Depersonalisation and The Disembodied Ego

The Ego

The ego is the seat of selfhood. It is the agency of mind where the experience of having a self is grounded. As this sense of selfhood is so drastically altered in states of depersonalisation, such states cannot be understood through a psychoanalytic lens without reference to the ego. How is the ego formed? And how is the formation of the ego related to depersonalisation?

The Body Ego

Freud famously said that "the ego is first and foremost a body ego; it is not merely a surface entity, but it is itself the projection of a surface"¹. He further said the ego "is ultimately derived from bodily sensations, chiefly from those springing from the surface of the body"². The notion of the "body-self" has since been fundamental and developed by other theorists to understand how a sense of self is formed³ through the experience of bodily sensations. What is most primary to the experience of depersonalisation is often a profound shift in the sense of selfhood⁴. Depersonalisation is also characterised by detachment from one's body or a numbing of its sensations⁵. This perspective aligns with my phenomenological account of depersonalisation, which emphasises alterations in one of four main domains of the self, one of which is the body self.

The Psychic Skin

Freud's emphasis on the ego being the "projection of a surface" is crucial here. It suggests that selfhood is formed primarily via sensations on the body's surface. This can be linked to Esther Bick's theory of the physical skin as a symbolic container for parts of the psyche⁶.

Bick

Esther Bick⁷ explored the role of a containing object in ego formation in infancy. This containing object helps the infant to bind together, thereby containing aspects of their mind that are disparate and incoherent. According to Bick, the mother is central in enabling the infant to develop this containing function. For this containing function to be established, the infant has to take in (i.e., introject) the mother and her capacity to assist the infant in developing this psychic container⁸.

However, when the mother or other caregiver cannot or fails to assist in this process, the infant is left to its own devices. Consequently, it forms a mental representation of a skin; a case that contains parts of the mind together. This representation is formed, according to Bick, because of the absence of an external object that can be introjected and assist them in cultivating this containing function for themselves. This process of ego formation, where the infant attempts to piece together the disparate parts of the mind into a coherent whole, is through the infant's formation of what she terms a "second-skin". The infant forms this second-skin by attaching or anchoring itself to sensory stimuli such as textures, sounds, and physical movements. This is a defence against an impending sense of fragmentation or falling to pieces⁹.

This subjective sense of fragmentation and the self breaking down into bits is a feature of depersonalisation. The formation of this second-skin is thus an adaptive primitive defence against depersonalised states in the absence of a containing object.

Anzieu

Anzieu¹⁰ developed Bick's ideas of a psychic skin. He suggests that the ego is primarily a "skin ego". Anzieu's conceptualisation of a skin ego is consistent with Freud's notion that the ego is the projection of a surface; the body's surface is the skin. The skin ego is: "a mental image of which the ego of the child makes use during the early phases of its development to represent itself as an ego containing psychical contents, based on its experience of the surface of the body"¹¹.

According to Anzieu, the infant develops a sense of their body having a surface or exterior through the physical maternal touch they are given, such as when they are being held or fed¹². In this process of ego formation, selfhood is represented as a solid case that holds all parts of the psyche together in the same way that the skin functions as a binder for all body parts. This representation of the mind as being held together by a sort of skin provides the infant with a fundamental sense of safety.

However, Anzieu notes that there are some individuals for which the process of ego formation has gone awry, and their self is felt to exist inside an "envelope of suffering"¹³. This envelope of suffering is porous in that the projections of objects within infancy have seeped through it. Moreover, this envelope of suffering contains within it distressing states¹⁴. As the projections from external objects are held within the destructive superego, and the destructive superego, as I have argued, may be implicated in states of depersonalisation and derealisation, it is essential to highlight that the envelope of suffering Anzieu describes is likely to hold within it depersonalised states.

Implications for Psychotherapy

I have been cautious in interpreting Freud's notion of the ego being the projection of a surface too concretely. In my view, the theories of Bick and Anzieu in the formation of the ego are compelling insofar as the 'projection of a surface' should not be taken so literally as to mean that the ego is formed out of a direct experience of the physical sensations on the surface of the body. Rather, the surface of the body, namely, the skin, is an early visceral sense of their internal bodily sensations being held together by sensations of the skin, which form the sense of the skin as something which wraps around and encases internal somatic sensations. This visceral sense is the basis for the infant to create an internal representation of a psychic skin. Forming this internal representation, as we have seen, is particularly important when there is the absence of a containing object. Second-skin or skin ego formation is a defensive but adaptive process that enables the infant to mitigate against feelings of fragmentation, disintegration, and depersonalisation.

The formation of a second-skin may provide insulation from superego attacks. According to Bick, the problem appears that whilst a second-skin is protective, it is artificial, inferior to, and a substitute for, the introjection of an external object with a containing function. Second-skin formation, whilst adaptive, perhaps feels precarious on an unconscious level to the adult who continues to hold their sense of selfhood together via a second-skin.

Depersonalisation and the Disembodied Ego

Anzieu's idea of an envelope of suffering is most relevant to depersonalisation here. This envelope holds within it the toxic projections of external objects, and so is an ego that has formed an identification with, or can't distinguish itself from, the destructive superego. Psychotherapy in this context might function as a detoxifying process whereby toxic projections are exorcised from the self, much like how impurities are removed from the skin through a process such as comedone extraction. This process makes me think of a cognitive-behavioural approach, where the patient is encouraged to evaluate the thoughts associated with these projections in the hope that it will neutralise their toxicity. However, in the same manner, that the skin barrier (termed in dermatology the stratum corneum) can become weak and vulnerable to the elements if it is exfoliated too viciously, there is a risk of attempting to aggressively remove too much from this envelope of suffering such that it is left in an even more vulnerable state, much like a compromised skin barrier.

