terms, narcissists have overcome the symbiotic phase and have

problems in the rapprochement phase. We should notice though that,

in contrast with borderline subjects, narcissists have pre-
representational capacities.
In the theory of trauma in psychoanalysis, after Ferenczi another
fundamental author for the switch from Freudian drive theory to
relational and interpersonal object relation is Fairbairn, who
notoriously maintained that “a relationship with the object, and not
gratification of impulse, is the ultimate aim of libidinal striving” (1952,
p. 60). He spoke of intolerable internalized bad objects, resulting from
abuse and trauma, that need to be “repressed” by the child because
they are unbearable and connected to shame. In contrast with
Fairbairn, instead of repression we now speak of dissociation for the
neurobiological reasons already explained; dissociation is a much
earlier result of traumatization and a primitive fragmentation of the
psyche with typical neurobiological correlates (fight or flight and in
extreme cases the parasympathetic effects of feigned death).
Repression in fact pertains to a later and more mature defensive
reaction that is not connected with early trauma (Mucci, 2016).
Fairbairn added to this explanation of the internalization of and
identification with the bad object another important aspect, so far
unacknowledged: that of shame. Fairbairn wrote, “It is interesting to
observe that a relationship with a bad object is felt by the child to be
not only intolerable, but also shameful” (1952, p. 63). The introjection
of the bad object for a child is achieved through identification starting
from the oral phase, according to Fairbairn—still following the Freud
of The Ego and the Id (1923/1953)—with one of these consequences:

Whether any given individual becomes delinquent,

psychoneurotic, psychotic or simply “normal” would appear to
depend in the main upon the operation of three factors: (1) the
extent to which bad objects have been installed in the
unconscious and the degree of badness by which they are
characterized, (2) the extent to which the ego is identified with
internalized bad objects, and (3) the nature and strength of the
 defenses which protect the ego from these objects. (Fairbairn,
1952, p. 64)

And as a further consequence:

It becomes obvious, therefore, that the child would rather be

bad himself than have bad objects; and accordingly we have
some justification for surmising that one of his motives in
becoming bad is to make his objects “good.” In becoming bad
he is really taking upon himself the burden of badness which
appears to reside in his objects. (Fairbairn, 1952, p. 64,
emphasis added)

Fairbairn continues with an elaborate explanation about how guilt is

created by this internal identification. It seems to me that Ferenczi’s
explanation of the sense of guilt of the victim as a result of the
internalization of the split guilt of the persecutor is more clinically
convincing: Ferenczi’s understanding of the traumatic process as
responsible for dissociation (which he terms fragmentation) and not
for repression (Freud’s term) is fundamental to really understand the
more severe damage to the psychic structure induced by
traumatization. To Fairbairn we owe nonetheless the clarification of
and the introduction of the affect of shame as a result of the
internalization. I will explain how shame is created in the
neurobiological and neuroscientific model described by Schore which
accounts also for object relation formation when I discuss the
neuroscientific development of narcissism.

FROM CHILD OMNIPOTENCE TO TRAUMA

Despite the differences, all contemporary researchers seem to agree

that at the base of narcissistic personality features is a lack of
empathy (the feeling of understanding and sharing the other’s
emotions) and a pathologic grandiose self, the latter defined by
Kernberg as early as 1975 as “a hungry, enraged, empty self, full of
impotent anger at being frustrated, and fearful of a world which
seems as hateful and revengeful as the patient himself” (1975, p. 233).
Moreover, “the greatest fear of these patients is to be dependent on
anybody else because to depend means to hate, envy, and expose
themselves to the danger of being exploited, mistreated, and
frustrated” (1975, p. 235). The interrelational nature of the cause of the
disorders is clearly hinted at here, together with the oral, destructive
components of ego formation, but they are mainly understood as due
to innate aggressiveness.
Pointing at a relational and intersubjective explanation of the
difficulties in the child, Philip Bromberg more than 30 years ago
defined this pathologic structure as “a core patterning of self-other
representation” that was created to maintain the illusion of self-
sufficiency at all costs (1983, p. 361), while anxiety was the major
affect of this kind of personality and identity, always in need of
mirroring. For the narcissist, the other exists not as a separate
identity but rather as a self-satisfying function, and this is the major
difficulty to overcome in the treatment; actually, the therapeutic
setting with its restrictions and rules and the restricted self–other
focus provides the best arena for the analysis of the problems in the
relational exchange and a good gym to practice new behaviors and
relational exchanges.
Bromberg in his influential 1983 article viewed the anxiety of this
kind of patient as the affective mark of the separation–individuation
phase, the moment in which a mental representation of the first
differentiation between self and other starts to be in place. Even if the
so-called recognition memory (Fraiberg, 1969) seems in place for the
child as early as 8 months of age, the possibility to evoke an object
when absent does not come before the 18-month to 2-year period,
when from the initial omnipotence the child starts accepting the
outside world as reality, which in turn creates a new anxiety for the
real development of a self in relation to an other, without which or
against which the self is created. This new threat for the child is
eloquently described by Bromberg stressing the original traumatic
and frustrating experience:
 External reality, which is too discrepant with the experience of
self-contained gratification (omnipotence), reinforces the need
to retain the security of omnipotent self-containment by
controlling rather than internalizing reality. . . . It occurs at a
time during the separation-individuation process that optimal
development of self and object representation is, according to
Mahler (1968, p. 20), dependent upon: “. . . the child’s
achievement of separate functioning in the presence and
emotional availability of the mother.” “Even in this situation,”
Mahler states, “this process by its very nature continually
confronts the toddler with minimal threats of object loss.”
Trauma during this early practising subphase (seven to ten
months of age) interferes with what Mahler describes (1972, p.
336) as the infant’s later capacity for exchanging some of his
magical omnipotence for autonomy and developing self-
esteem. (Bromberg, 1998, p. 88)

A similar explanation for the development of this pathologically

grandiose self had been given early on and in contrast with Freud’s
positive concept of infantile narcissism (Freud, 1914/1953) by
Ferenczi as early as 1913, when in his article “Stages in the
Development of the Sense of Reality” he spoke of the reactive rage of
the frustrated child and his development of omnipotent fantasies as a
defense. Ferenczi wrote about the attempt of the child to magically
preserve “the feeling that one has all that one wants, and that one
has nothing left to wish for” (1913, p. 219).
The child and subsequently the adult go to an extreme to protect
the stability of the grandiose self, to the point of
avoiding/denying/warding off any experience that would lead to the
depletion of his or her grandiose image, using an inflated self as
protection from the wounds of reality.
 NARCISSISTIC SPECTRUM

Kernberg (1975) has described a continuum of narcissistic

personalities, from neurotic narcissism to antisocial personality
disorder (Figure 7.1):

• Neurotic narcissism: Narcissistic personality functioning at the

neurotic level with inflated self-esteem, excessive self-focus, but
a reasonably stable sense of representation of self and other
(even if with the fundamental idealization–devaluation defense
mechanism and some omnipotent control and grandiosity.
• Narcissistic features at the borderline level of organization
(narcissistic personality disorder): Following Kernberg’s
model, it implies identity diffusion, primitive defenses, and
retained reality testing. This structure often leads to self-
destructiveness and eating disorders, with problems between
self and other; there are always problems with self-regulation
and self-esteem.
• Malignant narcissism: This is a clinical term coined by
Kernberg and implies the most severe level of narcissism with
(a) borderline level of narcissistic personality; (b) egosyntonic
aggressiveness; (c) antisocial behaviors plus (d) paranoid
features. These patients can be very dangerous to themselves
and to others, including the therapist, as they could perform
violent acts. They are mostly aggressive and destructive against
others but can be destructive against themselves in a calculated
and often exhibitionist way.
• Antisocial personality proper (what used to be called
“psychopathy” ): These individuals usually do not seek
treatment (unless they can use therapy for manipulative and
therefore antisocial reasons, such as to obtain reductions in
sentences for crimes; therefore, they hardly ever make
themselves available for treatment). Kernberg says that the
“prognosis is zero” for these subjects and that they are almost
untreatable.
Figure 7.1 Narcissistic Continuum from Neurotic to Antisocial

NARCISSISTIC PERSONALITY DISORDERS

Because the regulation of affect is the main problem in the

development of these subjects and in their functioning, and they
present internalization of bad introjections due to early frustration,
abuse, and trauma, they may cut themselves or present addictions
(eating disorders, alcohol and substance abuse) as a way of
regulating themselves, and they might present all kinds of destructive
behavior toward themselves and toward others.
The object relation capacity of these subjects is limited because
they lack empathy and because the self is totally invested, to the
detriment of the other; as Wallin (Wallin, 2007) says, in their mind
there is room only for the self. Self-esteem is the problem and
becomes a dysregulator of mood and behavior. Their self-esteem
depends on the admiration of others, which makes them prone to
lying and to manipulation in order to create fake scenarios in which to
present themselves to others to receive the attention they constantly
need to maintain an inflated self-esteem. (Consider the efforts they
make to create a “likable image” of themselves in the social networks,
sometimes even in total disregard or denial of reality.) Many
politicians and jet-set protagonists belong to this category.
DYSREGULATION OF AFFECT FOR NARCISSISTIC DISORDERS

