In the early 2000s, I stepped outside the psychoanalytic world that had been my home for 20 years. By then, I had experienced the life-changing power of psychoanalysis, but I had also witnessed the analyses of many dedicated people, working with kind and skillful practitioners, founder abruptly, or shatter beyond repair. I saw that despite intense theoretical debates, no analytic school consistently negotiated these destructive eruptions of need and rage.
The impasses involved early trauma, often sexual. I thought about Freud’s repudiation of the seduction hypothesis, Ferenczi’s exile from analytic respectability, and how discussion of trauma, outside the mother-infant attachment bond, was stifled for nearly a century. (Kernberg’s 1984 volume, Severe Personality Disorders, does not even mention trauma in its index.)
Searching for a wider scope and new approaches, I trained in EMDR, sensorimotor psychotherapy, and Internal Family Systems, among other modalities. The concepts “holding” and “containment” took on deeper meaning for me. A psyche that’s held, and contained when holding slips, can reflect and connect. Traditionally, analysts use verbal engagement and attention to the therapeutic relationship to hold and contain our patients. We think much less about external containment. There’s not much literature about the containing function of financial security, stable housing, adequate healthcare, meaningful work, supportive relationships, spiritual beliefs—or just being free to leave home without fearing attack because you appear to belong to a targeted group.
In the classic mid-century presentations of psychoanalysis with severe disturbances, troubled patients engaged in profound, often inspiring, analytic work. Most, though, were young and white, and all were living in safe, privileged conditions. Margaret Little was a working analyst, but Winnicott could hospitalize her during a month-long vacation while she was deeply regressed, knowing she would receive attentive care. Rosenfeld’s psychotic patient Mildred lived, financially secure, with her extraordinarily long-suffering mother. Marion Milner’s famous patient Susan lived with the Winnicotts. Searles, Sullivan, and Fromm-Reichmann were often treating residential patients. These analysts could all assume that more intensive treatment, including an inpatient stay, offered genuine backup, not just a stopgap measure for acutely dangerous states. They offered their patients intensive, truly open-ended analyses.
We rarely work in conditions that approach these. Our patients may lack money, time, or both, and deep regressions, whatever their potential value, remain out of the question when folks have children to care for and rent to pay. Social safety nets are in tatters. Add in the internal minefields that severe trauma creates, and we begin to see how much we must navigate without the support systems renowned mid-century analysts could count on.
When there’s too much to hold, you have to grow the container or shrink the contained.
Unheld or uncontained psyches resort to desperate measures, attempting to shrink the contained by splitting it off through numbing, distraction, denial, and projective processes. They challenge our desire to promote integration by clinging to the perceived safety of dissociation.
Work with these patients especially can benefit from the insights of trauma theory. Trauma affects not just emotions, beliefs, and fantasies, but also the nervous system, the hormonal system, memory, musculature, and perception. Such understanding can help our patients shrink the contained in more deliberate, useful ways, both temporarily and long-term.
They can use it to expand their psychic container, opening themselves to more and more of their experience.
A sophisticated colleague recently came to me for consultation on a difficult case. While discussing the dangers of intense dependent regressions with early trauma, she said, “Of course, that’s inevitable at some point.” But what if it’s not, or it’s far less inevitable than we’ve come to believe?
Trauma techniques share a set of core organizing principles that attenuate the risks.
Present-moment mindfulness encourages steadiness, even in the presence of intense feelings.
Attention to the body increases insight into the unthought knowns of procedural memory while helping patients use internal signals to pace their work. Cultivating self-regulatory capacities, and maintaining felt contact with present safety, build confidence in the ability to handle formerly overwhelming states. Close attention to dissociative processes guards against frustrating repetitions and shocking reversals. Shifting emphasis toward patients’ relationships to their inner worlds, and away from dependent transference dynamics, supports self-care and self-compassion in the face of mis-attunements and disruptions. [I discuss these principles in more detail, along with case examples, in two recent articles (Dent 2020, Dent 2021)].
None of these changes involves making the work mechanical or detracting from depth or insight. Trauma processing techniques can seem almost magical when conditions are right, transforming long-held fear and pain into equanimity within just a few sessions. But EMDR, IFS, and somatic therapies don’t just process trauma, they create gateways to meaning. I’ll end with a simple example, from work with an exceptionally kind woman in the midst of a painful divorce. I asked her to slowly and mindfully let her arm extend, as if she were reaching for help. She laughed uncomfortably. “It won’t move. Wow. I can’t reach out. What do you know.” “You want to work on that?” “Absolutely.”
References:
Dent, V (2020). When the body keeps the score: Some implications of trauma theory and practice for psychoanalytic work. Psychoanalytic Inquiry, 40:6, 435-447.
Dent, V (2021). When understanding and connecting aren’t enough: Working with traumatic states. Fort Da, 27:1, 56-74.
