By Edie Boxer
I often use literature and poetry as a way to inform and expand my thoughts and feelings. In that spirit, and in keeping with the theme of my paper, LIVING WITHIN THE SURROUND OF DEATH: REGULATING TRAUMA/DISSOCIATION/SELF AND OTHER IN THE ANALYTIC SURROUND, I offer an excerpt from a child’s book as an introduction to my presentation.
“For a long time I used to go to bed early,
But now I go to bed late.
I am not sleeping at night.
And I wake up in the dark,
And my mind is spinning.
And I start to go into a panic.
And that’s when I have to switch on my Ruby flashlight-I keep it by my bed.
It’s in the shape of a piece of wood.
It’s disguised, like most Ruby things.
I am currently reading THE RUBY REDFORT SURVIVAL HANDBOOK: WHAT TO DO WHEN
YOUR WORST WORRY COMES YOUR WAY….
It is a very handy book and it is crammed with brilliant ideas.
Most of them involved standing still.
For instance, what to do if a tiger comes along-
And the whole book is about escaping or getting out of and dealing with tricky situations.
You wouldn’t believe some of the tricky situations Ruby can get into, and although it is unlikely that
I will find myself in a swamp with an alligator,
Who can say that I won’t?
And what I always think is, I would rather know
Something than not know something.
Don’t you think?” (Pages 6-7)
I find it hard to escape the fact that death includes everyone. I vividly ‘live death’ whenever I allow myself to think about actually dying; I am frightened, and want to get as far away as possible from the incomprehensible notion of no longer living my life. I know that I am not alone with this overwhelming feeling of impermanence. The French Renaissance writer Michel de Montaigne wrote, “There is no place on earth where death cannot find us- even if we constantly twist our heads about in all directions as in a dubious and suspect land… If there were any way of sheltering from death’s blows… But it is madness to think that you can succeed…” (Page 15)
‘Living death’ became my conscious daily companion from the age of nineteen. I was home from college, alone in the living room of my parents’ house, watching television when, for no apparent reason with which I can associate, I felt terrified at the idea of ‘no longer existing’. I do remember the sensation of being flooded with dread and then almost instantly knew a solution: to live my life as fully as possible (whatever that meant) and the terror subsided. In my late teens, I had convinced myself that there was no need to worry- I had so many years ahead. But, in my sixties, I realize that time has flown by with the proverbial less ahead than behind me.
I am struck with the realization that I did not talk with anyone about this ‘sudden’ onset of terror or how I decided to manage it. I just knew that I was supposed to know how to take care of things and to do it perfectly. Feelings and their impact had never been a topic of discussion in my family; there was no avenue of expression – except my mother’s rage. Following these rages, there was her silent withdrawal until I figured out some way to break the silence and reconnect with her. At the same time, I dissociated my own thoughts and feelings of sadness, hurt, fear, and anger.
In the years since that significant evening, I have come to know that I was born with a sensitive self already in place. If my self-hypothesis is correct, it is a starting place to understand my preoccupation with reminiscing, connection, separation, and death. I have always felt vulnerable when exposed to the ordinary, yet painful events in life, which leave one with a lingering sense of sadness. Now as I recall dissociated memories, it makes sense to me that I was sad and lonely. I only existed in my mother’s mind as her object that she needed to perfect so that she could see herself as having done a perfect job of raising two children. Socarides and Stolorow in their seminal article, “Affects and Self-Objects” wrote, “We believe that what is crucial to the child’s (or patient’s) growing capacity to integrate [her] sadness and [her] painful disappointments in [herself] and others is the reliable presence of a calming, understanding caregiver, irrespective of the ‘amount’ or intensity of the affects involved” (p. 75). Thank goodness, to say the least, for the responsive others in my life who have helped me to experience myself as feeling more interconnected and vitalized. Still, as I grew up, I often felt a lingering preoccupation with sadness, loneliness, and death.
The rediscovery of an event that happened over sixty plus years ago allowed me to understand the genesis of my ongoing thoughts about death. What I did not know early in life was that my parents lost their first-born child/son. He died after four or five days of life from a heart condition and was buried. I learned this information when I was ten years old, calling out to my mother, who was in a near-by room, to ask if I could dress my doll in the baby clothes I discovered in a closet. My mother told me that I could not use the baby clothes. She said they belonged to her first child who had died after several days. I remember asking her a few more questions, but there was never another discussion with her, my father, or my older brother. Since I remembered this moment, I realized I have many feelings and thoughts that went unacknowledged and unanswered.
