Artículos de Psicoterapia Integrativa

Inquiry, Attunement, and Involvement
in the Psychotherapy of Dissociation

Richard G. Erskine

This essay distills a quarter century of experience as a psychotherapist with clients who use dissociation as a strategy for coping with traumatic events and stressors. My most challenging professional developments have resulted from my therapeutic errors—errors that demonstrated either ineffectiveness or the reinforcement of defenses that result from the methods of interrogation, confrontation, and explanation and the techniques of behavioral change, redecision, and reparenting. When using these methods and techniques, we as psychotherapists often fail to value the client’s sense of vulnerability and perceived need for self-protection; we fail to respect the client’s integrity in constructing his or her system of making meaning, and we fail to realize how our interventions may increase the client’s sense of shame for having his or her experiences and defenses.

My clinical experience has demonstrated that the defense of dissociation results not only from traumatic experiences but, equally or even more importantly, from the lack of a protective and reparative relationship. Therefore, clients who use dissociation require a relationship-oriented psychotherapy that emphasizes contact through gentle inquiry into the client’s experience, attunement to the client’s affect and developmental level of functioning, and an interpersonal involvement that provides consistency and dependability through acknowledgment, validation, normalization, and the reliable presence of the therapist. I invite you to share in my professional journey and to expand on the therapeutic experiences and methods I present here so that together we may evolve an even more effective psychotherapy.

Dissociative Defenses

Dissociation is a complex defensive process that maintains mental and physical stability. During a traumatic experience, dissociation allows a person to remove himself or herself cognitively and emotionally from the experience and to physically adapt and behaviorally conform to external demands. Continuing the dissociation after a traumatic event enables a person to disengage from related needs and emotions and to evade the memory and its devastating impact.

Dissociation is the predominant defense present in multiple personality disorder, post-traumatic stress disorder, and schizoid disorder. It is also found in many less pronounced disorders, often masked by anxiety or depression. The presence of dissociation is a highly reliable indicator of previous mental, physical, and/or sexual abuse. In some cases dissociation is a reaction to early abandonment, severe sustained pain, near-death experiences, and/or prolonged neglect. These overwhelming experiences, usually, but not always, in childhood, threaten the cognitive and emotional stability and physical security, if not the life, of the individual.

Psychological defenses protect against the pain of overwhelming stimuli, unmet needs, and unexpressed emotions. In order to get on with life and to adapt as well as possible, many people keep these needs, feelings, and traumatic memories out of awareness. This results in a fixation of defenses—the habitual maintenance today of patterns of coping and psychological defense that were necessary at a previous time. These fixated defenses interrupt an individual’s ability to be contactful both internally with self and externally with others. It is because of the fixation of contact-interrupting defenses that traumatic experiences remain dissociated as separate states of the ego or self rather than being integrated into a here-and-now whole—a neopsychic ego.

The neopsychic ego—at every age—is a continually contacting, integrating, and emerging process. If a traumatized person also suffered from a failure of contact in a caretaking relationship, clinical experience indicates that the traumatic experience will most likely not be integrated. The unmet needs for empathy, nurturing, and protection during the trauma are not acknowledged or validated satisfactorily, further compounding the trauma. This initiates the process of isolating the experience from awareness and, in more extreme situations, may lead to isolating aspects of self from awareness as well. The person must engage in a complex set of defenses in order to limit internal contact and to encapsulate the awareness of the traumatizing experience, related feelings, and unmet needs. These needs, feelings, and experiences reside within the ego in a separate state of consciousness, neither contacting nor contactable. Thus the fixated trauma does not become integrated with later experience and learning.

Ego fragmentation and dissociation. Following traumatization there is an intense need for a reliable other to respond empathically to the individual’s extreme emotional reactions and unmet needs, to be attuned to the unspeakable, to offer a realistic understanding of what happened, and to provide safety through continued involvement and problem solving. Dissociation begins because those in the person’s life fail to provide necessary restorative and nurturing functions. In many incest situations the child was told that he or she “liked it,” or the child’s withdrawal and depression were ignored by adults. Without attunement, validation, and empathic transactions from a significant person, a child does his or her best to deeply sequester those feelings, needs, and memories, sometimes to the point of no longer even realizing his or her need for relationship. This is the process of ego fragmentation and dissociation.

