Knowing, Not-Knowing and Sort-of-Knowing: Psychoanalysis and the Experience of Uncertainty

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A contemporary, wide-ranging exploration of one of the most provocative topics currently under psychoanalytic investigation: the relationship of dissociation to varieties of knowing and unknowing. The twenty-eight essays collected here invite readers to reflect upon the ways the mind is structured around and through knowing, not-knowing, and sort-of-knowing or uncertainty.The authors explore the ramifications of being up against the limits of what they can know as through their clinical practice, and theoretical considerations, they simultaneously attempt to open up psychic and physical experience. How, they ask, do we tolerate ambiguity and blind spots as we try to know? And how do we make all of this useful to our patients and ourselves?The authors approach these and similar epistemological questions through an impressively wide variety of clinical dilemmas (e.g., the impact of new technologies upon the analytic dyad) and theoretical specialties (e.g., neurobiology). Some of the numerous issues under examination here include important and, in some instances, under-theorized topics in psychoanalysis such as uncanny communication as the next frontier of intersubjectivity, secrets, criminal violence, the relationship of the body to knowing, disclosure of the analyst's joy, dissociative identity disorder, pornography and sex workers.

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CHAPTER ONE: The enigma of the transference

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The enigma of the transference

Edgar A. Levenson, M.D.

Psychoanalysis from its inception has been biased towards theory, metapsychology, presumably the font of the mutative therapeutic action. Far less emphasis has been put on the phenomenology of therapeutic action; that is, on how people change. This valorization of metapsychology is increasingly coming under scrutiny, however, as the erstwhile sharp-edged doctrinaire distinctions between positions blur and attention shifts to an emergent neu-ropsychological paradigm; at this stage of knowledge really more a metaphor than a genuine model (Pulver 2003). In other words, now that it is less clear that we are right and that you are wrong, we are all beginning to wonder what it is we are doing when we do what we all know how to do.

Metapsychology, for all its claim to ontological truth, always reflects the current culture, the social context in which we are all imbedded, but of which we are largely unaware. As Gregory Bateson said, the point of the probe is always in the heart of the explorer (Bateson 1979: 87). The current emphasis on the vicissitudes of early mothering, especially as described in attachment theory, reflects a cultural change, from the patriarchal, Oedipal-oriented (conflict and envy) world in which I both grew up and became an analyst, to a matriarchal, nurturing one in which mothering (early) and empathy is privileged. One also notes, not inconsequentially, that the demographics of psychoanalysis have shifted from largely male and medical to female and psychological along with a radical shift in the economics. Believe it or not, when I entered the field in the early fifties, psychoanalysis was the second highest paid medical specialty and we had waiting lists! Clearly this made for a therapeutic milieu that tolerated more frustration and tempted therapist less to over-aggressive interventions.

 

CHAPTER TWO: The nearness of you: Navigating selfhood, otherness, and uncertainty

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The nearness of you: Navigating
selfhood, otherness, and uncertainty

Philip M. Bromberg, Ph.D.

In deciding how to write this Keynote Address I was helped by the two memorable Keynotes delivered by Adrienne Harris and Irwin Hoffman at the 2007 Division 39 Spring meeting in Toronto. I noticed while listening to them that the speaker is allowed remarkable personal latitude to write in whatever form and about whatever topic he or she chooses as long as it is germane to the theme of the conference. Harris (21 April, 2007) wrote autobiographically—and did it as though she were born to it—even though, as I discovered on my own, it is harder than it looks. In Hoffman’s Keynote (22 April, 2007), I was equally struck by the speaker’s freedom to write a position paper on whatever aspect of the theme he holds to be of most personal significance. In my own Keynote I have appreciatively drawn upon what they each did with this gift of freedom, by developing a perspective on “Knowing, Not-Knowing, and Sort-of-Knowing” that I believe speaks to the future of psychoanalysis in its relevance as a therapeutic process and in its value to society. I am going to begin autobiographically, using my relationship to writing as the point of entry.

