Borderline Bodies: Affect Regulation Therapy for Personality Disorders, a new book by Clara Mucci connects interpersonal neurobiology, attachment theory, and psychoanalytic theory with cognitive and neuroscientific work on implicit memory, trauma theory, and dissociation to propose an integrated method for treating severe borderline and narcissistic disorders, with the prime aim of resolving the affect dysregulation that affects the various realms of bodily discomfort and existential pain. the book proposes a revision of the origin of personality disorders. Read an interview with the Clara Mucci below.
Public Seminar [PS]: Why did you write Borderline Bodies: Affect Regulation Therapy for Personality Disorders?
Clara Mucci [CM]: While working with borderline patients over the years, and after the six months spent as a fellow at the Personality Disorders Institute Directed by Otto Kernberg in New York, I saw that there were things the psychoanalytic psychotherapy I had been trained in could not explain. Trauma of human development, and disorganized attachment as a precipitant of vulnerability dissociation and the development of Complex PTSD were not taken into account. I felt they were major reasons explaining the destructive behavior and the emotional turmoil these patients were prone to. I felt that affect dysregulation was the major trigger and this was of traumatic origin. The abuse they had received was enacted on their own bodies via an internalized dyad between a part of self as victim and a part of self as persecutor. In essence, they were repeating the abuse they had received at the hands of others which they later internalized into the dynamic of their own minds. In their life-stories these subjects showed that the etiopathogenesis of the disorder was intergenerational, cumulative or complex trauma. Research and theory from the fields of interpersonal neurobiology of trauma and neuroscience in combination with attachment and psychoanalysis, was of great help in my psychotherapeutic work with them.
Additionally, in my previous work on trauma theory I reworked Sandor Ferenczi’s trauma theory through the lens provided by Allan Schore’s neurobiological conceptualization of early relational trauma. Furthermore, in my practice I had seen interdisciplinary connections that pointed to the “borderline body” as the real, not fantasied, basis on which these subjects were forced to express dynamics and negative introjections of intergenerational origin – because of both attachment and abuse – that became attacks on the body. These attacks could be repaired by a kind of therapy that used mirroring, forms of right brain connections like enactments and other ways of enabling affect regulation at the window of emotional tolerance for the patient.
I also felt the need to revise traditional psychoanalytic concepts that are fundamental tools but needed a modern reorganization. For example, the concept of the “unconscious” needed to be reconfigured. With Schore, I see it as implicit memory – as something that has an effect in guiding the interrelations with other subjects – following established internal working models of right brain connection. Another is the concept of dissociation, as opposed to repression, was dominant in psychopathology according to Freud. Now we see dissociation as a more primitive way of functioning connected to trauma. Finally, borderline subjects point call for a revision of the Oedipus complex, the developmental stages of sexuality, and even of the death drive. If the origin of psychopathology is traumatic, there is no possibility of retaining the concept of innate aggressiveness: violence and aggression are born and acquired relationally, within a relationship.
PS: Borderline Bodiesis a remarkable transdisciplinary achievement, synthesizing concepts, findings and lines of inquiry from psychoanalysis, object relations and interpersonal neurobiology. Can you briefly detail the core ideas underlying your particular approach to the treatment of personality pathology?
First of all, we need to distinguish between the trauma of human agency from trauma caused by accident or natural catastrophe. The former has much more severe consequences on the human psyche especially if “the evil” is experienced within the family, where the life of the child should be most cherished and enforced. I have postulated three levels of trauma of human agency. The first is a lack of attunement between caregiver and child (early relational trauma), but without actual maltreatment and abuse. The second level, more connected to the borderline psychopathology is real maltreatment and abuse or incest. The last level is massive social traumatization such as the Shoah. Borderline disorders stem from the first or second level of traumatization. The last level does not cause borderline disorders, but the parent who has undergone massive traumatization like genocide or war might not be in a position to be able to establish secure attachment with their child. Here, dissociation can be transferred through generations despite the lack of actual maltreatment and abuse, simply through attachment. As Allan Schore would say, the mother downloads her amygdala, the part of the brain responsible for the experiencing of emotions, into the amygdala of the child. The three levels can obviously intersect or cumulate, with worsening consequences.
I see borderline disorders as developmental disorders. Their origin, or etiopathogenesis, stems from early relational trauma or trauma due to severe maltreatment, abuse and/or incest. This explains why the major symptomatology stems from affect dysregulation (a sign of lack of attunement between caregiver and child, and a sign of disruption of all the neurobiological circuits). The second level of trauma – i.e. abuse – explains the peculiar dynamics of the destructiveness and the “persecution” of the subject against their own body. Eating disorders, addictions and various destructive behaviors are ways to down-regulate the mind-body-brain system. Self-attacks like self-cutting or suicidality clearly point at a destructiveness that sees in the body a sort of alien, another against which to exert anger and violence or self-loathing. This replicates an internal structure in which the self, namely the child, has experienced trauma at the hand of another, a caregiver.