Self-regulatory failure underlies the pathology of narcissism as a

developmental syndrome and is created by environmental problems
in attachment and in primary relationships leading to early relational
trauma with disturbed psychodynamics between self and other in
conjunction with biological features. In particular, regulation of shame
presents special problems for these pathologies, as I will explain in
further detail.
The dyadic interchange between caregiver and child especially in
critical periods of maturation of certain areas of the brain sets the
stage for an imprinting for mood regulation, images of the self, self-
esteem, and self-aggressive behavior resulting in an incapacity to
regulate negative affect and especially shame and self-esteem.
In his neuroscientific developmental model, which is consistent
with object relation theory, Allan Schore indicates that the most
severe developmental problems involving more severe symptoms
correspond to earlier traumatizations:

• For the development of possible antisocial personality disorder,

the traumatic condition has been experienced very early,
between 4 and 9 months, so that the amygdala itself has not
been fully developed (resulting in possible cellular death), but
also prenatal development is crucial to explain amygdala
deficits or even cell death in this area.
• As already explained in previous chapters, for the development
of a possible borderline disorder (borderline in the sense
exemplified by DSM-5, which for the sake of brevity we will refer
to as “borderline proper” ), the following 9–12 months are crucial
for the connection between the amygdala and the development
of the orbitofrontal circuits that should control and regulate the
amygdala; difficulties in impulse control and instability of moods
become established. This means that the capacity for object
relation is not formed in the presence of this disorder, as the
child has no representational capacities at the age of the
traumatization. Also, perinatal influences are crucial toward the
 development of a borderline disorder (from birth to the first 2 or 3
months).
• If the traumatization in the relationship happens after 18 months
or later (after the separation–individuation phase), the lack of
attunement between the mother and the child might provoke
narcissistic problems in the development: the representational
capacity of the object is formed at this time, with the
consequence of the internalization of a bad object. Right-brain
development is impaired, with consequences for morality,
empathy, and imagination.

In the middle to the end of the second year, the right-brain growth
spurt ends, and the onset of the left-hemisphere growth spurt allows
for imprinting of a paternal or third-term relationship and the
emergence of agency and autonomy. This model has to be
understood in relation to the differences in the rate of maturation of
the male and female right brain as explained by Schore (2017a) in his
study.

OTHER ASPECTS TO BE CONSIDERED FOR

DIAGNOSIS AND CLINICAL WORK

In line with Rosenfeld (1987), it is still useful to distinguish clinically

between a thick-skinned and a thin-skinned narcissist, the first
characterized by a sense of entitlement, arrogance, and grandiosity
(Ronningstam & Gunderson, 1991), the second by extreme
sensitivity, shyness, and anxiety reactions in relationships; in
common with the former they share the sense that the world revolves
around themselves, so even the slightest nuance of criticism or
negative action of others toward them results in a dysregulation of
their behavior. The slightest imperfection of the therapist regarding
how they are treated, or how their material is treated (the patients’
dreams, the schedule, even the lighting in the office), might become a
point of contention and are lived as minor offenses, signs of rejection,
or evidence of the therapist’s carelessness. For narcissistic patients,
the very fact that they must accept what others have chosen and
what they feel does not precisely fit their style, their schedule, their
arrangements, is felt as a humiliation, a restriction of their power and
a reduction of their sense of entitlement.
The thin-skinned is similar to the hypervigilant type defined by
Gabbard (2005) as having low self-esteem, rejection sensitivity, and
diminished energy and vitality, and also to the “covert” as opposed to
the “overt” type as defined by Cooper (1981, 1998) and by Akhtar
(1989; Akhtar and Thomson, 1982). This second type of introverted
narcissist presents an inhibited self, is shy, self-effacing, and avoids
being the center of attention, but self-devaluation exists side by side
with a subtle form of superiority and entitlement (Broucek, 1991). We
have seen some of these features in the case of Bertha that was
presented in Chapter 5.
The distinction between two fundamental types of narcissist has
been questioned (Pincus et al., 2009) insofar as both types present
the same features of grandiosity and vulnerability: both are self-
absorbed and can be dissociative or mostly of an egotistical type
(Broucek, 1982).
Our understanding of the underlying psychodynamics is that both
features are present in both types, one being the reverse side of the
other: the grandiosity comes as a defense for the perceived inner
fragility and vulnerability, which are created in the specific
relationship with the caregiver, as I will explain. In terms of
developmental differences, the more grandiose type (thick-skinned,
or overt) is characterized by hyperarousal, and the more vulnerable-
sensitive type is characterized by hypoarousal. Psychodynamically,
the difference can be explained easily: as I have said following
Ferenczi (1913), the omnipotence derives from the attempt to try to
maintain a grandiose manic defense from the frustration of reality and
real relationships, where the child is not kept in mind and is not seen
for what he or she is (Bach, 2006; Frankel, 2017).
The features of the thick-skinned and the thin-skinned types as
described by Rosenfeld are not too distant from what Kohut had
already noted in the 1970s: “The specific affective experiences of the
narcissist ranges from anxious grandiosity and excitement on the one
hand to mild embarrassment and self-consciousness and severe
shame, hypochondria, and depression on the other” (1971, p. 200).

LEVELS OF AGGRESSIVENESS IN NARCISSISM FOR

DIAGNOSIS AND PROGNOSIS

According to Kernberg (1975), levels of aggression and egosyntonic

aggressiveness help clarify the diagnosis and also present important
prognostic features: both types (thick and thin skinned, or overt and
covert narcissism) show aggression and narcissistic traits, but the
first type is mostly aggressive toward other and reacts with rage and
aggressive acts to slight triggers, while the second type tends to turn
aggressiveness against himself or herself (as in the case of Fabian in
Chapter 8).
In self-destructive acts and suicidal tendencies, narcissists are
different from the borderline-proper patients insofar as, for borderline
propers, self-destructiveness manifests itself as an impulsive act, out
of rage and anger, and usually it involves a relationship or is directed
against another even when one’s body is the target. For the
borderline proper, the self-destructive act almost always has an
addressee and originates within a relationship (after a fight, for fear of
abandonment, to accuse the other, or to attract attention), while for
the narcissist who might be aggressive toward his or her own body,
usually the act is consummated in a cold, calculated, unrelational way
and presents aspects of triumph over the usual rules and fears of the
world, in a sort of grandiose and arrogant attitude, even when self-
directed. That is why the destructive act in a narcissistic subject often
involves a sort of exhibitionistic grandiose scene or setting, with
several other people involved. Often, contemporary terrorist attacks
and the solitary attacks of gunmen at schools or other institutions
have this narcissistic grandiosity and carelessly destructive, criminal
omnipotent control at their core. The grandiosity is reaffirmed even in
the destructiveness: the aim is that the act performed is very visible
and receives notoriety, for instance publicized on the Web even in
advance or posted on social media. In addition to these narcissistic
features, terrorism should be considered within the framework of a
paranoid personal stance in which an idealized strong regime of
terror is viewed as providing that sense of protection and
predominance or omnipotent control that the personalities of the
extremists desire, as several authors have cogently demonstrated
(see Kernberg, 2003a, 2003b; Varvin & Volkan, 2003). We should also
remember that paranoid features are present in what Kernberg terms
malignant narcissism (“the world is hostile and dangerous and will
attack me, so I need to attack first” ).
Omnipotent control as a defense (from an internal
fragility/fear/terror/sense of humiliation that is denied) is always active
in murderers and criminals together with the sadistic pleasure of
reducing the other to one’s own will (as in malignant narcissism and
antisocial personality disorders, which as we have seen are at the
very end of the narcissistic spectrum as the most severe type and are
considered almost untreatable).
During adolescence, the group identity strengthens the individual
sense of power and agency (it is often an identity based on group
ideals, or ego ideals, in place of a proper superego, which is in fact
lacking) (see also Freud, 1923). In a similar dynamic, the ideology of a
totalitarian regime or a religion taken as a grandiose idealization and
paranoid protection of a deprived and fundamentally humiliated self
can help the narcissistic, dysfunctional self create the highly
idealized, sadistic, and omnipotent scenario needed for devastation
and extermination of an other perceived as an enemy and can
therefore arm the hand of the aggressive and fundamentally
frustrated subject.
The development of malignant narcissism to the extreme end of
antisocial personality disorder reveals a consistent deficit in empathy
with the subsequent lack of affect and emotional coldness (Baskin-
Sommers, Krusemark, & Ronningstam, 2014). I will discuss this
particularly violent and destructive form of narcissism when
describing the neuroscientific development of the antisocial disorder.
 NEURAL MECHANISMS OF EMPATHY

The neural mechanisms underlying emotional empathy have been

widely studied with functional imaging of healthy participants.
As a recent review study has explained (Hill, 2015), two somewhat
distinct models of empathy emerge from the literature on cognitive
neuroscience. One model specifies two dissociable systems: one
developmentally and phylogenetically “early” system for emotional
contagion (the ability to recognize and share the feelings of another
person) and one developmentally and phylogenetically “later” system
for perspective-taking (the ability to make inferences about what
another person is thinking or feeling). These systems seem to
operate in parallel with distinct neural structures.
Another model includes these same cognitive functions as stages
or components of processing within a single system underlying
empathy. That is, emotional empathy may require one to become
aware of the emotional state of the other person and identify with it to
some degree (emotional contagion), then ascribe the emotion to
another agent and suppress one’s own perspective (perspective-
taking) (Decety & Jackson, 2004). The mentalizing capacities seem to
be the basis for mature empathy versus emotional contagion, which
means that proper orbitofrontal development is necessary for mature
empathic development; this orbitofrontal regulation deficit is precisely
the major cause of emotional and cognitive deficit in all personality
disorders.
Several studies converged in support of the proposal that the
medial prefrontal cortex, anterior insula, anterior cingulate, amygdala,
and the temporoparietal junction are important for particular broad
components of empathy, such as emotional contagion or cognitive
perspective-taking. Decety and Jackson propose that three major
functional components dynamically interact to produce the
experience of empathy in humans: affective sharing between the self
and the other, based on perception-action coupling that leads to
shared representations; self–other awareness with no confusion
between self and other; and mental flexibility to adopt the subjective
perspective of the other and also regulatory processes. All these
features are impaired in narcissists.