 

CHAPTER THREE: The unconscious as a knowledge processing centre

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The unconscious as a knowledge processing centre

Arnold H. Modell, M.D.

The theme of this meeting, “knowing and not knowing”, challenged us to reconsider a fundamental aspect of human nature, the relationship between our unconscious and our conscious mind. Psychoanalysis from its inception has focused on the connections between unconscious knowledge and conscious awareness. We can approach a definition of unconscious knowledge by asking the following questions: how can we know something without being aware of it? And how can we be aware of something that we don’t know? In either case let us assume that the unconscious mind knows–that the unconscious retains in memory a lifetime of emotionally significant experiences and emotionally salient fantasies. This would include the memory of those experiences with one’s caretakers that occurred prior to the age of two or three, prior to the age of retrievable memories. We may unable to recall such memories because prior to that age the hippocampus, that structure in the brain that is necessary for the recall of a memory, has not yet matured. These memories remain as unthought knowns (Bollas 2007). Such memories have also been referred to as somatic memories, indicating that our body remembers even if we can’t remember. All of this is to indicate that the unconscious is a source of knowledge, but as I plan to illustrate, the unconscious is the area of the psyche in which knowledge is processed.

 

CHAPTER FOUR: Shooting in the spaces: Violent crime as dissociated enactment

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Shooting in the spaces: Violent crime
as dissociated enactment

Abby Stein, Ph.D.

When Philip M. Bromberg (1996) coined the phrase “standing in the spaces”, he fashioned a brilliant theoretic toggle. His word string demoted the minable, linear Freudian subject who had epitomized the late nineteenth and early twentieth centuries, and instead privileged the myriad internal characters that both cantilever and sabotage subjectivity. In clinical papers throughout the decade, Bromberg deftly and convincingly conjoined the unitary and continuous self with its more evanescent and excursive overlords: those divided selves, untethered from the constraints of temporal perspective, who demonstrated that consciousness was a corrugated continuum and not, as had been averred, a simple Freudian divide: conscious, unconscious, preconscious.

What gave Bromberg’s assertions clinical power was that he managed to address the way that people dropped defensive anchor in a protean internal sea, even as they responded to shifting externalities that revealed their own fractionation. Bromberg (1998) engaged core linearity (“staying the same”) respectfully, while distinguishing multiplicity as the potential site of change.

 

CHAPTER FIVE: Dissociative identity disorder: The abused child and the spurned diagnosis

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Dissociative identity disorder: The
abused child and the spurned diagnosis

Sheldon Itzkowitz, Ph.D.

For the past fifteen years I have been working with patients suffering with Dissociative Identity Disorder. During that time, I have encountered clinicians who have accepted this diagnosis as legitimate, others who ran the gamut from skeptical to critical, disbelieving, and shaming of patients and therapists who work so hard to help them. I chose to present the work with my patient, Yolanda, in the hopes of informing and enlightening clinicians about the reality of this disorder. To that end, a panel, and now chapter, entitled “Dissociative Identity Disorder: The Abused Child and the Spurned Diagnosis” was created.

After a brief description of my patient, Yolanda, are two discussion Chapters (six and seven) by Elizabeth Howell, Ph.D. and Elizabeth Hegeman, Ph.D. At the Div. 39 conference, a video clip from a session with Yolanda was presented. The video documents the transition of Yolanda from adult woman, to Carlos, a young boy around the age of six, and back to her adult self again. The audience saw the striking and dramatic shifts in self states from adult to child with the accompanying changes in body posture and movements, tone and timbre of voice, and rate and rhythm of speech, that accompanied her shift in cognition.

 

CHAPTER SIX: Dissociation and dissociative disorders: Commentary and context

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Dissociation and dissociative disorders:
Commentary and context

Elizabeth Howell, Ph.D.

In this chapter I discuss the personality organization of highly dissociative individuals as well as the dissociative organization of our culture. Not only does the first mirror the second, but there are also profound interactions, based largely on shame and shaming and victim/aggressor dynamics. These dynamics increase the dissociation between contradictory cultural beliefs, such as the enacted belief in the ownership of children and the right to abuse them (for example, manifested in the extremely high prevalence of child sexual abuse), existing side by side with the even greater rate of its denial. These dissociatively based contradictions in cultural knowledge also further isolate those people who are highly dissociative.

