A Quarter Century of Being with Dissociation
by Kathy Steele
(Editors’ Introduction: Kathy Steele is a psychotherapist, consultant and trainer based in Atlanta, Georgia. She is author of “The Haunted Self” (2006) and “Coping with Trauma-Related Dissociation” (2011) both published by W. W. Norton. She specialises in working with complex trauma and dissociation.)
“There is no road. The road is made by walking”
Antonio Machado (1988)
I have been walking, making the road with my steps, for a long time. Around twenty-four thousand hours to be nearly exact. Twenty-four thousand hours of walking alongside people who have been seriously traumatized, severely dissociative. It seems implausible, that number, but I counted up the hours of therapy I have given, and it is correct. It is only in learning so much over these years that I realize how little I (we all) still know. Working with dissociative patients can be a lot of things, but you can always count on it being a lesson in humility. In spite of standing on the shoulders of many great masters, and having an array of theories and treatments at my fingertips, vast territories of dissociation remain blank spaces on a half-filled map. And so it is also for integration, the antithesis of dissociation. That map, too, is full of gaps and vacancies. What a privilege – though a hard one – to walk these half-known lands time and again, as my steps and my patients’ forge the road.
Two Roads Diverged
I am about to begin a session with a patient whom I will call “Mary”. She has a severe dissociative disorder. Dissociation is the ultimate failure of integration, the inability to be here and now and to be me, myself, and I. It is a fragmentation between Mary, very much stuck in the traumatic past, and Mary who believed she left the past behind in order to move on with her life. Or so she thought. Two roads diverged in a dark wood and Mary had to take both. Her flawless skin is a pristine bandage, covering third degree burns of shame and fractured bones of despair. Its loveliness makes me wince, because I have some idea of the anguish that lies beneath. Not many parts of Mary know how to manage the terror of therapy, nor the bigger terror of her life. She changes often so as to not be her own self, not live Mary’s life, not feel or know. On bad days, she is terrified even of breath and hope. This is apparently a bad day. Mary is very afraid of the road her walking might make. She is afraid each step forward will propel her closer to her past. So as much as possible, she tries not to walk. This is problematic, because therapy is the walking, which makes the road, which is the way out of her miserable past.
Mary’s dissociation began because she was unable to integrate overwhelming experiences (sexual abuse, in an absolute void of human kindness or empathic acknowledgement). But over time this integrative failure became a default coping strategy, which eventually evolved into a curse. It does not free her, but rather entombs her. Often encased in a crucible with no opening, she is unable to touch the air, feel her skin, love her partner, know herself. She tells me she feels like cardboard, a one-dimensional mummy wrapped in cotton batting.
Reality is in the Eye of the Beholder
Dissociation involves an unexpected third reality (Kluft, 1998, 2006), beyond the external shared ones of the therapist and the patient. The third reality is the dissociative inner world of non-realization: the inability to fully realize experiences of essential importance that shape one’s self and view of reality. This subterfuge world has an internal, idiosyncratic logic of its own, rising up and taking the patient and therapist by surprise, again and again. It is a world of dissimulation and distraction, denial and self-delusion, of time warps and shifting contexts, and of multiple and contradictory versions of self and other.
The third reality makes its own road of twists and turns, abrupt deadends and detours, covering its tracks to deny there is either road or footsteps. In the third reality we are down a rabbit hole, where time and context perpetually morph, and self is as fluid as water and slippery as ice. We are accustomed to being firmly tethered to time and space: “I am here, in this place, now, at this time.” But this is not so in the third reality. The therapist must be prepared to enter with care and caution, with mind and heart, while remaining in the embodied present. A feat not always easy or even possible to achieve, I can tell you from experience.
I have decided that, like the absence of road before footfall, there can be no integration before being in the moment. Walking makes the road: being here and now makes integration. Integration can be found in the brief moment of eye contact, the shared smile, the empathic word, the silence of knowing something hard, the mutual understanding, the flow between two human beings, one in the role of therapist and the other in the role of patient. It is found in resonant dance between two minds embodied in their respective physical spaces. Integration is not something we achieve, but occurs in moments of fully being and doing. Integration is not something the self does, but what the self is in the present (Loevinger, 1976; Van der Hart et al., 2006).