During one of my own analytic hours, as I recounted an experience from a recent seminar, I rediscovered this early memory. Prior to the seminar, one of the facilitators had sent an email saying that the meeting would be held despite the very recent death of her mother and brother-in-law. She wrote, “Life does and will go on, not in denial of loss but in embracing it, using loss to enlarge sensibilities and experience. That is, after all, the message of this year’s piece of literature suggested for the seminar [Ted Chang’s “Stories of Your Life] how a shift of perspective makes loss part of life and of living and learning” (Vida, 2008, personal communication).
Despite that welcoming beginning, I struggled with hearing about death and loss and really wanted to leave. Instead, with the encouragement of my colleague, I began to talk during a break about my experience and feelings of increasing disconnection and deadness. When we reconvened, one of the facilitators responded to me with a statement about facing into the challenge, to talk about what was on my mind. I immediately felt alive and engaged with his words even if I could not then or now state exactly what he said. I just remember feeling like there was air in the room and in my lungs!
As we continued dialoguing, I heard my inner voice saying ‘I want to live as expansively as possible within the context of making my fears, including the inevitability of death, as manageable as possible’. As the facilitator said something about my fears being about loneliness, I could then let myself know that I was often a very lonely child. I ‘forget’ that because it has not been my experience in the last forty plus years. But, I also ‘know’ that loneliness and figuring out how to manage loneliness can still be part of my state of mind. In that moment, hearing his words, I did not feel alone.
As I mentioned, it was at my analytic hour that I began the session by telling my analyst about the seminar. He noted that death and the shock of hearing troubling news is often with me. I often start or end my sessions talking about my fear of death and about sudden, frightening traumas. This state of mind is the backdrop of my fears and often predominant in my thinking as I attempt to regulate my anxiety. At that moment, as my analyst wondered what could have happened to make me often think of death, I made the connection in my mind that I had not thought about since I was ten years old. We both stopped as he said something like, “My God”. He was as clearly stunned as was I and commented that no wonder I have death on my mind! I was shocked to know that I had never connected this event/set of facts to my worries. I certainly could never figure out why death was predominant even when I was working on exploring other thoughts. He made the observation that there was death in the house- in many ways besides this standout loss- and that the air was filled with heaviness among many other stifling styles of relating.
I am certain that there was never another discussion of my brother’s death. It was just part of the dissociated fabric of our family. As an adult and a psychoanalyst, I know the impact of such events on a parent(s), subsequent siblings – the family as a whole. As a child, I only knew it as a fact that I did not know before I opened the closet door and did not know much more after my mother answered me. At least she was able to tell me the truth. Unanswered questions, my curiosity about how they managed to go on will never be answered. I can only imagine.
Interestingly, the rest of that pivotal week brought many important considerations professionally as I noted and seemed to linger over and consider my patients’ pain. I found myself feeling very connected to them. Thus, in the balance of this presentation, I hope to demonstrate the usefulness of the analyst’s on-going self-reflection and willingness to discover, not only one’s own metamorphosis, but also all that that means in the whole of the analytic surround.
One patient, Jay, highlighted the fact that as I was going through my own process of self-discovery, I became more enlivened and curious about him. Each time we meet, we are confronted by his psychological survival and self-imposed feeling of impending death that puts him in jeopardy on an on-going basis. His thoughts and fears are expressed in such a way that mental health professionals who have treated him previously termed his behavior “psychotic”.
While we were piecing together more of his narrative history, I began to hypothesize to myself that his unarticulated traumas were active contributors to his elevated level of fear helping me to see his seeming psychosis as a dynamic interplay of these dissociated experiences.
Through this new lens, I have discovered that I am beginning to provide an innovative link to his life, even though he cannot yet consider the luxury of living more expansively or, at times, the possibility of survival in the moment given the inevitability of trauma and mortality. He cannot yet consider many of my thoughts that may give some meaning to his historical trauma and he struggles against allowing his deepest fears to become known to him. While an internal panel of biblical judges assaults him psychologically, mainly at night into the morning, (as he said “Well, I am in crisis.”), he is more and more permitting me to have a glimpse into his experience of frightening persecution: allowing me to bear that which he can not manage by accepting my empathy and support while all the while insisting that there is no link between his terrifying, auditory experiences and any past or current traumas.