First, I am going to comment on Dr. Itzkowitz’s case of Yolanda and introduce some generalities about Dissociative Identity Disorder (DID). Then, I will offer a response to Dr. Itzkowitz’s observations regarding the spurned diagnosis.

 

CHAPTER SEVEN: Multiple personality disorder and spirit possession: Alike, yet not alike

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Multiple personality disorder and spirit
possession: Alike, yet not alike

Elizabeth Hegeman, Ph.D.

First I will compare my views of Multiple Personality Disorder (MPD) and Spirit Possession, and then talk about how I see them overlap in the patient, Yolanda, presented by Dr. Itkzowitz (see Chapter five). Both MPD the diagnosis and Spirit Possession as a widespread cultural tradition, challenge the Western definition of the self as highly bounded, individual, and autonomous. In fact, Western cultures are in the minority in doubting and pathologizing self states: ninety per cent of the world’s 488 non-Western cultures accept some form of altered state experience, and at least fifty per cent have a structured belief in Spirit Possession as a valued and valid aspect of self. Second, and most salient to the case presented in Chapter five and the discussion in Chapter six, I believe that MPD definitely, and Spirit Possession potentially, serve to deny and disguise trauma, simultaneously hiding it and representing it in a disguised form. MPD is a ‘spurned’ diagnosis first, because unlike other cultures, Western culture valorizes a highly bounded self, and second, as Elizabeth Howell, Ph.D. (Chapter six) has shown, because the abuse of power that engenders it is still (and perhaps always will be) disavowed. Disbelief is the universal Western affective counter-transference both to the abuse, and to shifts in identity. To illustrate this devaluation: try noticing your own reactions to the diagnosis as you think about it—can you track disbelief, subtle contempt, skepticism, even if you think you ‘believe’ in the importance of understanding dissociative processes? I still feel those feelings when I talk about MPD. Fragmentation of the unitary self makes us anxious. Lawyers long ago abandoned dissociation as a defense in criminal trials because of the knowledge that juries dismiss it as simply an attempt to evade responsibility. So, we pathologize this form of human experience both from our ethnocentrism and from our need to deny and ignore the injustice of illegitimate dominance/subjugation.

 

CHAPTER EIGHT: Masochistic relating, dissociation, and the wish to rescue the loved one: A view from multiple self-state theory

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Masochistic relating, dissociation,
and the wish to rescue the loved one:
A view from multiple self-state theory

Peter Lessem, Ph.D.

In working with Ned I was amazed and often frustrated by his willingness to allow himself to be repeatedly exploited and maligned by his wife. I was struck by his acquiescing to her numerous and usually unfair criticisms, her many outrageous and exploitive demands, and her remarkable sense of entitlement towards him. Yet, Ned maintained that she was entitled to act this way particularly because of his inadequacy and his being undeserving. I was impressed to see that he held this view tenaciously for a very long time despite my best efforts to question it, connect it with his relevant childhood experience, speculate about the functions it served for him, and point out how he was recurrently hurting himself in the process. I do not think that this is an unfamiliar scenario for us to hear about in our offices.

In this paper I will use the term “masochistic” in a particular, restricted way. I will use it solely to refer to a style of relating in which, in the analyst’s opinion, the patient winds up being repeatedly mistreated. I want to be clear that I am not subscribing to a drive theory conception of masochism as seeking pain as a necessary precondition for, or accompaniment of, sexual pleasure. Also, I am not using the term to refer to particular sexual practices or to the practice of inflicting pain on oneself in order to shore up self-cohesion or to stimulate a sense of aliveness, or to assuage a sense of guilt.

 

CHAPTER NINE: Things that go bump in the night: Secrets after dark

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Things that go bump in the night:
Secrets after dark

Jean Petrucelli, Ph.D.