VIOLENCE AGAINST THE OTHER AND WITHIN SOCIETY

Analyzing a vast body of literature and tracking fundamental

interdisciplinary connections, Schore (2017a) has recently arrived at
the conclusion that the problem of early developmental trauma
seems to impact boys’ brains more critically. As Yildirim and Derksen
(2012) have recently shown, the activational effects of high levels of
testosterone and low HPA-axis responsivity are associated with
psychopathy. Elevated levels of fetal testosterone are consistently
found in this disorder, which is 10 to 14 times more likely in males
than in females. Citing recent research, they showed that heightened
developmental testosterone is an essential biological determinant in
the cause of psychopathy, and that “fetal testosterone may inhibit the
maturation of the right orbitofrontal cortex and circulating
testosterone may subsequently dampen its responsivity to social
cues resulting in lower empathy and higher aggressive behaviors,
processes that increase the risk for chronic antisocial behavior”
(Yildirim & Derksem, 2012, p. 999).
As we have repeatedly argued, following Schore (2003a, 2003b,
2012, 2017a), attachment trauma, such as abuse or neglect, interferes
with or precludes optimal interactive stress regulation, affecting HPA
capacity to down-regulate affect. Especially if the trauma occurs in
critical periods of right-brain development, it epigenetically generates
enduring maturational failures in the limbic system and in the HPA
axis, leaving structural deficits that if not repaired are reactivated in
adolescence, a time of substantial remodeling of cortical and limbic
circuits (Schore, 2017a; Siegel, 2013).
As Decety (2011) has demonstrated, there is strong evidence that
empathy has profound evolutionary, biochemical, and neurologic
underpinnings. Even the most advanced forms of empathy in humans
are built on very basic forms and remain connected to core
mechanisms associated with affective communication, social
attachment, and parental care.
Moreover, empathy in humans is assisted by other domain-
general high-level cognitive abilities, such as executive functions,
mentalizing, and language, which expand the range of behaviors that
can be driven by empathy.
Evolutionarily and dynamically, it is notable that the emotional
resonance necessary for empathy is the same involved in the affect
attunement that becomes established in a good relationship between
mother and child toward the end of the first year. This is a point that
D. N. Stern (1985) makes very clear: affect attunement (a critical step
toward symbolic capacity) occurs largely automatically and out of
awareness (i.e., implicitly as the result of previous development and a
good relationship between the two), whereas empathy requires the
mediation of cognitive processes, for instance the clear awareness of
the differentiation between who is feeling what (see also Basch,
1977).
I would stress therefore that affect regulation is necessary toward
the establishment of a symbolic capacity (orbitofrontal development
and regulation of subcortical areas) that is a precondition for the
establishment of empathy and other human “superior” qualities. The
role of orbitofrontal cortex in the dysregulation or regulation of
antisocial behavior has been demonstrated (Blair, 2004).

DISORGANIZED ATTACHMENT AND ANTISOCIAL

DEVELOPMENT IN MALES

Early studies (see Carlson, Cicchetti, Barnett, & Braunwald, 1989)

have shown how disorganized attachment is more frequent among
boys who were maltreated as infants in low-income situations.
Similarly, Lyons-Ruth, Bronfman, and Parsons (1999) found that
infant boys displayed significantly more disorganized attachment
behaviors and concluded that gender plays a role in the manifestation
of disorganized behavior pattern in high-risk samples. More recently,
Beebe and colleagues have reported in studies of the early origins of
disorganized attachment in 4-month-old infants that “Male infants
were overrepresented in future disorganized infants. . . . Moreover,
male infants are more emotionally reactive than female (Weinberg,
Tronick, Cohn, & Olson, 1999), so that they may be more vulnerable
to a disorganized form of insecurity” (Beebe et al., 2012, p. 359).
In the study mentioned earlier, Yildirim and Derksen underline
how, “Since the life-long functioning of the ventromedial prefrontal
(orbitofrontal) cortex is programmed and fine-tuned during the early
years of life, traumatic and abusive experiences can permanently
alter ventromedial cortex maturation and basal HPA axis throughout
life (2013, p. 1261). These authors conclude that the
interpersonal/affective facet of psychopathy arises from
insecure/disorganized attachment in childhood, congruent with
Schore’s studies (2003a, 2017a) that early attachment trauma and
right orbitofrontal dysfunction predispose to violence and severe
conduct disorders in adolescence.
In line with the observation that male adolescents and male
individuals in general are more prone to externalizing disorders, while
females are more prone to internalizing behavior, Schore stresses
that “under stress, HPA dysregulation can take two forms:
underregulation and overregulation, which in turn underlie the
susceptibility of males to externalizing disorders and of females to
internalizing disorders” (2017a, p. 25).
Could this be the reason why traumatized females are more prone
as adolescents and adults to depression and self-destructiveness
(and internalizing disorders) more on the borderline side of the
spectrum, while traumatized males are more prone to develop
narcissistic and antisocial behavior (and externalizing disorders), up
to the malignant narcissistic and antisocial/psychopathic side of the
spectrum? It is interesting to note how, even in the cases that I am
presenting in this book to exemplify the various disorders and the
destructive spectrum, we go from female cases of hysteric (Ariadna;
Chapter 4), borderline-covert narcissistic (Bertha; Chapter 5),
borderline proper (Dorothy; Chapter 6), to more severe cases of
narcissism (Fabian; Chapter 8) and antisocial–hypochondriac,
alexithymic male patients with possible sexual perversion (see the
cases of John and Tom in Chapter 10). On the continuum of severity
of the cases I present, Elizabeth (Chapter 9) stands in the middle as a
severely deprived, vulnerable, overt narcissist with psychosomatic
tendencies and with a clear masochistic, self-destructive bent.
Might this be a typical bias of our societies, in which violence
toward the other and aggressiveness are viewed as more acceptable
or even reinforced to a certain level for males, while females are still
generally taught to be more passive, more obedient, less aggressive,
and to comply more? In my experience, the identification with the
aggressor that is present in both traumatized males and females is
more likely to take the path of aggressiveness against the other in
males, while women are more often prone to victimization. Fabian is
an interesting case of aggressiveness toward the self in connection
with a clear sexual identity diffusion.

DEFICIT IN AFFECT REGULATION AND IN OBJECT FORMATION

IN NARCISSISM

According to Schore (1994) and his extensive interdisciplinary

research, the positive affect that fuels grandiose states indicates that
these individuals, unlike subjects with other pathologies, have
successfully negotiated the symbiotic early phase.
His developmental object relation and neuroscientific model
(Schore, 1991) views the emergence of shame during Mahler’s
practicing period of separation–individuation, in which shame
becomes critical in the regulation of subsequent socioemotional
development. Shame seems to be instrumental to the effective
resolution of the later rapprochement crisis, especially in the
modulation of the so-called narcissistic rage and the further
development of psychological and gender identification processes.
Shame is also at the basis of the fundamental pathology of
narcissistic disorders insofar as it is responsible for the formation of a
pathologic ego ideal, a component of the superego, which becomes
the fundamental mood regulator (or dysregulator we should say)
whose persecutory and sadistic precursors will be responsible for the
attacks to the self we see in the most severe cases (see the case of
Fabian in Chapter 8).
According to Schore, in the developmental trend for the narcissist,
the mother might be capable of coordinating the attunement with the
child in the symbiotic phase, but not in the so-called rapprochement
of the separation–individuation phase, when she rewards the child’s
growth only in relation to her own needs. When the child is in a
positive, grandiose state, mirroring her own narcissism, the mother is
emotionally accessible, but she cannot adequately modulate and
contain the child’s affect or establish the proper rules and boundaries.
When the child is in a negative hyperaroused state, such as
aggressive separation protest, the caregiver, especially if a narcissist
herself, fails to modulate the infant or even hyperstimulates him or
her into a state of dyscontrol (she can even trigger it, as the child is
not a mirroring object for her anymore).
Therefore, inconsistent attunement is an important element in the
cause of the disorder: the caregiver triggers negative states because
of shame–stress depletion of narcissistic affect in a clear
intergenerational dynamic.
In particular, the dynamics of devaluation and shame, “the primary
social emotion” (Scheff, 1988) with lack of regulation, is described by
Schore (1994) very effectively as follows:

After a shame-induced infant-caregiver misattunement, the

infant too frequently encounters at reunion a narcissistically
injured, aggressively teasing, and humiliating mother who
rather than decreasing distress hyperstimulates the child into
an agitated state of narcissistic rage. No caregiver acts to
modulate shame, and this prevents the internalization and
organization of a shame regulatory system in the child that can
reduce hyperstimulated states and allow for recovery from
hypostimulated states. The inner experience of the low arousal
affect of shame therefore becomes associated with an
expectation of a painful self-disorganizing internal state which
 cannot be modulated, and therefore is consciously avoided or
bypassed. (pp. 425–426)

This sudden shock from positive affect to deflated negative affect is

the template for this dysfunctional shame-regulation. We need to
stress therefore that under these circumstances (unless the father or
another caregiver intervenes positively), an effective dual-circuit
orbitofrontal system for mood and affect regulation is never enforced
(Schore, 1994, p. 427). Schore argues that both types of narcissists,
which he terms, after Broucek (1982), “egotistical” hyperaroused type
(I would say, sympathetic) and “dissociative” (parasympathetic)
hypoaroused type, never achieve self-regulatory and mood-
regulatory capacities. To this lack of affect regulation and therefore of
orbitofrontal development is connected the formation of partial self-
objects (which I see as rooted in the body or projected onto the body).
In the case of abuse and maltreatment, we have the introjection of
those bad objects with the emotional persecutory qualities of those
objects (internalized in the form of the victim–persecutor dyad).