Such integrative moments are the unobstructed road that opens us to the possibility of real and enduring change through the miracle of neural plasticity, the ability of brain and mind to grow and develop, moments when we dare to flourish. Sometimes these moments are not possible, such as when the road is a river, a raging torrent of a therapist’s overwhelming drive to rescue, to make it simple and clear, to obliterate pain, to dig up content without understanding process, to create a golden bubble of love and ecstatic healing. Other times, the road is obstructed by a therapist’s own twisted roots and brambles of impatience, disgust, anger, fear, or shame. These are the inauthentic countertransference poles of too much and too little, of enmeshment and distancing, places we all visit, hopefully for not too long. Thankfully, Mary has no idea how hard it is for a therapist, even the best and most experienced ones, to walk steadily some days on the path.
O Sister, Where Art Thou?
Mary is a lovely person, but I haven’t quite fully met her, though she has been coming to see me for a year. I settle in my chair, making sure I – my embodied self – am here, but also cloak myself in the mantle of the therapist’s role. That unique intertwining of self and role is an interesting journey in itself. It is full of potholes and astonishing vistas, an imperfect if serviceable road made only by rough and tumble journeys across the topography of the mind. It is a pleasure to feel that the longer I am a therapist, the more congruent I and my role are: most days we fit like comfortable old shoes.
But wait. Mary does not seem to be in my office with me any longer. She did walk in from the waiting room a moment ago with the same hesitant steps, the same scripted greeting as every week: “Hi. How are you? Did you have a good weekend?” I know this disconnected credo by heart, its flat cadence that does not ask for response. She sits for a moment on the edge of the sofa, clasping her hands primly. I mentally note that her primness and her history of severe sexual abuse are incongruent, and promptly feel a dialectical tension in myself, mirroring the stern angles of her body of which she is oblivious. She flails helplessly with a few more words, then leaves them and me in silence, transported to one of those uncharted places on the map.
Mary suffers from uncontrollable time travel, a diagnosis you will not find in the DSM-IV. It abruptly yanks her from here, indiscriminately depositing her in some other desolate place, some other desperate time, or in a grey limbo, nowhere, being no one. She leaves a chrysalis of herself behind with which I try to interact. Unlike the butterfly, she has no wings, but she flies as though she surely did, darting away to “not here.” Mary’s me, myself, and I flee past her initial hello to huddle in the back corner of her mind. To be unseen is the most important.
Mary suffers from “mindflight” (Steele, 2009), also not found among the pages of the DSM. Mindflight involves overwhelming fear, shame, or disgust of one’s own inner experiences (thoughts, memories, feelings, body sensations, wishes, needs, etc.) and subsequent phobic avoidance. Mary has a phobia of herself, of her inner experience, and this is the essence of traumatization. (Steele and Van der Hart, 2009; Van der Hart et al., 2006)
Mary has left me behind in my chair, feeling a little alone, just the tiniest bit stupid, as though I have been caught talking to myself in an empty room. I feel the edges of shame because I cannot manage not to scare Mary into oblivion; the taste of frustration because it is effortful to chase someone so utterly elusive; the flutter of excitement and curiosity because I am faced with an interesting challenge; a familiar sadness in my chest at witnessing someone so broken. Incongruously, a thought appears: “I must not forget to buy bread and tomatoes this evening”. This insipid non sequitur actually grounds me in reality and leads back to the awareness that I have a task before me. It reminds me that Mary also manages to shop for bread, to eat, sleep, is successful at work. She has a sharp mind and keen, dry wit. She is clever and determined. This woman has some real strengths and resources.
I like this awareness of my feelings and thoughts nibbling at me like little fishes: I own them, they are alive in me. Suddenly, I am grateful that I can notice them, even the shameful or scary ones. It is a process called “mindsight” (Siegel, 1999, 2007), an empathic insight into our own mind and that of another, combined with compassion and kindness. It supports wellbeing in mind, body and relationships. Mindsight is the walking that makes the road. Mary cannot do such a thing yet: She dare not walk her inner landscape, full of fear and the great unknown of all things “not me”.
Yet, even as I appreciate my mindsight, I note that I push that little feeling of sadness farthest out of my mind and body: it will slow me down, make me fumble the moment, I tell myself. But I also abandon it on purpose, with a shade too much intolerance. In truth, I do not want to own very much of it at the moment. Then the realization: I have just enacted a personal microcosm of Mary’s grand flight. An important fact: we all flee ourselves at times. Mindsight is often transient, constantly interrupted by flights, short or long.
