After Charcot: Notes on Working with Stuck States
Why changing the landscape matters more than changing the story
The Patient Who Knows But Doesn’t Change
She can tell you exactly what happened. The year, the room, the sensation of the carpet against her cheek. She’s told the story in three different therapies over twelve years. She has insight. She has language. She has a perfectly coherent trauma narrative.
And still, every time her partner raises their voice, even in frustration about something unrelated, her left arm goes numb, or her emotions turn off, or her mind floats away. Not anxious. Not avoidant. Numb. As if the nervous system has decided to stop speaking.
She knows the story. Her body doesn’t care.
This is the clinical mystery that narrative work alone cannot solve. And it’s the mystery that Charcot’s concept of the dynamic lesion was built to explain.
Let me be clear from the start: I am not saying narrative doesn’t matter. It matters. It can reduce shame, restore agency, and make a patient feel witnessed. I have sat with too many people whose healing began precisely when they found language for what had been unspeakable to ever dismiss the narrative dimension.
But narrative is often not sufficient. Especially for patients with deeply entrenched functional symptoms (eg. paralyses, seizures, chronic pain, dissociative collapses, etc.), insight and stuckness can coexist for years. Sometimes for decades.
They know. Their bodies don’t care.
This essay is about why that happens, and what changes when you stop asking “What’s the story?” and start asking “What’s keeping the system stuck?”
A Quick Refresher: The Dynamic Lesion as Attractor
In the first essay, I introduced a forgotten concept from Charcot’s Tuesday lectures at the Salpêtrière: the dynamic lesion (lésion dynamique).
Charcot’s term for a functional, reversible, but self-stabilizing disruption of nervous system dynamics. Not structural damage. Not imagination. A real pattern that the nervous system falls into and cannot easily leave. Under hypnosis, it could appear, disappear, or transfer from one limb to another. It was real, but it was not a matter of tissue.
We translated that into modern language: an aberrant attractor. A maladaptive basin of attraction. A stuck state.
Let me make that metaphor concrete.
Imagine the nervous system as a landscape with hills and valleys. The valleys are attractors, states the system naturally settles into. A healthy brain has many: focused attention, relaxed wakefulness, deep sleep, daydreaming. Each is a different valley.
A dynamic lesion is a valley that shouldn’t be there, or that has become too deep. The system rolls into it triggered by a sound, a tone of voice, a bodily sensation and cannot roll out. The walls are too steep. The basin is too stable.
Narrative work tells you how the valley was carved. It tells you about the trauma that dug the initial channel.
It does not lift the system out.
The Debate: Where Does Narrative Fit?
There is an ongoing debate in trauma therapy about the role of narrative.
At one pole: clinicians who argue that the story is everything. That traumatic memory must be integrated, sequenced, and narrated to be resolved. That insight is the engine of change.
At the other pole: clinicians who argue that narrative is irrelevant. That trauma lives in the body, in regulation, in the nervous system, and that words are a distraction at best. “Stop telling the story,” they say. “The body doesn’t speak English.”
I sit uncomfortably between these poles.
Narrative gives shape, meaning, and integration. It helps a patient feel seen. It can reduce shame and build coherence. A patient who cannot tell their own story is a patient who cannot locate themselves in time, in relationship, in agency. That matters.
But narrative does not, by itself, change the basin. A story doesn’t shift a dynamical state. It can prepare the ground. It can recruit the patient’s own agency. But the actual transition, from stuck attractor to a more flexible equilibrium, requires something else. A perturbation. A different kind of intervention.
Here is the sentence I keep coming back to, the one I want you to remember:
The story tells you where the pain lives. The landscape tells you why it won’t leave.
Neither is enough alone. But we have spent a century and a half developing the story part. The landscape part is what Charcot saw… and what we have mostly forgotten.
Three Clinical Reframes
These are not a toolkit. I’m not selling a protocol. They are shifts in orientation, ways of seeing stuck states differently. Try them on. See what fits.
Reframe 1: From “Why this symptom?” to “Why this symptom now, and why does it persist?”
Most case conceptualization asks about origin. What trauma? What loss? What violation? That’s the story question. It is a good question. It is not the only question.
The landscape question is different: What keeps this pattern self-sustaining? What feedback loops lock it in?
The symptom is not just an expression of the past. It is a current, ongoing equilibrium. If you want to change it, you have to understand what stabilizes it in the present.