I would like to provide, at this point, some general information about Jay and about our work over the past six or so years. He is in his mid 60’s and self referred. He is the oldest of three children – his two siblings were born to his parents when Jay was eight and seven years old. He continually reports a seemingly uncomplicated family life with a supportive family. Both of his parents have died during the course of the treatment. He has never specifically talked to his family about his symptoms, but they do know that he has a hard time both with physical symptoms and anxiety. In fact, he has often cancelled trips home at the last moment. When he has been able to go, he is usually sick or, on one occasion, consumed with anxiety, called me, and then decided to return to Los Angeles the next day. Jay attended a well-respected boarding school in high school and a well-considered college. Following his formal education, he left his home state and ultimately became involved with community service work. Jay also began heavy drug use during the 60’s and involvement in a spiritual group. He recently reported experiencing severe depression during this time, which ultimately led to his following the orders of one of the internal judges to jump from a building. He sustained a severe back injury, which required lengthy hospitalization and surgery. He has been married twice but with no children. He had some previous therapy and continues to be seen for a medication evaluation about every six months.
Jay has always been compliant with medication including anti psychotic drugs, but has always reported that they do not alter his symptoms. Over the time we have been meeting, I was mostly working in what I self-named, a social work model of support, education, and providing information. All the while, I had a hard time hearing about his internal world – a world that I could not relate to, but felt that I had to respect as Jay had no conflict with the idea that it existed. We wondered how we were going to be with his experiences and I was able to acknowledge that, for him, it was a large portion of his life and, therefore, I was more than prepared to work hard to accept how he thought about this impactful presence in his life.
In fact, over time, I resigned myself to offering only supportive therapy, to help him survive the turbulent times he described, as he was unable to consider or make use of any of my interpretations or most of my comments. I struggled with feelings that I knew were not that compassionate as I listened with undisclosed impatience to his litany of physical complaints, his low pain and anxiety tolerance level. I wanted him to choose the same path I chose many years ago – living as expansively as possible given the inevitability of time ending forever.
Often confronted with feelings of helplessness when he described his emotional and physical pain, I consulted with his various psychiatrists as they rotated through their training. Only one questioned Jay’s working diagnosis of manic depression, with depression being the most recent symptom. This young psychiatrist and I wondered together how accurate this diagnosis was and considered others, such as schizophrenia, along with wondering why none of the medications Jay took reliably seemed to give him any relief.
Perusing the DSM provided even fewer answers to the questions I had as to an accurate diagnosis. On the other hand, as I worked on my own fears, I was also reading Philip Bromberg on trauma and dissociation for a class that a colleague and myself were preparing. I felt that there was more to Jay’s historical narrative than he had articulated. One day, I was discussing with another colleague who specialized in working with unresolved trauma, my wishes, even need, of helping Jay choose my solution of living expansively, when she suggested that what appeared to be Jay’s resolution was his way of striving creatively to survive the unsurvivable. I realized from that discussion that everyone attempts to heal in his or her own unique and innovative manner. I began to think differently about the elaborate, creative behavior Jay enacts as a method to express his fears, anxiety, and unacceptable, scary feelings. Jay had said once, “ If you don’t know the reason for your pain, it’s hell. You have to sit with it and it could get worse- and overwhelm you (me).” Now, it was time for me to sit with him and learn of his hell. I became far more able to engage with compassion and patience with Jay, and others of my patients, fundamentally shifting in how I listened to their stories. As I did so, I was able to elicit from Jay the unfolding of his historical trauma.