Contact: Inquiry, Attunement, and Involvement

Contact internally is the full awareness of internal sensations, feelings, needs, sensorimotor activity, thoughts, and memories, and externally it involves the rapid shift to full awareness of external events as registered by each of the sensory organs. With full internal and external contact, experiences are continually integrated. Defenses interrupt full contact and impede awareness internally and/or externally. Contact is thus the medium through which the process of dissociation can be dissolved and the encapsulated traumatic experiences, hidden needs, and feelings can be integrated into a cohesive sense of self (a neopsychic ego). Contact also refers to the quality of the transactions between two people, that is, the full awareness of both one’s self and the other as exemplified in an authentic and sensitive encounter.

A guiding principle of contact-oriented psychotherapy is respect for the client’s integrity. Through respect, kindness, and compassion, a therapist establishes an interpersonal relationship that provides affirmation of such integrity. This respectfulness may be described best as a consistent invitation to interpersonal contact between client and therapist, with simultaneous support for the client’s contacting his or her internal experience and receiving external recognition of that experience. Withdrawing from contact may often be identified and discussed, but the client is never forced, trapped, or tricked into more openness than he or she is ready to handle.

Contact between client and therapist is the therapeutic context in which the client explores his or her feelings, needs, memories, and perceptions. Such contact is possible when the therapist is fully present, that is, attuned to his or her own inner processes and external behaviors, constantly aware of the boundary between self and client, and keenly observant of the client’s psychodynamics. Contact within psychotherapy is like the substructure of a building: It cannot be seen, but it undergirds and supports all that is above ground. Contact provides the safety that allows the client to drop defenses, to feel again, and to remember.

Psychotherapy often begins with conversation and engagement in a contracting process. The ongoing negotiation of therapeutic contracts is an important element in establishing a contactful therapeutic relationship. The traumas that produce the defenses comprising dissociation usually occur in situations in which clients could not negotiate with regard to their own needs for physical and mental security. Instead, they were deprived of a sense of impact, valuation, and efficacy. Rather than relying on negotiation as a means of achieving satisfaction of needs, such clients may anticipate either being overwhelmed or having to use strong methods of manipulation or control, including dissociation. Therefore, the use of contracts is an essential part of the initial therapeutic contact with clients who dissociate (perhaps even more than with other clients) because their mental and/or physical being has been violated.

When traumatic experiences are being actively remembered or relived, it is important to have a contract that specifically defines the therapeutic territory in advance. In therapy, vividly remembered experiences may arise that surprise both client and therapist. These spontaneous memories may not be predictable, and responses to them cannot always be specifically negotiated beforehand. Therefore, procedures should be agreed on in advance as to how the client can signal that the experience is becoming overwhelming and how the therapist will stop the intervention. For example, one client used a specific word to indicate an entire set of feelings, needs, and impending defenses; others have used gestures or sounds.

Inquiry. Inquiry is a constant focus in contact-oriented psychotherapy. It begins with the assumption that the therapist knows nothing about the client’s experience and thus must continually strive to understand the subjective meaning of the client’s behavior and intrapsychic process. As a result of respectful investigation of the client’s phenomenological experience, the client becomes increasingly aware of both current and archaic needs, feelings, and behaviors. It is with full awareness and the absence of internal defenses that needs and feelings that were fixated as a result of past traumas are integrated into a fully functioning neopsychic ego.

The process of inquiry is as important, if not more so, than the content. The therapist’s inquiry must be empathic with the client’s subjective experience to be effective in discovering and revealing the internal phenomena (physical sensations, feelings, thoughts, meanings, beliefs, decisions, hopes, and memories) and uncovering the internal and external interruptions to contact. Inquiry involves constantly focusing on the client’s experience of affect, motivation, beliefs, or fantasy and not on behavior alone or on a problem to be solved.

Inquiry begins with a genuine interest in a client’s subjective experience and construction of meaning. It proceeds with questions from the therapist as to what the client is feeling, how he or she experiences both self and others (including the psychotherapist), and what conclusions are reached. It may continue with historical questions about when an experience occurred and who was significant in the person’s life.

In the treatment of dissociation, inquiry is used in the preparatory phase of therapy to increase the client’s awareness of when and how he or she dissociates. It involves investigating the client’s experience of the component interruptions to contact that constitute the dissociation. What does he or she do? Are self-hypnotic activities being used? Some clients report that they roll their eyes back, get small inside, or wag a finger.