Affective neuroscience and interpersonal neurobiology help us understand both the healthy and unhealthy development of the self and of personality, with secure, insecure or disorganized attachment. In addition to this, we need to understand the major psychoanalytic dynamics of the introjection of the evil that these subjects direct towards their own bodies as the product of a fundamental victim-persecutor dyad. Without the positions of affective neuroscience, without attachment and the understanding that attachment provides to explain the mother-child connection, and without the psychoanalytic understanding of the introjection of the aggressiveness, we would not be able to understand the dysfunctional personality traits and destructive habits and behaviors which we need to address in treatment. The major neuroscientific finding regarding borderline disorders is the disconnection between amygdala, especially the right amygdala, and the orbitofrontal areas of the brain that control and downregulate negative emotions – mostly rage, sadness, desperation, anger and a sense of void and helplessness – that are so typical of the disorder. This malfunctioning is the effect of the lack of internalization of affect regulation that is the common consequence of good caregiving. When we say, in psychoanalytic terms, that borderline subjects lack the internalization of the good object, we are speaking, in neurobiological terms, of the lack of affect regulation produced by the proper functioning of a good integration between the limbic and the prefrontal areas of the brain. Since the superior areas develop as a consequence of the proper functioning and connection with the subcortical areas, the superior areas responsible for reflection, planning and control cannot develop properly and therefore impair the proper elaboration of the impulses and make further development of representational capacities difficult or even impossible. Two caregivers are important to achieve the optimal development that leads to the social, emotional, empathic, and symbolic capacities that describe the human.
My clinical approach begins with an assessment. For each patient I evaluate: a) intergenerational trauma and the trauma of human agency like abuse etc., and attachment, insecure, or disorganized; b) type of personality disorder, from less severe (conversion) to most severe (antisocial or malignant narcissism); c) types and levels of bodily symptomatology, from conversion to self-cutting, suicidality, eating disorders, and psychosomatic symptoms. Finally, I evaluate two dimensions that in my opinion are useful in the prognosis and in the treatment: capacity to dream, because more severe personality disordered patients are incapable of metaphorical thinking and symbolization; another important consideration has to do with sexual identity and gender position. I see the body as a product of nature and culture, and as totally cut through by cultural and power dimensions. I also consider how power is embodied and represented in the development of the subject and within the identities in the family. In terms of clinical intervention, mirroring is the first step. This is not simply reflecting the patient’s own affects but involves helping them connect with disconnected parts of themselves. Empathic connection, together with what I call the practice of “embodied witnessing” by the therapist and constant affect regulation are fundamental ways of sustaining the necessary attunement between patient and therapist.
Implicit work at the margins of affect tolerance between patient and therapist is a new way of understanding the unconscious, now considered as the implicit remnants of memory traces encoded in the amygdala and retained in the form of internal working models, to use John Bowlby’s language or representation of self in connection with another. Healing is the release of these identifications. This is finally a way of letting go, of liberating oneself. I explain in Beyond Individual and Collective Trauma, this entails “forgiving” – in the sense of realizing the past identifications with a part of self as victim and a part of self as persecutor.
PS: Can you give us a glimpse into your research, reading and writing process? How did the project evolve over time? Did your original idea go through many stages and changes?
CM: This is a complicated question, because in this case the process was very long and complicated, and also because each book is slightly different. I can say that this book has been very different in its process from the others that I have written in the past. First of all, it is born of years of collecting my cases and trying to understand what I had learnt working with them and what I had really done that was effective and how I could explain it to myself and to others. I wanted to give a real description of the development of borderline pathology that included a sense of continuum, from least severe to more severe pathology on the borderline spectrum – from conversion disorder to antisocial personality disorder. The earlier the traumatization or the more severe, the greater the damage in development and therefore in the pathology, if there had been no other healing or reparatory elements (another caregiver for instance).
So, after three introductory chapters explaining the theory, I wanted to give a real sense of how to work with these patients, explaining fundamental techniques, starting with mirroring, followed by embodied witnessing. Then I wanted to present for each case the major symptoms attacking the body – for instance, self-harming, self-cutting, and eating disorders or suicidality.