This narrative came out in bits and pieces over months interspersed with my empathic curiosity, occasional comments, and encouragement. I found out that Jay witnessed as a young child a friend being crushed to death while his mother told him everything would be all right. He was bullied by peers all the way through high school/boarding school where Jay was sent because he and his parents agreed that he wasn’t doing well in math and needed to begin succeeding. In fact, Jay was able to acknowledge that he was very different from his family in that getting up in the morning and being productive was not easy for him as it seemed to be for the rest of his family. He told me that his family moved often when he was quite young as his father moved up the corporate ladder; I gathered that he did not like the frequent moves. He had three terrifying dreams at ages five, seven, and nine that he did not tell his parents about as he thought they would not understand and that he was not sure he could explain these nightmares although he was terrified. He remembered his own emotional state as being happy to becoming depressed and having trouble staying focused and attentive after he experienced the dreams. Jay stated that his parents did the best they could particularly during his early twenties when he became a “long hair” and moved west. There, involving himself in drug use and a group that gave him spiritual guidance and support, Jay became extremely depressed, arranging to meet with the group leader. Trying to receive some help, he learned instead that the leader was embroiled in a sex scandal and unavailable. Jay dealt with what I think was his disappointment by literally jumping from a building on a directive from his internal world. I began to think about his dissociating because his feelings were unbearable. I realized that the overwhelming quality of his feelings could only be tolerated by his explaining their causality as the result of the internal judges’ directives. I began to see him as very lonely with no one to help him transform his terrified and unacceptable thoughts and feelings by sharing them. Instead, he became more and more agitated ending in the jump. In fact, Jay is extraordinarily lonely with no one but these judges as his counsel. Now, after a very long time where I was not able to really recognize his experiences, much was opening up for me- but not necessarily for him.
I continue to hypothesize that his internal world is a creative, albeit, painful way for him to understand what he can’t face. That is, no one has been able to comfort him, make him and his world safe in the reality of trauma that has been ever present in his life since early childhood. Since he seems to have been or felt essentially alone, trauma has gone unarticulated and he has, unknowingly, devised an internal world that helps him to understand his life and to contain unbearable, unacceptable feelings. It is a way – his way to feel safe – just as I have my way to keep on going – despite the knowledge that he will die one day. “Death is formidable- the ultimate in lack of control,” Jay told me one day to my astonishment.
A session in mid October illustrates my thoughts about what he deals with and how he dissociates his fears, thoughts and feelings on a regular basis. He came into the session telling me that he felt in crisis: that is, after I asked what he meant by being in crisis: off center, not solid, disconcerting.
Jay focused on the fact that if he could convince these internalized judges to think differently about life’s priorities, purpose- what life is about, living would be better for everyone because it would mean the end of Jay being harassed. Jay explained to me that if he could be successful in getting the judges to stop their harassment, he could feel safe and not upset which would make him more powerful rather than feel victimized. He wouldn’t have to ward off feelings of anger.
At the session I am describing, Jay went on to say that he doesn’t get angry very often because it is too scary. He told me that a man at his previous place of employment got angry all the time and that it was scary. He went on to state that anger is a type of poison, that the man at his office used to get angry for no good reason and that he was miserable. Recently Jay got a call from his former employer to say that the angry man committed suicide. It sounded to me that Jay found that perfectly reasonable, as the man was so angry. I tried to continue the topic of anger and he began to share more of his thoughts. He is relieved that he does not often feel angry because it backfires, is uncomfortable, brings you down, is not a good idea, and is negative. He has gotten angry, but he tries not to express the feeling. He also told me that in high school there was a student who made sure he got what he wanted. He was demanding and powerful and would override what Jay wanted to do.
I felt rather stunned to hear his thoughts and let him know that he has endured many challenging and scary experiences. I reminded him that he did not tell his parents about his three terrifying dreams because he did not think that they would understand and he could not explain himself. I told him that he has been alone and misunderstood. He has had to form a plan to feel safe. During this session, he characterized one of the internal judges as a New York judge helping him to remove the rest of the judges to Africa to be placed in a refugee camp where there were many black bodies, a great deal of poverty, and the place where they would be sent would be too far away to come back. I thought to myself that he was finding a new solution – one that would send these internal persecutors so far away they could never come back to harm him- he could experience himself as more powerful. The session was coming to an end, so I shared my warm feelings by letting Jay know about my idea that as we talked about his world, perhaps he would not have to feel so alone anymore.