Tea and Empathy
Mindflight is one thing. Empathy is entirely another. Don’t confuse the two. In truth, I keep myself at the slightest, almost imperceptible distance from Mary’s experiences. I don’t allow pictures to form in my mind of her being hurt as a child; I do not try to step too fully into her desperate pain and existential loneliness. I cannot let her experiences be more real than my own here and now, or else I would cease to be therapeutic. This is not mindflight, but the capacity to stay within the boundaries of my own skin while being with another in her own skin. I am present with, yet separated from Mary by a thin gossamer line that is the difference between sympathy and empathy. With mindsight, I am able to glide back and forth between my mind and Mary’s, my body and hers, searching for common space where we can meet, but not merge.
Of course, there are other times when mindflight takes me to the opposite end from sympathy, and I must struggle to meet Mary at all, wishing to have more distance between us than is therapeutic. In reality, it is not Mary’s intolerable experiences that send me into mindflight. It is my phobic avoidance of my own inner experience when I make her intolerable experiences more real to me than my own embodied experience in the present moment.
A Sheep in Wolf’s Clothing
In the meantime, Mary is still hiding in the darkest corners of her mind. There, as everywhere, she is haunted by a voice deep inside, so mind- splitting it makes her flinch: “Slut! Stupid! You are so incompetent! Everyone hates you!”. This is the hidden voice of survivors, the one they dare not reveal to you unless you ask, though it sometimes reverberates so violently that heads jerk and eyes roll. But this predator of the interior is not at all what it seems. A closer look reveals an embodied survival guide written by a child, a scaly armour that protects soft and vulnerable underbelly. It is assembled from a patchwork of painful lessons reaped from mindsight, this is what I hear underneath the vicious tirade: “I will toughen you up so they cannot hurt you. I will force you not to cry, as it is a great weakness they will exploit. I will not allow you to trust anyone, as they will only betray you. I will shame your needs away, as they make you too vulnerable and needy for anyone to tolerate. I will threaten you if you tell, so you will not be punished for speaking.”
Mary does not yet realize that this dreaded voice is what keeps her safe, albeit in the most convoluted way imaginable. But I understand and feel compassion toward that wounded child, a sheep in wolf’s clothing, with her fierce determination to hide the abyss of shame and loneliness behind frothing words. I try to communicate my empathy by simply saying, “How exhausting it must be for that voice to have to work so hard to protect you; and for you, too, when you do not understand what it is trying to warn you about.”I try to measure my resonance according to what Mary can tolerate, which isn’t much. My acceptance of the voice calms her. She thinks this is entirely strange. I, of course, do not, and smile a little smile of triumph inside.
Down Memory Lane
Mary is here again for a moment after that: I can feel the fleeting connection and try to hang on to it, try to maneuver my way toward that tenuous moving target between too close and too distant. We make the briefest of eye contact: too much! I miss the mark. Again! I was a little too overconfident, a little too connected. I am too much for Mary even as she fears she is too much for me. Her air loses oxygen, her skin lights afire with fear and shame. Before I can regroup, she disappears again, this time in an avalanche of memory. It crushes her and she tumbles down and down, until she is buried under its wordless weight. I halfway wonder where a shovel is and push my mind into gear, already talking to Mary in that grounding way that comes naturally now, hoping the slim thread of my voice finds its way to her. I am not afraid of what is happening. I know what to do and feel calm. But I do fear for her sometimes, for the intensity with which she flees herself. And of course, she also flees me, a representative of that alien species, humankind, with an emphasis on ‘kind’. It is still strange sometimes to have someone run from me, a vague disappointment, a little jolt, even though I know her fear has nought to do with me.
Then she switches again, becomes someone who is “not Mary”. Sometimes “not Mary” is a fiery rage, hammering the air with hot words, other times she is a bundle of raw need, sucking the very air from the room out of sheer starvation for human kindness. “Not Mary” is all the things Mary cannot bear to be. Her words abruptly cleave from her tongue; her hand hangs mid-gesture, eyes riveted down and to the right. Mary is gone again. This cycle swallows its tail again and again. Mary is wrenched from present to past, from knowing too little to knowing too much, from me to not me and back again. She is nearly consumed by her own coping. And I am nearly consumed by the balance between trying too hard and not hard enough. I feel exhausted on some level, though it is hard to pinpoint.