A paralyzed arm persists because the arm isn’t used, which reinforces the paralysis. A dissociative collapse persists because it temporarily reduces overwhelming input, which makes it more likely to be used again. The system is not being stubborn. It is being efficient, within a very narrow, very maladaptive basin.
When you shift from origin to persistence, your clinical attention moves. You stop digging for buried memories (though you may still find them). You start looking for the loops.
Reframe 2: From “What does this symptom mean?” to “What does this symptom do for the system?”
This one makes some therapists uncomfortable. It sounds too functional, too close to implying the symptom is chosen. It is not chosen. It is not strategic. But it is functional in the dynamical sense, it is doing something.
A paralyzed arm may mean “I am unsafe” or “I am frozen” or “I cannot act.” But it also does something: it reduces the need to move, it organizes attention away from threat, it simplifies a chaotic sensorimotor landscape. The symptom is not just a message. It is a solution – a terrible solution, but a solution – to a dynamical problem.
Until you offer the system a better basin, it will keep the one it has.
This is not blaming the patient. This is respecting the system’s intelligence. The system found a way to survive. That survival pattern is now self-stabilizing. Your job is not to shame it. Your job is to help the system discover that there is another valley, one that doesn’t require numbness or paralysis or collapse.
Reframe 3: From “Insight as the exit” to “Perturbation as the exit”
This is the hardest reframe for verbally oriented therapists. Including me.
Insight tells the system where it is. It does not move it.
To shift a basin, you need a perturbation, something that kicks the system out of its local minimum. A surprise. A disruption. A different input than the system expects.
In Charcot’s day, that perturbation was often hypnosis. A sudden shift in consciousness, a suggestion that temporarily broke the pattern. The dynamic lesion would lift, sometimes for minutes, sometimes for hours, and Charcot would demonstrate to his students that the symptom was reversible. That was the proof that it was dynamic, not organic.
Today, the perturbation might be sensorimotor intervention. A guided movement that the brain didn’t predict. A shift in breath. A change in posture. A well-timed silence. EMDR’s bilateral stimulation. Neurofeedback’s real-time display of brain activity.
The modality matters less than the principle: you cannot reason your way out of a valley. You have to be moved.
This does not mean insight is useless. Insight helps the patient stay in the new basin once they find it. It helps them recognize when they are slipping back. It gives them language to ask for help. But insight is not the engine of the transition. Perturbation is.
What This Doesn’t Mean (Addressing the Fear)
If you are a narrative therapist reading this and feeling defensive, please don’t.
I am not your enemy. I am not saying story work is useless. I am saying it has a boundary… and that boundary is the shape of stuckness itself.
There are patients for whom narrative is sufficient. Their trauma is held in explicit memory, and integration alone changes the dynamical landscape. Those patients exist. I am grateful for them. They remind us that story matters.
This essay is about the others. The ones for whom insight and stuckness have become strange roommates.
And if you are a clinician who believes narrative is irrelevant, that words are always a distraction, I would gently disagree with you too. A patient who cannot tell their own story is a patient who cannot locate themselves in time, in relationship, in agency. Narrative is not the whole answer. But it is not nothing.
The truth is probably somewhere in the middle, which is where most of us actually live. We have patients who need both. Who need the dignity of a coherent story and the physiological shift of a perturbation. Who need to understand and need to be moved.
That is not a failure of any single modality. That is just the difficulty of the work.
Closing: Charcot’s Quiet Lesson
Charcot never said the story didn’t matter. He was a neurologist, not a philosopher. But he noticed something that his students, Janet and Freud both, would partially obscure: that the nervous system’s patterns have a life of their own. They stabilize. They repeat. They resist change not because the patient is resistant, but because the dynamics are self-sustaining.
He called them dynamic lesions. We might call them attractors. Our patients just call them “It keeps happening and I don’t know why.”
The story tells you where the pain lives. The landscape tells you why it won’t leave.
Charcot saw the landscape. We are still learning to work with it.
In the next newsletter, I want to look at one specific kind of perturbation that Charcot used, hypnosis, and ask what its modern descendants (EMDR, neurofeedback, sensorimotor therapy) might share in common: a way of temporarily dislodging the dynamic lesion so the system can find a new equilibrium.
Or maybe we’ll take a different turn. Let me know what you’re wrestling with in your chair.
Really interesting piece, not pushing a narrative but accepting many - for many. Someone in our system immediately responded with ‘we’d build a trolley car out of the valley’ 😏 To answer your final question….. what are we wrestling with in the chair? This is where it gets so interesting for a functional poly system, the honest answer is nothing, because we are built to survive everything.