt bloated and then enter his bed and fixate on the television screen until he was totally exhausted. At other times he would fight sleep with obsessive rumination until he finally succumbed to overwhelming fatigue. The transitional period between his waking state and sleep state was harnessed with the tightest rein possible and was designed as an experience in which looking without seeing would lead to sleeping without falling asleep.

Mr. C was a prolific dreamer and for a long time had FLOODED the analysis—AND ME— with dreams (many of which I'm sure were not dreams, but I hadn’t yet learned enough about night terrors.). Even though I “sort-of” knew” that feeling helpless to deal with more than I could handle was—as an analyst—letting me experience HIS reality in the one way possible, it was still hard for me to take. The deluge-like quality of the dreams had been talked about between us, as had their expressive function, but the words that came out of his mouth and mine always felt colorless and unconvincing. The dreams, in contrast, were colorfully alive to the point of bursting, filled with shimmering meaning and begging to be analyzed. Early in treatment, the way he and I were relating to one another while we were talking ABOUT his dreams became woven into the dreams, he brought in the next session, with no sign that he had registered an interaction going on between us other than in his dutiful appreciation when I would probe for one. During this period, his dreams seemed as much a vehicle through which reality was being constructed as it was a channel through which it was revealed. As I look at this sentence, I can feel how particularly interesting this might be to compare with what happens in Art Therapy.

His earliest dreams in treatment were traumatic, chaotic, and often bizarre, filled with images of his severely damaged sense of self and his terrifying vulnerability to the world as embodied in the strange situation called psychoanalysis. There were dreams of gouged-out eyeballs speeding past his field of vision, calves whose throats had been cut out by the milkmaid who was unaware of what had happened to the calves, and radio programs that suddenly became real, leaving him nowhere to hide. It was as if the dreamer were signaling: “To preserve my sanity and emotional survival, the dangerous organs of seeing, knowing, and speaking shall be torn away”— and, in fact, was what increasingly beginning to take place in our sessions. His dissociative talents began to explicitly shape both his dreams and his mode of relating to me. Dreams of watching movies abounded. Dreams of prisons and concentration camps were frequent, but always created with guards who looked the other way while he briefly escaped. During this period, it was difficult for me to manage my feeling of helplessness in response to his half-awake/half-asleep state of consciousness. When I spoke, my words were taken in by him readily and hungrily, but they entered only his “false mouth”—an invisible anatomical lining within his real mouth, created in one of his dreams—a mouth that was “false” in both what it received and in what it emitted. I felt that his ability to relate to me at all depended on my own ability to have some direct impact that hopefully might increase over time. So, I kept trying, but even when my feelings were hopeful, the hope did not last long, and I did not have a sustained conviction that anything was palpably changing during the first three years. My deepest experience was that the impact of my presence was an ILLUSION I had created to keep from feeling hopelessly helpless. One thing, however, did feel real—even though it was not something I would have put on my wish list. It seemed that, only in my ability to accept my experience of helplessness and communicate it to him, any genuine impact was possible at all. When I was out in the open about my own helplessness I was able to reach something in him that felt genuine—his feelings of helplessness. But for the rest of the time, much of what went on felt therapeutically like “babble,” even though I most often found him personally interesting and even “wise.” So, I talked too much. But I was seldom sure how my words were being processed in the deeper domain of trauma and trust. I always felt as if I were trying to FEED him something that I simply knew would be good for him but which he “somehow” couldn’t take-in no matter how hard he tried. This configuration shaped our relationship for three years: The dreaded need for a maternal figure who “knew” what he needed but was unresponsive to his individuality—not an ungiving maternal figure, but one who disregarded his subjective existence and gave when she NEEDED to give—and would keep doing that FOREVER, if necessary.

The Isakower Session

We were just starting our fourth year of work when, on the couch, Mr. C directly experienced the Isakower phenomenon, which he had reported early in treatment as a childhood memory from ages three to six but which had not been mentioned since. It occurred following his uninvolved discourse on the previous day’s events, after which he then fell silent. He had lately been indulging in long periods of silence with even greater determination than usual, and I had not perceived that anything out of the ordinary was going on during the silence because it appeared to be simply another of his routine retreats into reverie. IN REALITY, HIS MENTAL STATE HAD CHANGED WHILE HE WAS LYING SILENTLY, AND HE HAD LET HIMSELF DRIFT INTO THE TWILIGHT STATE OF CONSCIOUSNESS THAT PRECEDES SLEEP.

It was at this point, he later confided, that he purposefully evoked the Isakower phenomenon and continued to remain silently in this hypnogogic state, eyes almost completely closed as he actively engaged it. After what he later estimated to be three minutes of this experience, he brought himself out of it and told me about it. His description of the sensory aspects were, except for one addition, identical to his early memory, but his affective perception was totally different in that it was not completely dissociated from his self-experience. HE WAS ACTIVELY AND PLEASURABLY PUSHING THE MASS AWAY, LETTING IT APPROACH, PUSHING IT AWAY AGAIN, AND CONTINUING THIS PUSH AND PULL AS THOUGH PLAYFULLY WRESTLING A GHOST FROM HIS PAST—A GHOST HE NO LONGER EXPERIENCED AS AN ENEMY, BUT NOT YET AS A FRIEND.