And then there is Jay and I – our relationship. It is, of course, part of human nature to relate to others. How that “looks” and is experienced is as diverse and potentially complicated as the number of people on earth. In his volume “Loss”, John Bowlby writes, “This… volume… explores the implications for the psychology and psychopathology of personality of the ways in which young children respond to a temporary or permanent loss of mother-figure” (p.1) Philip Bromberg tells us that trauma doesn’t have to be massive trauma. It can operate just as much and sometimes more extensively when early “developmental trauma” has created areas of dissociative mental structure with or without subsequent massive trauma. This form of trauma is also called relational trauma and is of such significance because it shapes the attachment patterns that establish what is to become a stable or unstable core self. The part that I am underlining in this presentation is relational trauma and its impact on both Jay and myself as individuals. The purpose of this presentation is not to expand the theoretical underpinnings of dissociation, loss, or attachment. But, the context is apparent, as I have described the early occurrences in both of our lives. Perhaps Barack Obama expresses my point both succinctly and sensitively when he wrote about the time when he was ten years old and his mother sent him back to Hawaii at the age of ten, to live with her parents and attend prep school. He describes “an adolescence shadowed by a sense of alienation. I didn’t feel [her absence] as a deprivation, but when I think about the fact that I was separated from her, I suspect it had more of an impact than I know.” (Time magazine)
“ I don’t like it when you leave.” That short declaration of intense feeling came during a session when Jay and I were confirming our meetings due to my previously announced time out of the office. It is one of the few instances that he ever mentioned a thought or feeling about our separation. As I acknowledged what we as therapists consider pretty standard feelings, I also began to explore more about anger in the family. Jay told me that anger was not part of the family- except when his father was occasionally angry which at the end of his life became overbearing and controlling. His mother was calm, cool and any anger was short lived; noting that she had a certain way to say no. It made me wonder if indeed all she could say to her little boy when he came running home to tell her that he had seen a child being crushed to death is it will be o.k.
I have been seeing Jay for about six years and this memory is about in the second year of treatment. In some ways, it now feels like a precursor to considering our relationship and the anger and loss that he feels at one point or another. I was away from the office and a colleague who was covering contacted me as I was vacationing. She told me that Jay had called and was not feeling good; he was not doing well emotionally. (I assume that meant he was having rough nights with the internalized judges) and needed to talk to her. She explained to me she suggested to Jay perhaps he was missing me. He definitively let her know that his mental condition had nothing to do with me. At the time, both my colleague and myself felt that her statement held a great deal of truth, but we both knew that was as far as it was going to go. I called him and he seemed to feel better with no further comments on my part regarding him missing me- or being angry with me.
Now, fast forward to our current work and his recent statement “I don’t like it when you leave”. Now I could ask him to talk about his thoughts. He let me know that they, as usual, were very limited. But, he did add that it felt like a pressure to cope with the situation and he had to tolerate it. I continued to pursue this sensitive area. I made some general statements like “My taking time away from the office affects you and I am the one who gets to choose.” We talked about the safety of a regular schedule and that it helps him to feel less lost/lonely. There is a predictable structure to his life. He doesn’t get a choice when I go away, but, I reminded him, he can say what he feels. In fact, I have been going away a bit more than I used to and we are in newer territory. He never asks where I go or what I am doing. I always have a colleague on call that he has met with and liked. He doesn’t like paying the non-insurance fee, and so he often refrains from calling.
On the other hand, he has always contacted me when he is having a hard time with his internal world. Our phone calls are usually short- he seems to feel better when I respond by asking him how he is doing, what he is experiencing, and then he thanks me and says he will call again if he needs to. I never feel like he is taking advantage of me or my time and now that I feel more comfortable with his internal experiences and with my own, I do not feel so helpless or needing to do more than listen, support his action of reaching out thus helping him to regulate himself.
As I was beginning to work on this final portion of the presentation, I knew that I was going to struggle with describing Jay and my relationship. I know that we rarely talk about us unless I bring it up. I know that he doesn’t give me much opportunity to do so. Our work focuses on him and how he is feeling either physically – even to the extent of the state of his bowel movements – or emotionally – or both. But, I am able to more carefully pay attention to those opportunities when we can include us into the relationship. Sometimes, however, when I am trying to suggest that he might feel – something – and I am practically alone stating my thoughts, he will ask if we can talk about something else! I am able to ask about his wanting to switch topics and he is just done with the topic. When I have been able to tell him – when he gives me the opening – what I think about him and his history and how it has affected/impacted his life, he is pretty quiet, but not requesting a change of subject.