PARTIAL OBJECT FORMATION IN THE NARCISSIST

For several authors of infant research, the intersubjective

communication between mother and infant is presymbolic and it is
considered symbolic for Stern after the first year of life (Beebe &
Lackmann, 1988; Beebe et al., 2012; Stern, 10974, 2004). In my model,
this symbolic capacity stems from the development of orbitofrontal
areas in connection with the limbic system, therefore it is a later
development, achieved through good parental experiences,
producing good internalized affect regulation.
In terms of object relation theory, the disrupted capacity for affect
regulation impedes the safe internalization of good objects; therefore
there are, in Kohut’s terms, (Kohut, 1971), only self-objects (objects
related to the self) that would stabilize psychobiological parameters
and are used to avoid fragmentation.
 These self-objects, which I see as rooted in the body and identified
with body parts, function as psychobiological regulators (Taylor,
1987), with unconscious, nonverbal, affect regulatory functions that
help stabilize the self structure against potential fragmentation. We
should keep in mind that in this phase, if the father or a caring and
sensitive third term in the dyad intervenes and can work as a
regulator, better functioning is established/insured, with some level of
reparation.
The later phase of development in which the traumatization occurs
in narcissists in comparison with that in other personality disorders
(after the symbiotic phase) determines differences in the
representational capacities of these patients; for instance, in
comparison with borderline-proper patients, while borderline subjects
have no object constancy, and the internal void prevails, narcissistic
patients have either partial self-objects (in less severe cases) or bad
introjects (in more severe cases). As Schore wrote, these individuals,
in contrast to borderline subjects, can access presymbolic
representational capacities, but they equally lack the reparative
functions of evocative memory (Schore, 1994).
This limited or partial object relation capacity might explain why
very often a narcissist structure presents hypochondriac traits; in fact,
hypochondria can be understood as the extreme level of a
narcissistic relation with one’s body (see Rosenfeld’s and Kernberg’s
explanation of the formation of hypochondria, Rosenfeld, 1987;
Kernberg, 1984), which has become the only object. Severe
hypochondriacs have a relationship only with their own bodies and
body parts, which might also explain why so much of their affect and
attention is concentrated on the body. The body might become
literally a work of art or the fetish of their attention, used to attract the
eye of the other (in a paroxystic mirroring devised to find the
unabating appreciation they might have received at one point but of
which they were unexpectedly deprived or which they might never
have received).
Literally more than having a relationship with the other, the body
becomes their object, and the relation with this object is used to
defuse tensions, anxiety, and sometimes destructive tendencies.
 This limited capacity for object representation might also explain
difficulties in verbalization and de-somatization (according to the
model of Krystal, 1988), which might clarify the connection in
personality disorders of a narcissistic structure with psychosomatic
disorders. We will see the link between partial object relation and
psychosomatics (in connection with severe moral masochism) in the
case of Elizabeth in Chapter 9.

BORDERLINE AND NARCISSISTIC STRUCTURE:

DIFFERENTIAL DIAGNOSIS

Both personality disorders present, due to their intersubjective

developmental vicissitudes, a less than fully evolved limbic system,
with insufficient capacity to regulate stress (and therefore cortisol and
catecholamines, with effects on the HPA axis). For these reasons,
such individuals cannot evolve the dual-circuit orbitofrontal system
necessary to develop the symbolic representations that would allow
them to perform self-soothing, reparatory functions encoded in
evocative memory of good objects or preliminary representations of
them.
The dyadic dysfunctions between the caregiver and the possible
borderline-to-be are already apparent in the first 6 months, when this
failure of the couple to overcome the challenges of the symbiotic
period is already evident.
As already pointed out, the narcissistic organization suggests a
better adaptation through most of the first year.
An insecure–resistant attachment is a contributing factor in
egotistical narcissistic personalities.
The lack of symbolic elaboration means that affect regulation
might take other forms (addictions of various kind, eating disorders,
substance abuse, and self-destructiveness to regulate affects,
especially negative affects). It might also imply the somatization of
affects that is very evident in severe narcissists, to the point of
reaching hypochondria, in which the relation with the body parts and
symptoms have taken over all the object relation capacity of the
subject.

SHAME VERSUS GUILT AND SUPEREGO DEFICIT IN THE

NARCISSIST

Shame has been repeatedly defined as the crucial narcissistic affect.

Affect is always created at the intersection between neurobiological
aspects and dynamic interrelational exchange with another and
appears at the interface between dyadic components and between
self, body, and mind.
As regards the psychodynamic context, several studies suggest
that the narcissistic disorder (especially in the hypoaroused type)
presents a background where the patient has been humiliated with
harsh, continual, and massive exposure to criticism and mortification;
maternal shame and rejection can be present (an intergenerational
base of the disorder).
In narcissistic personalities, shame predominates over guilt. In
fact, the presence of guilt in the initial diagnostic interview would be a
good predictor of a less severe personality disorder, implying a more
mature intrapsychic development, with superego development and a
better object relation capacity (which, as already said, is much
hampered in people with a narcissistic structure).
In fact, while guilt follows from the superego formation (as the
depository of parental and shared societal values), borderline
pathologies including narcissism at the borderline level (if we follow
Kernberg’s description) have not reached the developmental levels
that imply superego development, therefore these subjects cannot
experience a proper sense of guilt, which is an intrapsychic feeling
coming from a certain level of ego development in relation with the
other. On the contrary, they depend on shame management for
regulation of mood. The capacity for exchange with the other and to
feel the needs of the other (the empathic dimension mentioned
earlier) is clearly impaired in narcissistic personality disorders. We
have already explained (see Chapter 5) how superego follows the
resolution of the Oedipus complex, but these patients never reached
the Oedipal phase (see also Gabbard, 2005).10
Freud described a healthy, or “primary,” narcissism in the child as
a normal developmental phase, in which the self (which replaced the
Freudian term ego after Hartmann’s language; Hartmann, 1958) and
especially the corporeal self is invested with libidinal energy (“the ego
is first and foremost a bodily ego: it is not merely a surface entity but
is itself the projection of a surface” ; Freud, 1923/1953, p. 26). In his
theory, this healthy narcissism in which the child is totally absorbed in
himself or herself leaves its place to a capacity for relationship with
the other when all the other levels of (we would say relational and
intersubjective) development are satisfied, so that levels of object
formation and relationship with the object are reached. Subsequently,
the subject can go on toward the resolution of the Oedipus complex
with the formation of a fair superego whose demands are realistic,
and at the same time the development of the ego ideal is not too
demanding or grandiose (since the ego ideal does not need to
compensate or repair the wounds to the self the child has suffered;
see also Schore, 1991).
For this fundamental switch to take place, from being absorbed
with the self and one’s body to being connected with the other as
well, the child needs to be capable of introjection and identification
with the parents or the caregivers and with the parents’ pre- and post-
Oedipal introjections. If the intergenerational trauma is severe, or in
the case of abuse and very disturbed relationships, this movement
and healthy interaction between self and other is hampered, and we
have difficulties in the resolution of the Oedipus
complex/identification resulting in superego disorders and
dissociative experiences, which interfere with the maintenance of
good self-esteem and healthy narcissism and the construction of the
ego ideal.
If the parental figures have been experienced as nonempathic or
even neglecting and abusive, the introjection of good parental values
and qualities is impossible, and there is instead the establishment of
a lack of affection and a lack of empathy and care for the other, or
even persecutory features. These last features are particularly
present in connection with more thin-skinned individuals with fewer
externalizing traits, with punitive and persecutory superego
precursors (“precursors” because if there is no Oedipal resolution,
there can be no superego formation proper) that replace the parental
figures, who are experienced as nonempathic, neglectful, or even
violent and aggressive. (This is what happens in the severe case of
Fabian that I will present in Chapter 8, where there is high risk of
suicide.) In some cases that present very early and severe neglect or
abuse, antisocial features emerge (when there has been damage to
the amygdala, there is a damaged capacity for empathy). (This is not
the case with Fabian, who seemed to have had good early parenting
in spite of the negative situation that occurred later on.)