His recall of the event in childhood was of visual and kinesthetic phenomena only. In this voluntary reeexperience, the one addition he reported was of a rough and tingling feeling on the left side of his face, a sensation he had no memory of from childhood. It was a manifestation that was, to the best of his recollection, completely new and a total surprise, and was immediately associated by him with the fact that he could sleep only if he was lying on his left side with his own arm cradling the left side of his face. It was the first time that sleeping had been associated with anything that involved his personal preference as to how the PHYSICAL ACT of sleeping was to be shaped.

The event can be conceptualized theoretically from a number of vantage points, but the overriding quality, as Mr. C described it, was that of a very young child using a newly discovered physical capability and seeing how far they could safely and creatively go with it. In the context of his specific life experience, past and present, I would conjecture that in the act of “playing” with the Isakower phenomenon during his session, Mr. C. let himself reencounter the interpersonal and intrapsychic elements of his core traumatic situation, and played with their “otherness” hypnogogically, while simultaneously “playing” with the previously frightening analytic situation itself in an identical manner. In other words, what frames this event conceptually is not simply the intrapsychic locale of the autosymbolic hallucination, but that it took place in the context of a relationship that then felt secure enough to enable him both to let the event occur and to use himself that way in my presence—to “play” with it and with me at the same time.

He later stated that as part of his background experience he had been aware that he had to make a choice between reporting it and letting it happen, and that he chose to keep it going until he had had enough. He further stated that unlike previous sessions, in which he was afraid I might become angry if he fell asleep, he was not focused on what my response might be and just “let himself go.” It was a statement of his growing sense of feeling real in the real world and the existence of a state of mind in which he could acknowledge my presence without loss of his own. It was as if—at this moment—his preverbal and verbal domains of experience were synthesizing under the umbrella of a newly emerging sense of self that he knew about, but which I felt as only illusory.

With his self-authorized, “private” USE of the Isakower phenomenon, Mr. C had created something personal between US. I had been hungry for an alive relationship, and I was now starting to have what I had felt deprived of. Sure, some of my hunger was part of the enactment, but some of it was not. I LIKED this guy. I liked him personally, and I wanted us to have more of what I knew existed somewhere in both of us.

So, Then What Happened?

Mr. C's participation in the analytic process, and also in real life, was characterized not by a sudden or dramatic shift from a state of half-sleep to a state of full engagement, but by a transitional period during which he did with me what he had done with the Isakower Phenomenon: lying on the couch, sometimes in a half-awake state; playing with my potentially smothering ideas as they approached him, pushing them away, looking at them from different perspectives, challenging them with ideas of his own; and gradually using the interpersonal context in a creative act—partly procedural, partly verbal—that more and more felt as if it belonged to both of us. In his outside life, his relationships both personally and professionally had become richer and more fulfilling. His use of language was employed less as a shield to neutralize the potentially traumatic impact of otherness, and more as a means of negotiating with it. Internally and externally, the synthesis of thoughts and affect became a genuine expression of his pleasure IN becoming the person he WAS becoming.

Something now became possible that was not possible before. He participated experientially in exploring psychodynamic issues that had always been lurking around, but were unavailable to self-reflection. For example, we began to work with his experiences of vivid sexual memories from the time he slept in his parents’ bed. These memories included perceptual images that had appeared throughout his treatment in dreams and symptoms, but that had been hollow and intellectualized or overly dramatized by him whenever I suggested we might explore it together. This hyperaroused aspect of his early life and the issue of its impact on both his personality development and the colorless way he was forced to LIVE, was now alive and real to him. I'm also happy to say that this included the disappearance of the sexual potency problem that had originally brought him to my office.

Early on, we had talked no avail about his long history of turning the TV to a different channel when there was KISSING going on. I want to emphasize again, however, that it was in my ability to ENGAGE the ACT of turning away—not in talking about what he turned away FROM—that his affective life, erotic and otherwise, became real enough to be representable mentally as “ME,” and thus genuinely explorable. The fact was that he also tuned out to nonsexual aspects of real life: For example, when in conversations with friends the topic turned from abstract politics to something “real” like how to invest one’s money, or interesting restaurants to try, he would stare vacantly into space. The source of therapeutic action was not the content of what he was trying to hide from, but in our playing out together the act of hiding itself.