Sometimes, I have noticed that following just such a moment or moments, the session goes on, but the next session he will report that he has had less interference at night. He doesn’t know why (I usually ask if he has any ideas as to the causality) and I haven’t gotten to the point of suggesting that perhaps it has something to do with the previous session where I told him I didn’t think he was crazy or the cause might be that we are thinking and feeling together in a different way. I still don’t trust that he would even begin to engage in that idea and I have wondered to myself how careful I need to be so as not to dismantle the world that he has created. It is only with his internal life that he can make sense of his experiences and have a solution that will result in allowing him to contain his feelings and secure a peaceful, trauma free world. I believe that he is involved in this daunting task because he could not feel safe and comforted in his life and cannot tolerate the idea that his caretakers could not consistently provide an environment that would nurture his growth and development.
I often catch a glance of possible connection/affection, or hear Jay thank me for a return phone call, or for talking to him about the topics in which he is interested. He rarely initiates a conversation other than to ask me what movies I have seen or what is going on in the world.
As for me- in a clinical sense, I think that we are doing o.k. – we are continuing to establish and develop our connection, but moving very slowly- and I feel more tolerant of that. In some ways, I feel like I am coming out of a dissociated state that is allowing me to be more recognizant of Jay and his struggles as I am more empathic toward myself and my facing into my fears. We are both trying to make our way and when we are together, we are doing the same with me leading the way.
When I sit back and think about my work with Jay, I become even more aware of the major influences that I have talked about in this presentation that have helped inform my experience with him. I think also of Stephen Mitchell, one of the most well known relational school theoreticians who stated that “the relational analyst’s expertise lies solely in her ability to engage the client in the active creation of new life-meanings, meanings that offer him a wider range for personal engagement, authenticity, and freedom.” I think back also to my social work foundation and the work of Jessie Taft a social work therapist and educator who entered the field before the First World War and became a leading voice in social work at the University of Pennsylvania School of Social Work. She wrote in her professional biography published in 1962 “ The basic need of the individual, after all, is not pleasure but more life, to make more and more of the underlying energy accessible for integration, to go with the life process instead of fighting it, and to find and use his own capacity for relationship and for creativity, however slight.” (p. 336) I find it helpful to think in this way so that I can sustain myself when I wonder if I am being helpful; if he is developing a more integrated self – a self that is not so bombarded by either physical or emotional turmoil. In a session just before I left for Boston, he reported that he had nothing much to report other than he was reading and watching movies. I thought to myself that the fact he was able to concentrate on something other than his internal world was significant. He also let me know that the flu shot he received had affected him in that he felt like he had the flu. He told me of a series of symptoms and what he was doing to take care of himself and then, in answer to my question, reported that his internal world was quiet right now. I said something like that was probably a relief. But I know that we can only talk about certain facts with no reflection other than mine about the phenomenon of his threatening self-states. My hope is that as I continue to appreciate my own struggles, I can also continue to appreciate his and how he tries to cope with what confronts him daily while he learns to face his fears in a less punitive and sequestered, distinctive approach.
- Bowlby, J. (1980). Attachment and Loss: Vol 3 Loss: Sadness and depression. New York: Basic Books.
- Bromberg, P. M. (2006). Awakening the Dreamer Clinical Journeys. Mahwah: The Analytic Press
- Child, L. (2006). Clarice Bean, Don’t Look Now. Cambridge, Candlewick Press de Montaigne, M. The Essays of Michel de Montaigne, translated and edited by M.A. Screech (London: Allan Lane, 1991), p.95.
- Mitchell, S.A. (1993). Hope and Dread in Psychoanalysis. New York: Basic Books, Socarides, D.S. Stolorow, R.D., Brandchaft, B. & Atwood, G. (1987). Affects and Selfobjects. In R. Stolorow, Brandchaft, B. & Atwood, G. (Eds.) Psychoanalytic Treatment An Intersubjective Approach. (pp.66-87). Hillsdale: The Analytic Press
- Taft, J. (1962). Jessie Taft Therapist and Social Work Educator A Professional Biography (Ed., Robinson, V.P.) ( p.336) London: Oxford University Press
Please note that this is a partial reference list in terms of the absence of citations for the theoretical issue of unresolved trauma on page 6 (personal communication, Gwyn Erwin, 2008) and a quote from Time magazine by Barack Obama on page 10. Should you want a more complete list, please contact me @ email@example.com.