When treating a client who dissociates it may be important to assess the function of the dissociation relevant to the needs of the whole person and to the needs of fragmented ego states. With multiple personalities, one might ask each part, “What is your role?” Each personality may have a specific function to fulfill, such as expressing a particular feeling (only anger or only sadness), engaging in an isolated defense (compulsive cleaning or amnesia), or coping with life’s demands (organization or productivity). Frequently a personality serves a protective and/or nurturing function that was missing in the past and that may still be unfulfilled in current relationships, such as validation, attunement to needs and feelings, or providing safety and nurturing.

It is essential to inquire about who failed to provide the developmentally necessary functions that should have been fulfilled by a responsible caretaker. How did they fail? Inquiry is also essential about the client’s likely anticipation that others will again fail him or her in a relationship. This anticipation constitutes one of the dimensions of transference—the dread of retraumatization—and the justification for maintaining defenses against contactful relationships.

In the psychotherapy of dissociation it is crucial that the therapist understand each client’s unique need for a stabilizing, validating, and reparative other person to take on some of the relationship functions that the client is attempting to manage alone. A contact-oriented relationship therapy requires that the therapist be attuned to these relationship needs and be involved, through empathic validation of feelings and needs and by providing safety and support.

Attunement. Attunement is a two-part process: It involves both being fully aware of another person’s sensations, needs, or feelings and communicating that awareness to the other.

Attunement requires understanding the developmentally based needs and related feelings that were fixated in the traumatic experience and that are now requiring expression. More than just understanding, attunement is a kinesthetic and emotional sensing of the other—knowing the other’s experience by metaphorically being in his or her skin. Effective attunement also requires that the therapist simultaneously remain aware of the boundary between client and therapist. It is enhanced by focusing on the client at the developmental age of the trauma and knowing what a traumatized person of that age is attempting to express, what he or she requires in the way of experiencing needs, and his or her need for a protective, safe, and validating relationship with a caretaker.

The communication of attunement validates the client’s needs and feelings and lays the foundation for repairing the failures of previous relationships. Attunement may be demonstrated by what we say, such as “that hurt,” “you seemed frightened,” or “you needed someone to be there with you.” It is more frequently communicated by the therapist’s facial or body movements signaling to the client that his or her affect exists, that it is perceived by the therapist to be significant, and that it makes an impact on the therapist.

Attunement is often experienced by the client as the therapist gently moving past the defenses that protect the client from awareness of trauma and its related needs and feelings and making contact with the long-forgotten parts of the client’s Child ego state. Over time, this results in a lessening of external interruptions to contact and a corresponding dissolving of internal defenses. Needs and feelings can then be increasingly expressed with the comfort and assurance that they will be met with an empathic response. Frequently the attunement provides a sense of safety and stability that enables the client to begin to remember and to endure regressing into the traumatic experience, becoming fully aware of the pain of the trauma, the failure of relationship(s), and the loss of a sense of self.

Juxtaposition. The juxtaposition of the therapist’s attunement with the memory of the lack of attunement in previous significant relationships produces intense, emotional memories of needs not being met. Rather than experience those feelings, the client may react defensively to the contact offered by the therapist with fear, anger, or even further dissociation. The contrast between the contact available with the therapist and the lack of contact in the original trauma(s) is often more than clients can bear, so they defend against the current contact to avoid the emotional memories.

It is important for the therapist to work sensitively with the process of juxtaposition. The affect and behavior expressed by the client are an attempt to disavow emotional memories. Therapists who do not account for these defensive reactions may mistakenly identify the juxtaposition reaction as negative transference and/or experience intense countertransference feelings in response to the client’s avoidance of interpersonal contact. The concept of juxtaposition helps therapists to understand the intense difficulty the client has in contrasting the current contact offered by the therapist with the awareness that needs for contactful relationship were unfulfilled in the past.

Juxtaposition reactions may signal that the therapist is proceeding faster than the client can assimilate. Frequently it is wise to return to the therapeutic contract and clarify the purpose of the therapy. Explaining the concept of juxtaposition has been beneficial in some situations. Most often a careful inquiry into the phenomenological experience of the current interruption to contact will reveal the emotional memories of disappointment and painful relationships.