GRANDIOSE SELF

I agree with Schore (and the case of Fabian provides evidence to this
effect) that the continual activation of the grandiose self in these
personalities serves the purpose of reducing the depressive reaction.
In order not to feel the deprivation and the humiliation they have
experienced in relation to the other (the caregiver), they need to
emotionally detach and disconnect from the other and from the
feeling of humiliation and deprivation, and they resort to a defensive
omnipotent reaction, with grandiosity and usually devaluation of the
other and negation of the need of the other (in order to be totally self-
sufficient). The need for the other would in fact arouse the feeling of
lacking something inside, of an internal state of need and fragility that
is unrecognized and therefore deleted. At the same time, if the other
is seen as capable of giving what he or she does not have, he or she
is therefore envied, which might create aggressiveness and a sense
of harsh competition.
 LACK OF APPROPRIATE MIRRORING

While for other personality disorders the developmental etiopathology

is clearer and more univocal, for narcissistic disorders there are
several developmental paths, which also explains the variety of
manifestations of the disorder, even if a cluster of personality features
and behaviors is common. One of the most frequently attributed
causes for the development of the disorder is what several authors
call “lack of appropriate mirroring” with René Spitz (1965), who
speaks of a “wrong kind of mothering.” Narcissistic insecure mothers
are more concerned with their own emotional needs than with the
child’s: even in the absence of emotional deprivation and severe
neglect, this dynamic ends up with a similar lack of attunement with
the child’s real needs. The child is not seen for his or her qualities and
features but only as a self/object at the service of the mother’s needs
for mirroring.11 For the child, this results in a kind of overstimulation
that becomes even more aversive than understimulation; ultimately, it
can create a false-self identity in the sense that the child learns how
to obey the mother’s requests in order to be accepted but never has
the possibility to actually express who he or she really is, a possibility
that would only arise if there had been appropriate early care.
According to Broucek (1991), this inadequate mirroring results in a
sense of shame for the child in several ways, from the infant’s sense
of interpersonal inefficacy (as his or her caregiver is not responsive to
his or her needs) or sense of shame based on a kind of self-
objectification rooted in a basic self-alienation or primary dissociation
(what we have hinted at as what may create a sort of false self), to a
kind of shame that might manifest itself as extreme sensitivity to
one’s own needs and presence, stemming from the experience of not
being loved, a feeling of rejection, or of being scapegoated by
significant others. These fundamental deficits create a kind of
impoverishment of the self, with the compensatory self’s
overinvestment in an idealized self-image and a devaluation of the
actual self. In psychoanalytic terms, in less severe cases (on the
verge between neurotic and borderline narcissistic developments),
this might be explained as the particularly inflated ego ideal to be
distinguished from what Freud called ideal ego.
In general, the caregivers are intrusive and controlling (sometimes
even predatory) instead of mirroring and containing and providing the
adequate regulation that needs eventually to become self-regulation.
In the literature, there are several examples of a reverted kind of
mirroring between parent and child; a very appropriate example,
provided by Kohut (1977), is that of a mother basically wanting
mirroring from the child instead of providing it:

On innumerable occasions she (the mother) appeared to have

been totally absorbed in the child—over caressing him,
completely in tune with every nuance of his needs and wishes
—only to withdraw from him suddenly, either by turning her
attention totally to other interests or by grossly or grotesquely
misunderstanding his own wishes and needs. (p. 52)

Notably, Broucek wrote that such individuals often are reared by

“adoring,” doting, narcissistically disturbed parents who have made
the child a sort of self-object and have projected onto the child
aspects of their own idealized self. These parents cannot mirror and
foster the child’s true sense of self, because they are unable to
provide enough realistic mirroring and therefore sustain mostly an
idealized self in the child (1991, p. 60). In other words, these are
parents who instead of mirroring the child, mirror themselves and
their own expectations projected onto the child. The child is not only
“not seen” in himself or herself, but might be strongly rejected if not
capable of mirroring the parent as she or he would like to be mirrored.
It is very common for narcissistic patients (incapable of the
appropriate mirroring) to foster narcissistic children, in a chain that
cannot be broken unless the possibility arises of really addressing the
issues in therapy. But the narcissistic patient does not willingly come
to therapy, precisely for his or her defensive patterns, as he or she
“doesn‘t need any help,” “does not lack anything,” and is incapable of
depending on anything or anyone. They might come to therapy either
because their partners or parents ask them to or after they have
reached the age of 40 or even later and have seen their own dreams
fail and are therefore in a depressed state, which often complicates
the diagnosis. Only a very skilled therapist will immediately recognize
underneath the depressed surface the too-high ego ideal demands
and the excessive grandiose requests that have created that
emotionally depleted self and that depressive sense of failure.

CASE VIGNETTE OF A SEVERE NARCISSIST: ANDREW

The case of Andrew will provide the example of an almost psychotic

breakdown in a severe narcissist. He started treatment at the age of
almost 40; he presented some antisocial features but was still
capable of levels of empathy (strengthened in treatment), with some
sensitive and altruistic qualities. He had, up to that point in his life,
played the role of the careless and triumphant macho, but the
unexpected humiliation of a break-up with his last girlfriend (whom he
nonetheless afterward acknowledged he had treated without care or
concern) triggered a severe, almost psychotic breakdown in which his
“armor” (his word, surprisingly in accordance with the terminology
used in bioenergetics for certain types of narcissistic body structures)
had broken down, revealing (in his own description) a soft and too
vulnerable, fragile nature. His disturbances had acquired the traits of
a hypochondriac syndrome: he would come to the sessions for
months with a folder full with all the series of medical exams he was
taking, because he could not believe that his breakdown had to be
understood in terms of the neurobiological and psychological
response to the stressful events he had been facing—the problem
must have resided in the body.
The recent interpersonal psychological events and traumatic
responses involving the complex mind–body–psyche set of his entire
being had created in him the sensation that something was “broken”
in his body. He felt all of a sudden “smaller” and empty: his muscles,
which he had been pumping through repeated physical exercise and
dietary supplements, seemed all of a sudden deflated to him. He was
so worried about his physical appearance that he would continually
need to look at his face in the glass of a framed painting I have
behind my chair in my office, and before going out he would spend a
few seconds in front of the mirror I have in the entrance of the room.
He was obsessed with his face being different (especially his eyes)
from what it used to be, and he felt he had literally lost what he
thought was his good-looking and strong, powerful appearance, the
physical appearance he had so carefully maintained through his
fashionable clothes, his elaborate hairstyle, his earrings, and his
jewelry. He was showing (and experiencing) a collapse of the
external image (corresponding to his fragile identity) that he had been
struggling to maintain, and he was in search of a new, reassuring,
appropriate mirroring that he was incapable of finding at this point in
himself.
His mother was a sort of really macho military type who had been
severely damaged by extreme early deprivation. She had been born
during the war to a woman who could not keep her (the paternal
origin of his mother was unclear to the patient) and sent her to a
convent where she had been raised and had learned to defend
herself and to survive through apparent or real lack of feelings,
sadistic attitudes (possible identification with the aggressor), and a
toughness where sensitivity was considered mere weakness
(becoming a sort of macho herself). We can imagine how many
difficulties this woman must have had in raising her children (how
could she give them what she had never received?) and how harsh
and demanding she must have been toward her only male child: he
needed to be harsh and strong while she was continually diminishing,
disdaining, reproaching, and even beating him at any expression of
rebellion of the child or adolescent. I remember very well that the very
first phone call this patient made to me to make an appointment had
been interrupted by his mother, who all of a sudden had grabbed the
phone from the hand of her nearly 40-year-old son to make the
appointment for “her child”: I simply asked her how old “this child”
was, and I asked her to give the phone back to her son. But the
picture was already clear.
 Obviously, the path for this patient was to find autonomous ways
for him to find his own value and his own meaning and identity
outside the original family and the abusive and controlling (predatory)
mother. In his continual taking on and leaving girlfriends, he was
trying to reassure himself he was a valuable, likeable, and strong
man (receiving good mirroring), while never getting too close to a
woman, whom he expected would be menacing, denigrating, and
predatory like his mother had been with him. He always had to keep
himself at a safe distance from any potentially damaging experience
with women, while at the same time desiring continual reassurance
and positive mirroring from them. Sometimes in the middle of a
session he would stand up and say “May I take my jacket off?” or “Do
you mind if I take my jacket off?” (with the sense of showing his body
to me). Therapy with a woman was a turning point for him, where he
could start experiencing trust and esteem on both ends of the
relationship (he went spontaneously from calling me “Miss” in a sort
of disdaining attitude to calling me “Doctor” ).
To summarize, several interrelational problems and early paths of
development, all involving a negative, humiliating, and frustrating
mirroring, caused the child to be incapable of regulating affects or of
modulating realistic ideals of self and resulted in his fundamentally
lacking self-esteem and resorting to defensive operations such as
omnipotent control, grandiosity, idealization of self and others who
were considered self-objects, with devaluation of others and lack of
empathy.

THE DEAD MOTHER COMPLEX AND SEVERE DISORDERS

Even though psychoanalytic theory from Freud to Winnicott to Green

to Lacan has viewed loss and separation as necessary instruments
for further mental development, capacity for representation, abstract
thinking and for symbolization, nonetheless there needs to be a
certain basis for that loss to be conceptualized and represented (i.e.,
the mind needs to be structured enough for that kind of
conceptualization to take place). In other words, there needs to have
been enough “mothering” done for the child to accept that the mother
is away or momentarily not available. In a sense, severe patients
have never experienced a sense of safety and a capacity to feel
alone in the presence of anybody or by themselves. In order for a
safe object to be internalized, there needs to have been the
experience of safety with the object, then safety by oneself in the
presence of the mother and then safety alone, but the internal space
is not inhabited by good internal objects if the reality of that presence
has not been experienced as good or reassuring.
We have used André Green’s concept of the dead mother
complex in patients in which the mother was not available for the
child (because of mental illness, as in the case of Ariadna, but luckily
Ariadna had the possibility of another caregiver); we can only imagine
how unstructuring for the psyche of the child it must be when a
mother is really not reflecting the child but her own needs and even
projecting her own despair/difficulties/hostility onto the other-infant or
child.