When I was five years old, one of my favorite experiences was to have a sleepover at my Italian grandmother’s house. It was a house filled with magical things—silk sheets, delicious smells of pasta, coffee and garlic—and I could always count on Tony Bennett or Frank Sinatra to be singing in the background. There was just one thing I wasn’t so crazy about. My Grandmother, although well-meaning, was insistent that when it was bedtime, it was bedtime. So instead of singing me a lullaby or lulling me to sleep, she’d tell me her version of a bedtime story. It went something like this: “From ghoulies and ghosties to four legged beasties … Giovonna Maria Theresina Petruccelli [as she would call me], rememberrr … there are thingsa that go bumpa in the nighta”. Out of the corner of my eye I would see her wink as she said it, trying to only “sort-of” scare me so I wouldn’t get out of bed. And on one level … it sort-of worked. I stayed in bed. However, my mind travelled to many a scary place. I never told her that I was afraid of these “thingsa”. Pretending to be brave and being the good grandchild, I had to hold the secret that I was scared. Appearing brave allowed me to believe the fantasy that my grandmother admired my bravery. Not acknowledging my fear relegated this experience to a more private domain.

 

CHAPTER TEN: Psychoanalytic treatment of panic attacks

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Psychoanalytic treatment
of panic attacks

Mark J. Blechner, Ph.D.

Panic attacks are a major mental health problem in the United States today. It has been estimated that between 1% and 3% of the general population experience panic attacks during their lifetimes (Schuman et al. 1985; Katon 1996). Patients with panic attacks use up a lot of time in medical practices and emergency rooms, when they show up repeatedly, thinking they are having a heart attack or a stroke or some other medical crisis. Of course, tests have to be run to make sure that they are not really having a heart attack or a stroke, so a lot of time and money is wasted. I think that psychoanalytic therapists should be the first line of treatment for patients with panic attacks, but that is not the case today. The conventional wisdom is that such patients should be sent to a cognitive-behavioural therapist or a psychopharmacologist. This is not good for the patients, and it is not good for psychoanalysts. I will explain why.

I will describe three patients I have seen in treatment. I will summarize what I observed with them and then discuss the theoretical implications of this data. After presenting my own data, I will summarize some of the generalizations that have been made about panic patients and then evaluate them in terms of my own clinical data. I will suggest some ways in which we might revise our theory of panic attacks and test out a newly formulated theory.

 

CHAPTER ELEVEN: On getting away with it: On the experiences we dont have

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On getting away with it: On the
experiences we don’t have

Adam Phillips

If guilt is the psychoanalytic word for not getting away with it, what is the psychoanalytic word for getting away with it? In the psychoanalytic story people are ambivalent and transgressive, whatever else they are; and these predispositions raise, by implication, the issue of getting away with something, of avoiding what are deemed to be the inevitable consequences of certain actions. So it needs to be said right at the start that if the human subject, as described by psychoanalysis, is a split subject, in conflict, by definition, with himself and others, then getting away with it—acts of harming those you love, desiring forbidden objects, letting yourself and others down, sacrificing your desire—is not an option. There is no truthful, no realistic description in the language of psychoanalysis, for getting away with it. And yet, of course, psychoanalysis also urges us to take our wishes seriously, to read them as disguised formulations of unconscious desire. And there is perhaps no stronger wish—beginning, of course, in childhood—than the wish to get away with things. It is worth wondering what the wish to get away with it is a wish for; and of course it may be different in each instance.

 

CHAPTER TWELVE: The right brain implicit self: A central mechanism of the psychotherapy change process

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The right brain implicit self:
A central mechanism of the
psychotherapy change process

Allan N. Schore, Ph.D.

After a century of disconnection, psychoanalysis is returning to its psychological and biological sources, and this re-integration is generating a palpable surge of energy and revitalization of the field. At the centre of both theoretical and clinical psychoanalysis is the concept of the unconscious. The field’s unique contribution to science has been its explorations of the psychic structures and processes that operate beneath conscious awareness in order to generate essential survival functions. In the last ten years implicit unconscious phenomena have finally become a legitimate area of not only psychoanalytic but also scientific inquiry. Writing to the broader field of psychology, Bargh and Morsella (2008: 73) now conclude, “Freud’s model of the unconscious as the primary guiding influence over every day life, even today, is more specific and detailed than any to be found in contemporary cognitive or social psychology”.