Once the interruptions to contact have dissolved, the relationship offered by the therapist provides the client with a sense of validation, care, support, and understanding—“someone is there for me.” This involvement is an essential factor in dissolving the defenses that constitute dissociation and in resolving and integrating previous traumas and unrequited relationships.

Involvement. Involvement is best understood via the client’s perception; it is a sense that the therapist is contactful. It evolves from the therapist’s empathic inquiry into the client’s experience and is developed through the therapist’s attunement with the client’s affect and validation of the client’s needs. Involvement is the result of the therapist being fully present, with and for the client, in a way that is appropriate to the client’s developmental level. It includes a genuine interest in the client’s intrapsychic and interpersonal world and a communication of that interest through attentiveness, inquiry, and patience.

Involvement begins with the therapist’s commitment to the client’s welfare and a respect for the client’s phenomenological experience. Full contact becomes possible when the client experiences that the therapist: (1) respects each defense; (2) stays attuned to his or her affect and needs; (3) is sensitive to the psychological functioning at the developmental age when the trauma(s) occurred; and (4) is interested in understanding the client’s way of constructing the meaning of the trauma(s).

The complex set of defenses that constitutes dissociation was erected in the absence of a caring and respectful involvement by a reliable and dependable other. Clients who have relied on dissociation as a protective measure experienced that they had to protect and comfort themselves in the face of impinging and overwhelming stimuli. It is in the absence of reliable and consistent need-fulfilling contact with a dependable other that defenses become fixated.

Therapeutic involvement that emphasizes acknowledgment, validation, normalization, and presence diminishes the internal discounting that is part of dissociation. These engagements allow previously disavowed feelings and denied experiences to come to full awareness. The therapist’s acknowledgment of the client’s feelings begins with attunement to the client’s affect, even if the affect is unexpressed. Through sensitivity to the physiological expression of emotions the therapist guides the client to express his or her feelings or to acknowledge that feelings or physical sensations may be the memory—the only memory available. For instance, if the person’s eyes were closed during a traumatic event there will be no visual memory. In other situations the child may have been too young to remember cognitively. In many cases of trauma, the person’s feelings were not acknowledged, and it may be necessary in psychotherapy to help such individuals develop a vocabulary with which to voice those feelings. Acknowledgment of physical sensations and affect helps the client claim her or his own phenomenological experience. Acknowledgment includes a receptive other who knows and communicates about the existence of nonverbal movements, tensing of muscles, affect, or even fantasy.

There are times in clients’ lives when their feelings were acknowledged but not validated. Validation communicates to the client that his or her affect or physical sensations are related to something significant. Validation is linking cause and effect. For example: “Based on what you described, you feel sad because no one was there for you,” or “Your fantasies and dreams are saying something important.” Validation diminishes the possibility of the client internally discounting the significance of affect, physical sensation, memory, or dreams. It enhances for the client the value of his or her phenomenological experience and therefore an increased sense of self-esteem.

Normalization depathologizes the client’s or the other’s categorization or definition of internal experience or behavioral attempts to cope with the effects of trauma. Under extreme circumstances it is normal to dissociate. It may be essential for the therapist to counter societal or parental messages such as, “You’re crazy for feeling scared,” with “Anyone would be scared in that situation.” Many flashbacks, bizarre fantasies, and nightmares as well as much confusion, panic, and defensiveness are normal coping phenomena in abnormal situations. It is imperative that the therapist communicate that the client’s experience is a normal defensive reaction, not pathological.

Presence is provided by the psychotherapist’s sustained empathic responses to both the verbal and nonverbal expressions of the client. It occurs when the behavior and communication of the psychotherapist respects and enhances the client’s integrity. Presence includes the therapist’s receptivity to the client’s affect, that is, to being impacted and moved by the client’s emotions and yet not to become anxious, depressed, or angry. Presence is an expression of the psychotherapist’s availability for full internal and external contact. It communicates the psychotherapist’s responsibility, dependability, and reliability.

Remembering traumatic and neglectful experiences may be frightening and painful for the client; therefore, therapeutic involvement is maintained by the therapist’s constant vigilance in providing an environment and a relationship that is safe and secure. The therapist, of necessity, must be constantly attuned to the client’s ability to tolerate the emerging awareness of the traumatic experience(s) so that he or she is not overwhelmed again in the therapy as he or she was in the original traumatic situation. When inquiry into the client’s phenomenological experiences and therapeutic regressions occurs in surroundings that are calming and containing, the fixated defenses are relaxed further, and the needs and feelings that derive from the traumatic experience(s) are integrated.