I needed to accomplish several things at once: a revision of basic psychoanalytic concepts (like sexuality or Oediupal structures) together with a revision of the etiopathogenis of disorders through the necessary tools of trauma theory, so that personality disorders could be viewed as developmental disorders in a problematic cultural structure. This implied giving the body the privilege that is usually denied by psychoanalysis and even by major therapies for personality disorder, like transference-focused therapy (TFP), mindfulness-based therapy (MBT) and dialectical behavioral therapy (DBT). Affect regulation therapy puts the body first where it is conceived at the nexus of self/other dynamics and the culture/nature divide. I think this understanding is really strongly needed in our culture, with the prevalence of narcissistic disorders, eating disorders, and the more severe attacks to the body like suicidality.
The other difficulty for me was to find my own voice, to express my own cases and to reveal so many things about what I really do with my patients. I have been trained rather traditionally in psychoanalysis, without an understand of attachment, and without a neuroscientific explanation of relations. Really the most difficult part was to really speak up or speak out, without referring to other people. I have had amazing masters, from Kernberg, to Schore, to Liotti, to Ferenczi, but the way I integrate in my own way of working them was difficult to verbalize sometimes.
PS: Can you tell us a bit about your academic history and background as a writer? You have written extensively on Shakespeare. Did your sensibility as a literary scholar shape and influence your ways of thinking about the interaction of biology, environment and personality?
This is a fascinating question. Can we say that Hamlet, Macbeth, the witches, the Fool in King Lear or Caliban in The Tempest were borderline bodies? May be so. Those are my favorite characters. I wrote four books on Shakespeare, psychoanalysis and cultural politics before I turned to trauma theory and psychoanalysis only. I was intrigued by “borderline bodies” – they cross cultural boundaries like female/male, animal/human, corporeal/ethereal. They also practice a transgressive form of language based on the pun and polysemy. They subvert power distinctions through their bodies – Macbeth’s witches were “bearded women” and very powerful beings. They overturn traditional power definitions. The Fool is wiser than the king in King Lear. Caliban, the vulgar and base animal, speaks the most lyrical lines in The Tempest. I would say the way marginality and power are reflected in the transgressive bodies and language of the characters were my major interest as a Shakespearean scholar. I preferred the tragedies or the dark comedies, like the Merchant of Venice with the stranger-marginalized-Shylock. I also preferred the so called “last plays”, like The Tempest, Cymbeline, and Pericles. I don’t really like the comedies.
PS: The therapeutic activity of embodied witnessing you emphasize must take a toll on psychological and physical vitality. How can therapists adopt this practice while investing in self-care which is so critical in their continued helpfulness to their patients?
CM: It is certainly something to learn through as we practice. I still have not totally put that kind of wisdom into practice, since we are the very instruments that we need to use for the practice. I think discipline is fundamental (as it is in the work with the patients) – discipline in life, like a balanced and nutritious diet, resting, taking time off, drinking plenty of water, devoting enough hours to sleep, and finding the kind of recreational activities that the mind-body-brain needs according to the stage of life we are in. A balanced emotional life is the first requirement. This usually means that we must have had a very good training in which we are helped to recognize our own strengths and weaknesses. We need to know with whom we work best, and with whom we are less functional. I remember very well how Otto Kernberg would recommend this to us and would regularly take open group supervision for cases he felt he were experiencing difficulties. So, first of all we need to recognize what we are struggling with and what can be of help to us.
PS: Finally, What’s next? Do you have other book projects in the works?
CM: I am translating Borderline bodies into Italian. I want the patients to have their own voice, I can’t let it be translated by other people, but it is taking a long time! I also have a contract for a book on resilience to be published at the end of 2019.I think we need to carefully study how we can foster resilience in times of trauma to sustain hope and help future generations. I live in a country which is in need of recovering a sense of hope, solidarity, acceptance of the foreigner, tolerance and generosity. So, I think contributing to a social discourse is becoming more and more urgent. Writing is always an important tool. It is a way to contribute to building a “testimonial community,” a concept developed Dori Laub, who I value immensely. So, I guess I have to write, and to use words, as I am doing now. With you. Thank you.
Clara Mucci is a psychoanalytically-oriented psychotherapist practicing in Milan and Pescara, Italy. She is Full Professor of Clinical Psychology at the University of Chieti, where she taught English Literature and Shakespearean Drama. She received a PhD from Emory University, Atlanta, and was a fellow in 2005-2006 at the Personality Disorders Institute, New York, directed by Otto Kernberg. She is the author of several monographies on Shakespeare, psychoanalysis and literary theory, she has taught in London (Westminster College), Atlanta, and New York (Hunter College).
Joshua Maserow is a PhD student in clinical psychology at the New School for Social Research and an editor at Public Seminar. His scholarly interests include Relational Psychoanalysis, therapist and common factors in psychotherapy research, and global contemporary literature.