University of Pennsylvania ScholarlyCommons Doctorate in Social Work (DSW) Dissertations School of Social Policy and Practice Spring 5-13-2013 Do You Know What I Know? Examining the Therapist's Internal Experience when a Patient Dissociates in Session Jacqueline R. Strait University of Pennsylvania, [email protected] Follow this and additional works at: https://repository.upenn.edu/edissertations_sp2 Part of the Psychology Commons, and the Social Work Commons Recommended Citation Strait, Jacqueline R., "Do You Know What I Know? Examining the Therapist's Internal Experience when a Patient Dissociates in Session" (2013). Doctorate in Social Work (DSW) Dissertations. 36. https://repository.upenn.edu/edissertations_sp2/36 This paper is posted at ScholarlyCommons. https://repository.upenn.edu/edissertations_sp2/36 For more information, please contact [email protected]. Do You Know What I Know? Examining the Therapist's Internal Experience when a Patient Dissociates in Session Abstract There is rich theoretical literature that cites the importance of the therapist’s use of self as a way of knowing, especially in cases where a patient has been severely traumatized in early life. There is limited empirical research that explores the in-session experience of therapists working with traumatized patients in order to support these claims. This study employed a qualitative design to explore a therapist’s internal experience when a patient dissociates in session. The aim of this study was to further develop the theoretical construct of dissociative attunement to explain the way that therapist and patient engage in a nonverbal process of synchronicity that has the potential to communicate dissociated images, affect or somatosensory experiences by way of the therapist’s internal experience. Findings revealed that therapists have strong emotional and behavioral responses to a patient’s dissociation in session, which include anxiety, feelings of aloneness, retreat into one’s own subjectivity and alternating patterns of hyperarousal and mutual dissociation. Findings also revealed that the process of dissociative attunement is at play when a patient dissociates in session. The process of dissociative attunement was comprised of seven component parts: Disjunction and Connection, Perception of Nonverbal Cues, Induced Feeling, Therapist as Placeholder, Asymmetry of Roles and Responsibility in the Dyad, Containment, and Therapist Imaginings. Findings imply that a patient’s dissociation in session should be considered an interpersonal phenomenon that holds the potential to communicate important aspects of the patient’s affective experience and needs through examination of the therapist’s internal experiences. Degree Type Dissertation Degree Name Doctor of Social Work (DSW) First Advisor Jeffrey Applegate PhD Second Advisor Lina Hartocollis PhD Third Advisor Roberta G Sands PhD Keywords dissociative attunement, dissociate, intersubjective communication, countertransference Subject Categories Psychology | Social Work This dissertation is available at ScholarlyCommons: https://repository.upenn.edu/edissertations_sp2/36 DO YOU KNOW WHAT I KNOW? EXAMINING THE THERAPIST’S INTERNAL EXPERIENCE WHEN A PATIENT DISSOCIATES IN SESSION Jacqueline Russo Strait, MSW, LCSW A DISSERTATION in Social Work Presented to the Faculties of the University of Pennsylvania In Partial Fulfillment of the Requirements for the Degree of Doctor of Social Work 2013 Jeffrey Applegate, PhD Dissertation Chair Richard J. Gelles, PhD Dean, School of Social Policy and Practice Dissertation Committee Lina Hartocollis, PhD Roberta G. Sands, PhD Copyright 2013 by Strait, Jacqueline R. All rights reserved. iii Acknowledgements There is a story I’ve been told many times in my life. My mom awakens from a sound sleep with a startle. She sits up in bed and says, “One of the girls is sick.” My dad asks, “How do you know?” “I just know.” This is the essence of what attunement is. I have known it and lived it long before I knew the word. For this, I am eternally and enormously grateful. It has shaped my life in innumerable ways and made me the social worker, the clinician, and the mother I am today. Thank you to my loving, wonderful, generous parents for teaching me how to be in relationship with clear perception and an open heart. This dissertation topic is born of pain and love. I have been touched and inspired by the stories of many survivors of grave and early life trauma. I am honored to be with them in both pain and in love. To them, I am deeply grateful for allowing me to enter into the deepest recesses of their minds and hearts and to travel with them to the pain of their traumas and back. This dissertation would not be possible without the support of my dissertation