NARCISSISM AND THE GAZE OF THE MOTHER

I refer here to the useful metaphor of the mirror proposed by

Alessandra Lemma when she spoke about mothers functioning as a
“unidirectional mirror” or “opaque” surface, therefore difficult to read
and inaccessible. For Lemma, this kind of mother–child relation might
create the presupposition for the child to want to modify his or her
body in order to be more acceptable to the inaccessible and
fundamentally rejecting mother (referred to as the “enigmatic interior
of the mother” by Meltzer, 1988), who could not reflect a positive
image of the accepted child. Lemma added that a traumatization
around the time of birth, actual physical imperfections in the child, or
postpartum depression might interfere with “what the mother sees
when she looks at the child” (2010, p. 74). As a result, this might
create in the child a special anxiety about his or her body and the way
he or she looks, because the child has found a sort of blank space
instead of a reflected image (and an accepted and beloved image) of
himself or herself. As Kilborne (2002) argued, these are people who
continually need to reevaluate their own self-image to reassure
themselves (as in the case above of the trendy macho man).
Even worse is the case of the mother as “distorting mirror,” in
Lemma’s words, when interpersonal hostility is present: in this case,
the negative affects of the mother toward the child are actually
projected onto him or her, and the child takes them in. Hostility can be
open: when this mother looks at her child, she sees “something ugly”
(meaning something that she cannot accept in herself). Not only is
the child’s body not invested libidinally in a positive way, but the body
becomes the receptacle for the negative projections of the mother;
the “undigested” negative projections can be ingested directly into the
body. I see this as a sort of alien self transplant between mother and
child, and these negative feelings and representations of self and
other help trigger the attacks on the body in personality disorders (as
seen in the cases of Bertha and Dorothy and their self-cutting and
bulimia).
Lemma also referred to a subtype of this distorting mirror as the
“mother mirror-you-are-myself,” a mother who hyperstimulates the
body of the child because of her own needs for gratification and
admiration (for McDougall, this is the case of “one body and one
psyche for two people” ; McDougall, 1989, p. 37). In this case, the
mother does not project her negative parts/affects onto the body of
the child but intrudes into the child’s body and uses it for her own
bettering. It is as if the body of the child were the mother’s.
Following Rosenfeld’s distinction of thin-skinned and thick-skinned
narcissism, Lemma proposed that the thin-skinned is most often the
result of a unidirectional mirroring kind of mother, while the distorting
mirroring mother usually creates a dynamic in the child in the
direction of the thick-skinned kind of narcissism. In this second case,
the body is totally “dispossessed” (almost dissociated from the self),
and surgical alterations as instances of acting out reach a manic
proportion in the absence of a really embodied site of identity:
omnipotence is acted out through this physical control and
manipulation of the body, which is never really acquired by the
subject but continues to be a mere instrument as it was played out in
the intersubjective relationship between mother and child.
Instead of projective identification, in this case we speak of
introjective identification (with the negative parts of the mother
introjected). I see this dynamic as very similar to the introjective
identification of the victim with the persecutor/aggressor as described
by Ferenczi (1932a, 1932b). Lemma, following Freud (1917/1953),
described very appropriately how these patients present not only a
narcissistic identification with the object but also levels of splitting so
that the identification with the hated/hating (of the self) object (as they
are now the same) makes them identify the hated object with their
own body, which needs now to be attacked through the instances of
acting out, through destructive acts of several kinds (as I see in my
patients), or through surgical operations, according to Lemma, who
sees a kind of paranoid anxiety at work in this process. I would say
that the body has become the alien self that persecutes the rest of
the self. Lemma sees the thick-skinned patients as more rigidly
identified with a persecutory object, and therefore the attacks are
more violent, and it is more difficult to actually find space for the mind
in those bodies. I would say that not only do they show a difficulty in
the “embodied mind,” but they also show an impossibility in “minding
the body” (to paraphrase another book by Lemma, 2014): their own
mental state makes it impossible for them to be in their body between
self and other accepting both terms.

THE DEAD MOTHER AS A TRAUMA OBJECT

Mauro Mancia has cogently defined the dead mother concept as a

trauma object: this kind of mother will inevitably, he argued, force the
child to create for himself or herself some “prosthesic” object that will
necessarily be of a narcissistic kind, as he or she needs to do
everything by himself or herself, while at the same time he or she has
to attack this very disappointing object (a vision similar to Kohut’s).
The victory of this destructive narcissism (or malignant narcissism)
will bring about the reciprocal destruction or nullification of both the
ego and the object that has been found so disappointing. Mancia
wrote that if this peculiar attack on oneself and on the object
simultaneously attacks the ego-as-mind, the ego-as-thought, and the
ego-as-perception, there will be the establishment of psychosis; if the
attack is directed at the ego-soma, there will be psychosomatic
illness (Mancia, 2010).
It is also evident in my experience how in severe personality
disorders of any kind, there has been an extreme lack of good
parental relationship leading to the impossibility of good object
formation so that the territory between narcissism, perversion,
psychosomatization, and psychosis becomes extremely slippery, and
each case will have a component of one or the other or all of them (as
will be clear in the cases of Fabian, John, and Tom).
For Green (1993), the radical “de-objectification” of the dead
mother is at the root of self-mutilating narcissistic personalities. For
him, as for Kernberg (2012) in his most recent theorization, the death
drive predominates (although, as I have already shown, for Green the
death drive seems more connected to the actual relationship with the
mother than to an innate drive, contrary to Kernberg’s
understanding). Green, in line with classic psychoanalytic theory,
performs a step forward in the direction we are trying to take for the
etiopathogenesis of personality disorders, positing that the real
conditions of upbringing predominate over the innate qualities of
aggressiveness and are fundamental in shaping emotional and
relational development. Therefore, the origin of the disorder is not so
much in innate aggressiveness but in the inner representation of how
the relationship with the mother (or the caregiver) has been
experienced. In other words, in response to the usual psychoanalytic
criticism that attachment theory lacks a stronger symbolic and deep
unconscious base, we could say that the real conditions of child-
rearing (founding the attachment style) create the neuronal and
neurobiological bases in the body–mind–brain system toward the
internal and intrapsychic representations of the object.
 PATHOLOGIC NARCISSISM

For Kohut (1971), there is no real difference between normal and

pathologic narcissism, as all children invest their parents with a
narcissistic grandiosity and strong idealization, and the grandiose self
is the remains of the trauma or the disillusionment experienced from
the parents initially being perceived as self-objects. Otto Kernberg
instead makes a clear differentiation between normal and pathologic
narcissism. Normal narcissism reflects libidinal investment, with
integrated libidinal and aggressive components, an integrated
superego, and reasonable requests in the context of a reasonable
satisfaction of libidinal needs within stable object relations (i.e. with
integrated good and bad representations of self and other).
Pathologic narcissism instead reflects the investment of a pathologic
grandiose self, with an idealized self and devalued object
representations. Envy, idealization of oneself and devaluation of the
other, incapacity to depend on others, and unstable self-esteem
based on the need for approval and the admiration (not the love) of
others rule the emotional life of these individuals. As was observed
earlier, in these subjects the symptoms of borderline narcissism
combine with antisocial behavior, egosyntonic aggressiveness, and
paranoid traits.
The primitive aggressiveness of this character is very similar to the
destructiveness described in the Kleinian formulation of the death
wish, a desire to destroy life in oneself and others, also described by
Rosenfeld. It is this destructiveness consistent with the death wish
that makes this extreme of personality disorder so close to
perversion, a triumph of death over life in spiritual, psychological, and
material/corporeal ways. This kind of “destructive narcissist”
(Rosenfeld, 1987) or malignant narcissist (Kernberg, 1984) will find
pleasure in inflicting pain on others, either emotionally or physically,
as a way of manifesting his or her strength and triumphing over what
he or she perceives as the other person’s weakness, so that people
who are gentle and kind arouse the individual’s disdain and contempt
(as often happens with therapists). Paulina Kernberg (1989) sees this
trait even in young children when she gives examples of siblings
waiting for their sisters or brothers so they can deliberately close the
door with their siblings’ fingers still inside the frame.
Their behavior might be the result of an ancient wound that they
have learned to cover and despise as a weakness, something they
would never want to confront. The destructive and sadistic
components of their personalities have been defended to reinforce
the omnipotent sense of force and domination, so that their sense of
a power structure or power dynamic is so extreme that, as adults in
therapy, they could easily despise a therapist who is gentle and
empathic with them or they could continue with the treatment only to
prove how useless and despicable the therapist is. Joyce McDougall
(1982) presents an interesting case of this kind: a patient went on with
the therapy just to prove that both the therapist and what she had to
offer were useless, clearly attacking her status and esteem as a
therapist. (This is in accord with what Rosenfeld argues, that it is very
possible these patients only go on with therapy because they need a
relationship to attack and a vital/vibrant kind of exchange to satisfy
their sadism, which is true also for the other relationships they might
entertain.)
For Otto Kernberg, pathologic narcissism manifests a pervasive
pattern of grandiosity, with lack of empathy and unreasonable
expectations of entitlement, so that these subjects react to criticism
with rage, shame, and humiliation. The two apparent opposing
features of vulnerability and grandiosity easily coexist: “haughty
grandiosity, shyness, and feelings of inferiority (shame) may coexist
without affecting each other” (Kernberg, 1975, p. 265). This is in
coherence with Wink (1991), who maintains that grandiosity–
exhibitionistic features are often combined with a vulnerability–
sensitivity factor.