The psychotherapist’s involvement—through transactions that acknowledge, validate, and normalize the client’s phenomenological experience and sustain an empathic presence—fosters therapeutic potency that allows the client to safely depend on the relationship. Potency is the result of engagement that communicates that the therapist is fully invested in the client’s welfare. Acknowledgment, validation, and normalization provide the client with permission to know his or her own feelings, to value the significance of his or her affects, and to relate them to actual or anticipated events. Such therapeutic permission to diminish defenses, to know his or her physical sensations, feelings, and memories, and to reveal them must come only after the client experiences protection within the therapeutic environment. Such therapeutic protection is adequately provided only after there is a thorough assessment of dynamics related to intrapsychic punishment and the client feels safe.

Intrapsychic punishment involves the child’s perceived loss of bonding or attachment, shame, or threat of retribution. Protective interventions may include supporting a regressive dependency, providing a reliable and safe environment in which the client can rediscover what has been dissociated, and pacing the therapy so experiences may be fully integrated. Putting some memories on hold until others are dealt with is a way to ensure that the client will not be flooded with overwhelming anxiety. For example, for one client, traumatic memories first emerged in nightmares. She was often overwhelmed by terror and exhausted by lack of sleep. Periodically she was encouraged to stop dreaming until the material already dreamed had become clear and had been worked through. Once she connected her dreams to memories of childhood events and understood and resolved the ramifications of those events in her adult life, the therapist encouraged her to dream the next episode. The client was also encouraged to draw the dreams on a sketch pad so that she could go back to sleep or concentrate on her job the next day. She brought the sketch pad to therapy sessions as an aid to remembering and deciphering the dreams. Postponing or sketching her dreams served as a protection from overwhelming sensations.

There are times when a client attempts to elicit attunement and understanding by acting out a problem that cannot be expressed in any other way. Such acting out expressions are simultaneously a defensive deflection of the emotional memories and also an attempt to communicate the person’s internal conflicts. Confrontations or explanations can intensify the defenses making the awareness of needs and feelings less accessible. Involvement includes a gentle, respectful inquiring into the internal experience connected with the acting out. The therapist’s genuine interest in and honoring of the communication, which often may be without language, is an essential aspect of therapeutic involvement.

Involvement may include the therapist actively facilitating the client’s undoing repressive retroflections and the inhibition of activating responses, such as screaming for help or fighting back. The therapist’s considered revelation of his or her internal reactions or compassion is further expression of involvement. This may also include responding to earlier developmental needs in a way that symbolically represents need fulfillment, but the goal of a contact-oriented therapy is not the satisfaction of archaic needs. Rather, the goal is the dissolution of fixated, contact-interrupting defenses that interfere with the satisfaction of current needs and full contact with self and others. This is often accomplished by working transferentially to allow the intrapsychic conflict to be expressed within the therapeutic relationship and to be responded to with appropriate empathic transactions.

Conclusion

In work with dissociative clients, a contact-oriented psychotherapy using inquiry, attunement, and involvement responds to the individual’s current needs for an emotionally nurturing relationship that is reparative and sustaining. The aim of the therapy is the integration of affect-laden experiences and the intrapsychic reorganization of the client’s beliefs about self, others, and the quality of life. Contact facilitates the dissolution of defenses and the integration of the dissociated parts of the personality. Through contact, disowned, unconscious, and unresolved experiences are made part of a cohesive self. With integration it becomes possible for a person to face each moment with spontaneity and flexibility in solving life’s problems and in relating to people without resorting to the defense of dissociation.

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This article was originally published in the Transactional Analysis Journal, Volume 23, Number 4, October 1993, pp. 184-190. Portions of this paper were also presented at the Symposium on the Treatment of Dissociation held at the 29th Annual International Transactional Analysis Association Conference, October 26, 1991, in Stamford, Connecticut, U.S.A. The author wishes to thank the members of the Professional Development Seminars of the Institute for Integrative Psychotherapy in New York, New York, Kent, Connecticut, Chicago, Illinois, and Dayton, Ohio, for their valuable suggestions in the development of this essay.