A Thousand Points of Light
In case you wonder, I did get Mary back, or she got herself back. Or maybe we did it together, though that would be far too hard for Mary to admit just yet. I have an image of having dragged a half drowned person to shore and collapsing together in a wet heap. But this is familiar and I am not concerned, just tired. Soon enough the big hand on the clock announces our artificial ending that heralds both reluctance and relief for each of us in different ways. And so Mary drifts out the door, though I swear her feet do not touch the ground, so afraid is she to walk and make her road. She is swallowed up by the world again until next week. I stand up, feeling ever so slightly unsteady, Mary remaining in my mind for a moment. No one has ever held Mary in mind before, nor in heart, as far as I can tell. There is a sadness about that fact that demolishes words.
As I walk down the hall to lunch, I am already throwing aside the mantle of therapist, immersing myself back into my world, in the restorative normality of simple food, the blue linoleum and the irritating rattle of the old fridge, the lovely voices of my people, my co-workers and friends. Nevertheless, somewhere in me I fully realize, not just know, terrible facts about trauma. For instance, trauma is generally not the ennobling fire that forges the virtuous and the brave. It burns. It can burn a soul down to a smouldering pile of ashes, a super-heated furnace that melts parts of a self away. Mostly I have learned to coexist with such facts, however uneasily, like a cat that suspiciously eyes the sleeping dog before curling up to nap with one eye open.
These facts are the point, but then there is the counterpoint of healing. I hold to both, not too tightly to one or the other, lest I unbalance myself. I am filled with thousands, maybe millions of moments, tiny points of light, little healings along the way to which I have been witness, or which I have experienced. These most infinitesimal illuminations, so small they cannot be seen by the eye, but only by the heart, are the essence of integration. There is no grand healing, no great epiphany, no victory flag, just these minute luminosities appearing erratically, slowly, then gradually more surely and steadily, steps along the way that make the road.
There is one particular healing that bears mentioning. It is one of the most profound and difficult walkabouts in therapy: the realization of unbearable pain and cruelty, sans the need to fight or flee or change the facts; and then, the ability to move forward with that knowing in your bones. This awful and awesome point-counterpoint of hurt and healing leads me to my final statement. It is one I am unable to explain, but which you will understand if you have taken this road, either as therapist or patient, or both. As I walk, making this road, I have the strangest feeling that my heart has simultaneously diminished and expanded. And if this journey, which has both given and taken, be not entirely good, it is most certainly genuine and honest. It is a real and present encounter with our each other and our self. What more can we possibly ask of our walking, making our roads as we go?
Kathy Steele, MN, CS is Clinical Director at Metropolitan Counseling Services and in private practice in Atlanta, Georgia, USA. Her website
Kluft, R.P. (1998) ‘Reflections on the traumatic memories of dissociative disorder patients’ in S. Lynn and K. McConkey (eds) Truth in Memory (pp. 304-322). New York: Guilford.
Kluft, R.P. (2006) ‘Dealing with alters: A pragmatic clinical perspective’ in Psychiatric Clinics of North America. 29: 281-304.
Loevinger, J. (1976) Ego Development. San Francisco: Jossey-Bass.
Machado, A. (1988) Antonio Machado: Selected Poems (Trans. A. S. Trueblood). Cambridge, MA: Harvard University Press.
Siegel, D. (1999) The Developing Mind: Toward a Neurobiology of Interpersonal Experience. New York: Norton.
Siegel, D. (2007) The Mindful Brain: Reflection and Attunement in the Cultivation of Wellbeing. New York: Norton.
Steele, K. (2009) ‘Reflections on integration, mentalization, and institutional realization’ in Journal of Trauma and Dissociation. 4(1): 1-8.
Steele, K. and Van der Hart, O. (2009) ‘Treating Dissociation’ in C. Courtois and J. Ford (eds) Treating Complex Posttraumatic Stress Disorders: An Evidence-Based Guide. (pp. 145-165). New York: Guilford.
Van der Hart, O., Nijenhuis, E.R.S., and Steele, K. (2006) The haunted self: Structural Dissociation of the Personality and the Treatment of Chronic Traumatization. New York: Norton.
(This article is reprinted with the kind permission of Voices, the Journal of the American Academy of Psychotherapists. Copyright (2009) Voices, Volume 45 (2). All rights reserved.)