NARCISSISM OF DEATH

Otto Kernberg has explained how, under conditions of predominance

of aggression, there might be in the patient a fixation at the level of
primitive defenses and identity diffusion (typical of the borderline
personality organization). Aggression may be condensed within the
structure of a defensive pathologic grandiose self, constituting the
basis of the most severe constellations of pathologic narcissism.
Following Green, Kernberg has recently distinguished between a
narcissism with libidinal dominance and another narcissism where
the death drive predominates (as in the distinction between
narcissism of life and narcissism of death; Green, 1983). Green has
also suggested that this pathology is likely present in subjects who
engage in the horrifying terrorist attacks that are currently occurring
with ever increasing frequency.

ATTACHMENT AND INTERGENERATIONAL COMPONENTS

As Grotstein said: “All psychopathology constitutes primary or

secondary disorders of bonding or attachment and manifests itself as
disorders of the self and/or interactional regulation” (1986, p. 108).
Narcissistic and violent patients may be children of deprived and
devaluating parents, brought up in an emotional desert or even in a
violent environment. These children have used their parents’
defenses to protect themselves and to distance themselves from the
frustrations that the other created for them, so they have to inflate
their self-esteem and devaluate others. Their tension toward
achieving “perfection” is a means of protecting themselves from
shame and humiliation: the psychodynamics of their perfectionism is
therefore very different from that of the perfectionism of obsessive-
compulsive disorders, where there are extreme demands of the
superego and the ego ideal, with the attempt to overcome the sense
of guilt of their neurotic structure. On the contrary, severe narcissists,
as already explained, have severe deficits in superego formation and
therefore lack the sense of guilt connected to superego demands.
Instead of guilt (intrapsychic formation), they feel shame
(interpersonally based). Narcissists may refrain from certain behavior
when in the company of others that they would consider acceptable
when alone. This is also why in the anonymous context of the
Internet, they feel free to molest, bully, or harass people without moral
restraints.

NARCISSISTS WITH A PREVAILING IDEALIZATION MODEL IN

THEIR ATTACHMENT

Dismissing patients who idealize, in contrast with the group that

devaluates, usually have been raised by parents who were self-
absorbed and secretly insecure. They know that their parents and
their parents’ needs always came before their own. They have
learned as children that they would be safe only if they avoided
expressing their needs and feelings or, in some cases, only if they
catered to the narcissistic needs of their parents in a sort of role
reversal. They could be special only if they helped the parents feel
special (positively mirroring them), hiding their dependency on them
and masking their rage. For Wallin, (Wallin, 2007), this explains the
tendency of certain patients to idealize the analyst or at least to
ignore their own needs in order to fulfill the needs of the other
(including what they perceive as the implicit requests of the analyst,
at least until something forces them to reveal their true painful
feelings; this “crisis” in my experience can be a very positive
opportunity to change the implicit model of interpersonal dynamics).

THE CONTROL MODEL

Liotti and Farina (2011) have explained how a subject who has
insecure attachment beginning from preschool years might resort to
one of these dynamics that they call interpersonal motivational
systems (IMS): seductive, controlling, or “caring” in a sort of reversal
of roles.
The controlling IMS is one of the typical narcissistic ways to
manipulate and gain levels of safety and security in relationships with
parents and other adults. Everything in their relationship with the
therapist is a fight for power (the fee, the appointment, the schedule):
these patients are so afraid of being controlled that they need to be in
control and be controlling themselves. Oftentimes, they were raised
by parents who were controlling, feared, and avoided touching or
having physical contact or were openly hostile to the child. They may
have been parents who did not tolerate chaos, confusion, or the
expression of the child’s emotions and needs, and so they responded
to their children with intrusive control.

MORE SEVERE CASES, WITH ALIEN SELF AND TRAUMATIC

CORE

In more severe narcissistic cases, as in the case of Fabian in the next

chapter, I see a formation similar to the alien self (as initially defined
by Fonagy at the Anna Freud Center, London) or an inner persecutor
derived from the intersubjective experience with the caregiver that
incorporates the internal representation of an abusive attachment
figure.
The internal persecutor is projected through projective
identification so that it is the external world that becomes threatening
—the “evil” is outside and needs to be fought (some paranoid levels
are present in severe narcissism, a clear sign of hostile environment
and traumatic abuse).
Very often, the body becomes the vehicle for all the negative
affects the self has taken in from the other (in an early relationship),
and the body becomes the other in a sort of alienation of the body. It
is the receptacle of the dysregulation experienced and is the
scapegoat and the target of the aggression.

TAKING IN THE NEGATIVE PARTS IN THERAPY

A severe narcissistic patient with an abusive core internalized as an

alien self always has a double tension of good and bad objects
inside, negative and positive representations and split affects that are
undigested in his or her personality. Allowing for the expression of the
negative part helps the patient to feel the positive side he or she has
inside. When he or she is alone, these internal split parts torture him
or her, and the internal persecutory tension is often directed against
the self, with self-harm and other destructive behaviors, including
destructive eating habits and substance abuse. It is important that the
therapist be capable of accepting the presence of these negative
parts and able to contain them because this helps the patient to
observe them and acknowledge their presence in himself or herself,
without expressing anger or frustration but by calmly becoming aware
of his or her action in the dyad.
It is important to engage in the struggle with the patient, helping
him or her to see the parts as objectively as possible.

SELF-HARM AND SUICIDAL TENDENCIES

Within the spectrum of severe narcissism, these particularly

destructive and suicidal patients, more than dismissing patients, are
traumatized patients (in the Adult Attachment Interview, they would
be unresolved for trauma, i.e., abuse, or loss), therefore Unresolved
instead of Dismissing, but they do experience the affective
dysregulation coming from the lack of attunement and of secure base
between parent and child as described by Schore with the model of
affect regulation (amygdala/orbitofrontal deficit).
They might be prone to self-harm and suicide especially in the first
months of the treatment, precisely because of the activation of a
model of dysfunctional attachment evoked by the relationship with
the therapist.

VICTIM–PERSECUTOR DYAD

The severely traumatized always reexperience and continually

rehearse unconsciously (meaning implicitly, without being aware) in
real life, as well as in therapy, the major dyad they have inscribed in
their implicit memory, the victim–persecutor dyad (Mucci, 2013). Very
often, they become the persecutor of their body, which is the victim,
but also the playground of their horrific repetition of their destructive
parts onto themselves and their body, in some cases even starving
themselves, cannibalizing their own flesh or cutting parts of their
body.
While they play out death on their body in this way, they also
rehearse the traumatic experiences of their life and physically repeat
in their body–mind–brain system the template inscribed in them.
When they can repeat this in the relationship with another, they have
the most life-affirming experience of which they are capable, and in
this context they may finally escape from the life-as-death circuit they
have been inscribed in. When this life-as-death repetition comes to
the fore in the actual enactments of the treatment, there is a possible
way out for the patient. The body–mind–brain system enacts “what is
known but yet unthought” (Bollas, 1987).

SUICIDAL TENDENCIES IN SEVERE

BORDERLINE/NARCISSISTIC PATIENTS

In severe narcissists, acts of omnipotent control and grandiosity and

attempts at suicide are usually performed not out of impulsivity (as in
borderlines proper) but out of a calculated rage against the self
(identification with the aggressor); basically, a totally negative or dead
or, even worse, abusive and persecutory object has been
internalized.
The grandiosity consists in the “aggressive devaluation of the
external world, a radical devaluation of significant others and the self”
(Kernberg, 2014) and is basically the result of that “negative
narcissism” as described by Green (Green, 2001): the patient feels a
sense of omnipotence, even if in destructive terms, by controlling his
own death and destructiveness usually through attacks to the body
(not only cuts but, in the worst cases, cutting of nerves, bodily parts,
and so forth). A sense of superiority stems from the lack of fear and
the control over the body.
 What to Do
The therapist’s role is fundamental. The dyad enacted in the therapy
will be the repetition of the internal world and the internalized objects
of the patient:

• victim–persecutor is the main dyad, repeated continually and

inverted continually even in the same session;
• needy child–omnipotent (good) parent;
• needy child–sadistic and withdrawing (bad) parent.
The dyads will be repeated and enacted in the room with a
predominant transference but with constantly changing roles in the
transference, because of the internal fluctuations of the split internal
parts (constituting the identity diffusion). The capacity of the therapist
to recognize and empathize with these dynamics is fundamental in
order to highlight for the patient the parts of himself that are identified
with the aggressor against himself and the parts that are, from time to
time, identified with the victim. Sometimes the therapist becomes the
persecutor and the aggressor, and these shifts need to be elucidated
continually.

Suicidal Behavior and Conflicts

The split parts (death and life) and the grandiose self are particularly
harsh in their pursuit of destructiveness to the point of death: the
therapist should not take sides: it would be very dangerous to take
sides in this conflict. If the therapist were to take the side of life for
instance, by reinforcing and sustaining this side, with a supportive
attitude, there would also be a reinforcement in the patient of the
other side, the wish to die. The analyst’s taking sides in this case
would mean leaving the patient alone in the conflict, making the
danger worse.
As Kernberg wrote: “Highlighting the potential internal conflict in
the patient’s mind as it becomes activated in the transference, a true
struggle between the death wish and the wish to live is a major
therapeutic task in these cases” (2014), p. 878).

