Seeing Through the Fog: Learning to Work with Dissociation

Often the experience of learning from the patient is seamless, embedded in the unfolding clinical process. Patient and analyst bring their respective needs and capacities to this relationship and find new ways to collaborate toward the emotional growth of the patient, with the expectable amount of challenge and surprise along the way. Hopefully, analysts learn with every clinical encounter—but frequently it is when they are most challenged that they are aware of learning something particular from their patients about the therapeutic process. Patients with significant narcissistic vulnerabilities and corresponding narcissistic defenses can be quite challenging in treatment, especially in regards to the way that affects and whole sectors of the personality can be split-off and inaccessible in the treatment for a considerable time. It is the nature of this splitting-off, its subtle yet pervasive role in the treatment relationship, and the manner in which it led to both impasse and then insight, that became the focus of my learning from my patient. This article describes a treatment in which the dissociative process itself was dissociated, and how that came into awareness for both patient and analyst.