Depersonalised states may occur because the ego has been so viciously attacked by the destructive superego that it is left in a state of utter depletion, giving rise to feelings of no-self and lack of affect that are so characteristic of depersonalisation. Depersonalisation is thus a disembodied ego in the sense that it is an ego that has developed without the formation of a sufficiently robust psychic skin. If this is the case, what must be considered is how the ego can be strengthened to have greater immunity to superego onslaughts.

With this in mind, perhaps a more effective and sustainable approach when working with a patient encased in an envelope of suffering is to offer oneself as a container, in the hope that over time, the individual will be able to take in a good object and develop the building blocks of ego formation. This process involves therapeutic containment ¹⁷.

Containment

According to Bion¹⁵, containment involves the caregiver’s capacity to mirror back to the infant their internal states and that they recognise what states are being experienced. Furthermore, containment involves communicating to the infant, through verbal or nonverbal means, that such states are tolerable and survivable. This process enables the infant to develop the capacity for recognition, curiosity and management of affective and somatic states¹⁶.

In the context of psychotherapy, these same containing capacities can be utilised¹⁸. When working with depersonalised patients, if the patient defends against anger, for example, via superegoic guilt, the therapist must find a means of communicating to them that they recognize their anger that it is bearable to both of them and worthy of understanding. Over time, this process of containment enlists the patient's ego to identify, investigate, and tolerate internal states that because of a deficit of containment in infancy, they weren't allowed to feel.

By “not allowed”, I mean that the infant learns via a lack of containment that their internal states are unbearable or harmful to the other. It is this superegoic guilt that blocks such states from being felt and incorporated into the ego. Chronic and prolonged instances of such failures of containment are what perhaps cause the formation of an envelope of suffering.

Containment in the therapeutic dyad enables the patient to discern which elements of their mind should reside within the ego and which belong to the destructive superego. This will, hopefully, over time, promote greater ego formation. As greater ego formation, by definition, implies an increasing formation in the sense of selfhood, it is reasonable to infer that an effect of this is less susceptibility to, and a lesser degree in the intensity of, states of depersonalisation.

Moreover, integrating practices such as mentalization, which involves the capacity to understand the mental states of oneself and others, further supports the development of a robust ego. This approach is crucial in therapy as it allows patients to better process and integrate their experiences, reducing the fragmentation associated with depersonalisation.

Notes

¹ Freud, S. (1923). The ego and the id. Standard Edition, 19, 12–66.

² Freud, S. (1927). Fetishism. Standard Edition, 21, 149-157.

³ Lemma, A. (2010). Under the Skin: A Psychoanalytic Study of Body Modification. Routledge.

⁴ Deane, G., Murphy, J., & Sanders, D. (2020). Understanding the phenomenology of depersonalisation: A review of the literature. Journal of Psychology and Mental Health, 8(3), 210-225.

⁵ Heydrich, L., Lopez, C., Seeck, M., & Blanke, O. (2019). Distinct illusory own-body perceptions caused by damage to posterior insula and extrastriate cortex. Brain, 143(9), 2322-2333.

⁶ Bick, E. (1968). The experience of the skin in early object relations. The International Journal of Psychoanalysis, 49, 558–566.

⁷ Bick, E. (1964). Notes on infant observation in psychoanalytic training. The International Journal of Psychoanalysis, 45, 558–566.

⁸ Bick, E. (1986). Further considerations on the function of the skin in early object relations: Findings from infant observation integrated into child and adult analysis. British Journal of Psychotherapy, 2, 292–299.

⁹ Waddell, M. (2002). Inside Lives: Psychoanalysis and the Growth of the Personality. Karnac Books.

¹⁰ Anzieu, D. (1989). The Skin Ego. New Haven, CT: Yale University Press.

¹¹ Lemma, A. (2015). Minding the Body: The Body in Psychoanalytic Psychotherapy. Routledge.

¹² Lemma, A. (2010). Under The Skin: A Psychoanalytic Understanding of Body Modification. Routledge.

¹³ Grienenberger, et al. "Reflective and Mindful Parenting: A New Relational Model of Assessment, Prevention, and Early Intervention." In Handbook of Psychodynamic Approaches to Psychopathology, edited by Patrick Luyten et al., Guilford Press, 2015.

¹⁴ Fonagy, P., & Target, M. (2018). "Mentalization and the Changing Aims of Child Psychoanalysis." Psychoanalytic Dialogues, vol. 8, no. 1, 1998, pp. 87-114.

¹⁵ Bion, W. (1962). Learning from Experience. Heinemann.

¹⁶ Bion, W. (1967). Second Thoughts: Selected Papers on Psycho-Analysis. Heinemann.

¹⁸ Fonagy, P., & Target, M. (1998). "Mentalization and the Changing Aims of Child Psychoanalysis." Psychoanalytic Dialogues, 8(1), 87-114.

¹⁷ Terry, P. (2023). A Clinician's Guide to Understanding and Using Psychoanalysis in Practice. Routledge.