chair, Jeff Applegate. He is wise, conceptually brilliant, and yet utterly kind and gentle. He reviewed endless drafts speedily and with great care. His revisions and suggestions were an invaluable asset to the development of this project. Perhaps more precious to me, though, was his steady belief in the importance of this work. Just when I began to doubt the relevance of my topic or the significance of my findings, he offered enthusiasm at the precise moment I needed it. He ended almost every exchange with the familiar words “carry on” – and carry on I did with his unending encouragement. I am deeply grateful to Lina Hartocollis for her role in my professional development. Lina was my first year practice professor as an MSW student. From this early stage in my career, she has paid careful attention to my development as a social worker, a researcher, an instructor, iv and a person. She has contributed conceptual wisdom and expertise in the fields of dissociation and psychoanalysis to my dissertation. Beyond this, she has continued to serve as an important role model for me in her work as an educator and a scholar. I am especially grateful to Roberta Sands for her contributions to my dissertation. As my resident methodologist, she offered crucially important feedback for the development of my research methods and the construction of my findings chapters. Dr. Sands pushed me to be ever clearer and more precise. She offered thoughtful and detailed feedback balanced with gentleness and support. Many people admonish mothers of a new baby to “sleep when the baby sleeps!” Well, my motto was “write when the baby sleeps!” This would not have been possible without the enormous help from my devoted husband, who did countless loads of laundry, middle of the night diaper changes and trips to the grocery store. You stepped up big time when I needed you and I will be eternally grateful. You have been generous with your love and stingy with your criticism. You are my heart and my home. Without you, none of this would be possible, but with you, anything is. And last, my precious daughter, who was with me as I wove together the final chapters of this dissertation, often in my arms or on my chest. You have taught me firsthand the meaning of attunement, and perhaps more profoundly, the joy and the peace that comes from being in sync, right brain-to-right brain, with another human being. You stole my heart the moment you were born. I love you right up to the moon, and back. v ABSTRACT DO YOU KNOW WHAT I KNOW? EXAMINING THE THERAPIST’S INTERNAL EXPERIENCE WHEN A PATIENT DISSOCIATES IN SESSION Jacqueline Russo Strait, MSW, LCSW Jeffrey Applegate, PhD There is rich theoretical literature that cites the importance of the therapist’s use of self as a way of knowing, especially in cases where a patient has been severely traumatized in early life. There is limited empirical research that explores the in-session experience of therapists working with traumatized patients in order to support these claims. This study employed a qualitative design to explore a therapist’s internal experience when a patient dissociates in session. The aim of this study was to further develop the theoretical construct of dissociative attunement to explain the way that therapist and patient engage in a nonverbal process of synchronicity that has the potential to communicate dissociated images, affect or somatosensory experiences by way of the therapist’s internal experience. Findings revealed that therapists have strong emotional and behavioral responses to a patient’s dissociation in session, which include anxiety, feelings of aloneness, retreat into one’s own subjectivity and alternating patterns of hyperarousal and mutual dissociation. Findings also revealed that the process of dissociative attunement is at play when a patient dissociates in session. The process of dissociative attunement was comprised of seven component parts: Disjunction and Connection, Perception of Nonverbal Cues, Induced Feeling, Therapist as Placeholder, Asymmetry of Roles and Responsibility in the Dyad, Containment, and Therapist Imaginings. Findings imply that a patient’s dissociation in session should be vi considered an interpersonal phenomenon that holds the potential to communicate important aspects of the patient’s affective experience and needs through examination of the therapist’s internal experiences. vii TABLE OF CONTENTS Acknowledgements ………………………………………………………………...……………iii Abstract…...………………………………………………………………………………………v Preface….……………………………………………………………………………………….xiii Chapter I. INTRODUCTION Problem Statement……………………………………………………………………………….. 1 Purpose of Study ………………………………………………………………………………….6 II. LITERATURE REVIEW Trauma and Dissociation ………………………………………………………………………..