Mr. C personifies what makes attachment trauma qualitatively unique—the unrelenting pain caused by two DEVELOPMENTALLY ESSENTIAL NEEDS that are forced to be not only unmet, but to remain incompatible—the shared PLEASURE of Oneness, and the shared PLEASURE in a child’s developing sense of personal agency (both of which are normally shared by the parent even though the latter entails some conflict and loss). Because Mr. C's parents were perceptually blind to the existence of his subjective experience, they were blind to what he needed from them and blind to his deprivation. And during the attachment period, what is unrecognized by the parent as existing cannot be experienced by the child as existing without an onslaught of traumatic affect dysregulation.

Yet, developmental needs do not disappear. When either need was felt, there was no human relationship in which their legitimacy could be experienced as a safe and pleasurable part. Each need simply collided with the other as an inevitability from which escape was not possible. Since the collision is fueled by the deprivation brought on by the non-recognition, the only protection was to not know he felt deprived.

So, Mr. C had to hide from the personal reality of those needs as NEEDS, because his stability depended on keeping them inauthentic and “not-me.” Automatically “turning away” from full emotional involvement—with the external world and with his internal experience—was a way of dissociating from the potential destabilization that just about ANYTHING perceptually alive could trigger. And for Mr. C, just about anything did.

The irony is that when a patient like Mr. C enters our office, their fear of RECOGNITION is initially more upsetting to them than NON-recognition because hope and trust are hard to always prevent in a therapy relationship. If he was with someone who cared about what went on inside of him and who related with responsive interest to what they saw there, it could lead him to want MORE, or even worse, ASK for more, and—most catastrophic of all—DEMAND more. So words became a very important hiding place, something I more and more came to understand. But understanding the protective function of how he used language did not and could not in and of itself have transformed what we did together into psychotherapy. Something else took place at the same time—something that made “understanding” have personal meaning. I believe that the fact I genuinely enjoyed his mind and his wit, and that I continued to take personal pleasure in being with him during all the years we worked together—despite my helplessness— turned the droplets of “understanding” I was squeezing out of my helplessness, into something new that came to belong to both of us. A transition took place. I would like to say that I had all along felt the transition as authentic while it was going on, but as I described earlier, it was very hard for me, until the Isakower session, to know with any perceptual confidence whether I was making it up. And YET, even before that session I did feel something happening, but I was afraid to “trust” it. And if a Managed Care Company were listening to this talk, I doubt they would accept my uncertainty as a reason to pay for more sessions. But I'm not certain about that.

One last thing before I close. In case you are wondering whether we ever dealt with his dissociated ANGER, the answer is yes. It came up with regard to ME, around his belief that I did not handle the topic of “termination” well enough, and simultaneously with regard to his optometrist, who he believed gave him CONTACT lenses that didn’t fit him well enough. All this took place in the final phase of our work, and despite his fear of its sometimes uncontrolled quality when his anger surfaced, our engagement with it consolidated, rather than weakened, what had already been accomplished. By the time we ended, his anger had transitioned into assertive self-expression, sometimes confrontationally, but almost always leading to resolutions he became able to accept while retaining his right to feel they did not fit him quite well enough.

If there were more time, I would also say something about the way in which his affect dysregulation related to FEAR—most specifically the fear generated by the destabilizing shock of his father suddenly appearing at his crib screaming at him. The fear had in fact been already diminishing in response to his increased sense of personal agency, which is what allowed him to express anger at men without the preverbal dread that appeared in his early dreams of housecats turning into creatures from Hell. The relationship between fear and trauma—and why Mr. C's threshold for the automatic triggering of fear became higher and higher as he began to process the “trauma of non-recognition” is a fascinating subject to explore further, but I can at least say right now, that the more he could perceive, the more he could mentally represent the “otherness” of an other as part of self, and—in turn—the more he could confront an other in the real world without threat to selfhood. Perception, for him, became tied to “seeing” clearly—and seeing clearly became synchronous with self-agency.

Parenthetically, when I began to write about him, I needed to disguise his name and I chose “Mr. C” because by the time we ended, the word “see” had come to provide meaning that HE chose even more than I did. Also, I couldn’t resist the pun.

Notes

1 Editors’ Note: It is well known that Henry James kept extensive notebooks (see Edel & Powers, 1987) in which, for example, he sketched ideas for his stories and novels, reflected on situations he experienced or on impressions from his travels, and recorded anecdotes and snippets from social interactions and conversations. These musings were incorporated into all his writing.

2 According to Fonagy and Target (1996), the “psychic equivalence mode” in a child manifests when the “child behaves as though his inner experience is equivalent to and thus mirrors external reality, and that by extension others will have the same experience he does (p. 219).” In adults regressing to the psychic equivalence mode, “(m)ental states are experienced as real, as in dreams, flashbacks, and paranoid delusions (Allen, 2008, p. 91).” In Attachment Theory and Psychoanalysis, (2001), Fonagy clarifies further: “When psychic equivalence is the primary mode of experiencing psychic reality…mental experience cannot be conceived of in a symbolic way (and) thoughts and feelings have a direct and sometimes devastating impact that can only be avoided through drastic and primitive defensive moves” (p. 178).

3 See Fisher and Shevrin (2003) for a description of this work.