 

Right brain implicit processes and clinical intuition

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In my introduction I proposed that the therapist’s moment-to-moment navigation through these heightened affective moments occurs by not explicit verbal secondary process cognition, but rather by implicit non-verbal primary process clinical intuition. From a social neuro-science perspective, intuition is now being defined as “the subjective experience associated with the use of knowledge gained through implicit learning” (Lieberman 2000: 109). The description of intuition as “direct knowing that seeps into conscious awareness without the conscious mediation of logic or rational process” (Boucouvalas 1997: 7), clearly implies a right and not left brain function. Bugental (1987) refers to the therapist’s “intuitive sensing of what is happening in the patient back of his [sic] words and, often, back of his conscious awareness” (p. 11). In his last work Bowlby (1991) speculated, “Clearly the best therapy is done by the therapist who is naturally intuitive and also guided by the appropriate theory” (p. 16).

 

CHAPTER THIRTEEN: The uncertainty principle in the psychoanalytic process

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The uncertainty principle
in the psychoanalytic process

Wilma S. Bucci, Ph.D.

In his paper “The analyst’s self-revelation”, Bromberg (2006) says that change:

… “takes place not through thinking, ‘If I do this correctly, then that will happen’ but, rather, through an ineffable coming together of two minds in an unpredictable way”. (p. 147)

I have referred to this as Bromberg’s uncertainty principle; in this paper, I will try to deconstruct this principle and also extend it in some ways.

At a conference in Rome in July, 2007, on Psychoanalytic Theories of Unconscious Mental Functioning and Multiple Code Theory, two of the speakers, Giuseppe Moccia (2007), and Giuseppe Martini (2007), both members of the Italian Psychoanalytic Society, surveyed the domain of implicit or unconscious processes from psychoanalytic and philosophical perspectives, starting with Freud’s (1915) original insight concerning the nonrepressible part of the unconscious:

“Everything that is repressed must remain unconscious; but let us state at the very outset that the repressed does not cover everything that is unconscious. The unconscious has the wider compass: the repressed is a part of the unconscious”. (p. 166)

 

CHAPTER FOURTEEN: Implicit and explicit pathways to psychoanalytic change

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Implicit and explicit pathways
to psychoanalytic change

James L. Fosshage, Ph.D.

Theories of psychological development and therapeutic action require an understanding of how we learn, how we remember, how memory affects ongoing organization of experience, and how past learning, memory and psychological organization are transformed. Most contemporary cognitive science models differentiate between two, at times three, memory systems (Epstein 1994). The model that differentiates between two domains of learning and memory, the implicit/nondeclarative and explicit/declarative systems has recently received considerable focus in psychoanalysis with significant implications for therapeutic change.

Focusing their work on the implicit and explicit systems, the Boston Change Process Study Group (Stern et al. 1998; BCPSG 2005) have proposed that therapeutic change occurs principally in the area of “implicit relational knowing” during moments of emotional connection between analyst and patient called “moments of meeting”. These moments, they argue, occur typically at an implicit level. Changing implicit relational knowing through implicit moments of meeting underwrites the importance of new relational experience, often occurring outside conscious awareness. For the Boston Group, interpretation can contribute to a moment of meeting, but the moment of meeting is where the transformative action occurs.

 

CHAPTER FIFTEEN: Life as performance art: Right and left brain function, implicit knowing, and felt coherence

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Life as performance art: Right and left
brain function, implicit knowing, and
“felt coherence”

Richard A. Chefetz, M.D.

“Today Is A Day When It Is Hard To Keep Going. I Literally Got Through The Afternoon By Thinking About A Suicide Plan, Notes, A Sort Of “Make Shift” Will And I Even Picked Up My Room And Packed Another Box; As Though Tidying Up For Departure. But I Will See You Tomorrow Morning Though. J”

I have always marvelled at how understanding something, “getting it”, feels so good and behaves so powerfully. It is not that there is suddenly an intellectual understanding and something changes, it is that something ineffable, something felt but not necessarily clearly known, changes. There is a place within us all that seems to “know” even when we aren’t yet clear about “why” we know it—or sometimes even “what”—exactly. And when this happens, when we achieve this understanding, we feel better, relieved of tension, relaxed. This is a place of “felt coherence”. Conversely, there are times in all our lives when we behave in ways that are clearly purposeful, though perhaps not consciously intentional, and may even leave us gasping, wondering, how and why we could ever have “done” or “said” what we did! There is a way in which we know how to enact what we don’t even know we know or intend to communicate. Sometimes, we tell the story of the unbearable, the incoherent, with action. Perhaps at those times it’s the only way we stand a chance of knowing what part of our mind can’t bear to know, or is forbidden to know, but otherwise already knows, and in great detail.

 

CHAPTER SIXTEEN: Bridging neurobiology, cognitive science and psychoanalysis: Recent contributions to theories of therapeutic action

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Bridging neurobiology, cognitive
science and psychoanalysis:
Recent contributions to theories
of therapeutic action

Sandra G. Hershberg, M.D.

Chapters twelve, thirteen, fourteen and fifteen explore the ways in which knowledge and research about the implicit and explicit domains, in the context of relational experience, reconfigures concepts of memory, learning and a sense of self in the developing brain and, furthermore, contributes to a theory of mind. These findings, particularly in the areas of attachment, infant observation, and neuroscience, emphasize the primacy of relational experience and inform our notions of how psychoanalysis leads to change.

In an effort to achieve a sense of balance between coherence and chaos, Schore, Bucci, Chefetz, and Fosshage, have provided footholds of clarity and understanding as we consider various aspects of the implicit and explicit domains. Schore (1994, 2003a, 2003b, 2010), in his painstaking and creative endeavour to integrate the implicit self, psychoanalysis and neuroscience, focuses on the questions: Where in the brain do we locate the implicit self, that aspect of ourselves which is responsive to non-verbal expressions of emotions, the markers of attachment and emotional connection, and the seat of affect regulation, originally configured between infant and car-egiver? What are the implications of these findings, from his perspective, for the therapeutic process?

 

CHAPTER SEVENTEEN: Lights, camera, attachment: Female embodiment as seen through the lens of pornography

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Lights, camera, attachment:
Female embodiment as seen
through the lens of pornography

Jessica Zucker, Ph.D.

She had dildos on a shelf and a tray of paraphernalia tucked under her couch including lighters for her endless round of cigarettes. She had whips and gas masks dangling from a hook in the living room, chains, and what looked like a leash. She veered from timid and reserved to very “out there” in the telling of her life story, her expressive body almost preaching at times.

She was mesmerizing, but I found myself preoccupied by my car. Was I caught in a red zone? Would I be stuck here? Turns out, my car was fine, but I wasn’t sure that I was. “Good girl” researcher meets up with “bad girl” porn star—two sides of feminism, two sides of femininity. It was 2005, but in many ways, it was still 1975—we may have come a long way (baby), but we are still panicked by sex that is not embedded in relationships, especially when it is so obviously embedded in the market economy.

At the end of each of the interviews, I would typically ask if the interviewees had any questions for me. June took this opportunity to ask me what I fantasize about when I masturbate, what fetishes I have, and what my addictions are—turning the interview into something that felt like a desperate molestation. Was that the way I made her feel, despite my careful protocol of questions, many aimed at nothing more lurid than mother–daughter relationships? She pressed me, now squarely in her “out there” persona, to go to her sex show the following night, where she would be performing female ejaculation on stage—opining that it would be good for me and my husband. I politely declined (while internally I was roiling and frozen). She walked me to my car and I sensed that she wanted to get in and drive away with me. The trauma of her stories and history, while told with very little affect, were now lodged in me—an instance of projective identification I can understand in retrospect.

 

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