Involving the Family

Contrary to what is normally done in psychoanalytic treatment, with
these patients in affect regulation therapy the involvement of the
family is fundamental and reinforces the treatment frame and realistic
expectations. The risk of suicide needs to be expressed and
discussed openly with the family and the necessary
psychodynamically informed precautions taken to ensure that the
therapist works without pressure or threats.
The objective security of the therapist and “space” for working
through the countertransferential reactions are in fact of primary
importance.

9 For the sake of clarity, I have already explained how for Kernberg there is a
temperament that is mostly innate and the child responds to traumatizations with
the caregiver according to this temperament, so that the response of the child
becomes fundamental in understanding the levels of difficulty and of the
traumatization. On the contrary, we view the entire process as epigenetically
informed from the time of the prenatal intersubjective relationship. In our view,
Kernberg’s and classic Kleinian view of the innate aggressiveness of the child
create a basis for asserting that it is the innate temperament of the child (a genetic
view), not the environment (i.e., the intersubjective relationship), that is responsible.
If we view the process as biologically and genetically inscribed, obviously there is
not much that the mother (or any other caregiver or any early relationship including
a therapist) can do to improve the relationship and therefore the problem.
10 In the entire book, I have been using the terms Oedipal and superego as
shorthand to synthesize the classic description of development in psychodynamic
and psychoanalytic explanations for neurotics; I am referring to a level of psychic
and relational development that is not reached in borderlines and narcissists
because of early relational trauma and abuse.
11 Once again, we are not saying this to devalue mothers, who have an enormous
job in human society for which there is often little or no recognition: it is obvious that
these mothers have not had the possibility of being mirrored and of being in the
mind of their own caregivers in their turn. These observations instead stress the
intergenerational component of the pathologic dynamics, unfortunately. What we
are saying from the point of view of the children could easily be said for the mothers
or the caregivers: if they are unable to mirror their own children, it is because
nobody has done this to and for them. And besides, if 60% of the population has
secure attachments, we owe this to the excellent work of the caregivers, mostly
mothers (biological or not).
 CHAPTER 8

Suicidal Tendencies and Risk of Suicide in

Borderline and Narcissistic Patients

THE CASE OF FABIAN

I WILL USE THIS CASE of severe narcissistic personality disorder with

psychotic levels of functioning, major depression, self-cutting, and
eating disorder mostly for the suicidal threats it posited and how to
respond to them. I also want to show how these narcissistic patients
are the most difficult to treat, and their extreme traumatizations
repeated in therapy through dangerous dynamics are the most
challenging situations that severe personality disorders might re-
create.

Diagnostic Chart (Figure 8.1 and Figure 8.2)

Vertical axis 1: Traumatic history, intergenerational features,

and attachment; Adverse Childhood Experiences (ACE)
questionnaire
• Traumatic past (loss of mother and maltreatment from stepmother). The
mother died from cancer at age 48 when Fabian was 6; she had been a
nun until age 40, then left her convent and married Fabian’s father. As a
child, the mother had been placed in an institutional orphanage because
she had lost both parents to cancer.
• The father had bipolar disorder and sexual identity problems (afraid of
being homosexual; I learned this subsequently from his psychiatrist,
 who gave me this information unsolicited); he remarried when Fabian
was 7.
• Severe abuse by the stepmother: Fabian could not sit at the same
dinner table with the rest of the family; could not take a shower in their
house and had to go to the house where his father lived to shower
before the new marriage (because he was too “dirty” and he had a “bad
smell” ); could not sit on the family sofa (because he was “too fat, his
feet smell,” and so on); he had to leave the house every day after lunch
because the stepmother needed to clean the house and did not want
him around. She grossly devalued him and constantly offended him
(even when he did well at school, she humiliated him: “the school
successes mean nothing in the real world” he was a failure; he was
ugly; no woman will ever want him; and so on).
• Additional maltreatment results in the silence of the father, who is a
passive onlooker to the abuse (no defense or help from the other parent
results in vicarious traumatization in the terms indicated by Ferenczi,
1932a).
• At age 19, Fabian was diagnosed with depression and received
medication12 he attempted suicide several times between ages 19 and
21, after which he came to therapy.
• Attachment: Insecure attachment to the mother and disorganized
attachment to the father; he is unresolved for trauma and abuse with
respect to the stepmother.
• Major psychodynamics: Narcissism of death (or alien self) with
identification with the aggressor.
• ACE questionnaire: Psychological and physical abuse; family
dysfunctions; mental illness in the family; intergenerational violence (his
father’s father had been killed in a family feud over land-ownership
issues). Therefore four elements out of seven total in the questionnaire.

Vertical axis 2: Diagnosis of personality disorder

• Severe narcissism with borderline structure; no antisocial features, but
covert type with very fragile self-esteem. Omnipotent retreat into a world
of fantasy with some schizoid and psychotic features. Self-
destructiveness with major depression resulting in suicide attempts. His
borderline features are impulsivity, identity diffusion, sexual identity
diffusion, mood instability, a chaotic lifestyle, addiction to certain foods,
smoking (tobacco and cannabis), and poor impulse control.
• Aggression is egosyntonic only against the self; some paranoid
features.
Figure 8.1–8.2

Vertical axis 3: Bodily symptoms

• Self-cutting of his face in adolescence; obesity or excessive eating with
some vomiting in adolescence; bodily dissociation (frequent de-
realization and depersonalization even in therapy); extreme rejection of
his bodily image and of his sexuality (extreme self-loathing of his body,
so he can’t even think of getting close to women or men if he has
homosexual fantasies).

Horizontal axis 1: Dreams

 • Repeated themes in dreams. Snakes: a threatening cobra in bed with
his father; playing a video game trying to kill cobras; and so on.
Attraction for Dracula themes (the coffin, the disquieting border between
life and death).

Horizontal axis 2: Sexuality

• Extreme rejection of his physical and sexual aspect: muscular but with
at moments a sort of falsetto voice. No clear sexual orientation or sexual
desires (some masturbation with homosexual fantasies, but no
relationships with either men or women). Fantasies of having a woman
inside,13 but he maintains reality testing.

BEGINNING OF THERAPY: ATTUNEMENT, MIRRORING, AND

ACCEPTING

Considering Fabian’s background of severe deprivation, loss, and

trauma and his history, I was particularly careful in the first few
months to empathetically welcome his desire to spontaneously tell
me about and vent his anger over the severe neglect, loss of his dear
mother, and the subsequent maltreatment by his stepmother and
father. I allowed him complete freedom to express his grief, anger,
and resentment (against the stepmother and against the father). For
the first 2 weeks in therapy, he seemed almost disoriented and could
not even sit in his chair for a long time: he needed to stand up,
sometimes lifting his shirt out of agitation and restlessness and rage
in remembering the abuse. Sometimes I could not even understand
or follow his discourse, but he did not seem psychotic to me, just in a
total confusion of unbearable emotional states of which he felt a
pressure, an urgency, to be finally liberated and in which
predominated anger and the sense of outrage and injustice at having
been so terribly abused and rejected. I resorted to taking notes in
front of him as a strategy for getting him to slow down, reflect on what
he was saying, and gain consciousness so that he could find
connections in the torrent of words he was recounting, while giving
him the sense that I was taking him very seriously. I was literally his
container, and I had to stop him sometimes so that both of us would
be able to digest the amount of things he was recounting and focus
and connect the emotions present in his story and also to give him a
sense that there was another there in the room with him who really
wanted to listen and who accepted him. It seemed that it was new for
him to have a committed listener and somebody who could take in his
torrent of words and at the same time would not be overwhelmed or
reject or “kick him out” as I presumed everybody around him had
been doing for a long time. His attire was rather in disarray. As a
physical reaction to this intense containment (which entailed body–
mind–brain for the first few months), I had headaches during his
sessions, and the headaches would go away a few minutes after the
sessions ended. (With another very severe patient, I very often have
nausea in correspondence with her narrations of unbearable physical
and sexual abuse, which testifies to the extreme interconnection of
emotions with mental and bodily states. Here, Porges’s polyvagal
theory is perfectly equipped to explain the mechanism of
psychobiological response in the bodily countertransference).

BEING THE PARENTAL FIGURE HE HAD LACKED

I accepted for the first few months to be there simply as a sort of

parental nurturing figure to listen to him with curiosity and patience,
attention and warmth, asking some questions to better understand
him and implicitly trying through my body, voice, and gaze to imprint
in him a relational experience of acceptance and reassurance. As I
sensed that his body was the most deprived, and I picked up that he
wanted somebody to care about his weight and to give him
suggestions about how to eat healthier and lose weight, I decided to
bring a scale to the office in order to weigh him, and I would write
down his weight each time on the same sheet of paper, so that he
could receive total attention for a few minutes about a body that had
been “offended” and disliked and rejected so strongly by his
stepmother. I took this occasion to give him a sign of acceptance, of
concrete care and concern about the details of his life and his body,
something he certainly had not shared with anybody for a long time.
 By losing weight, he was getting rid of the toxic food he had
ingested with the words of the stepmother and the pain he had felt
when he had been left alone with the illness of the mother, her death,
and the subsequent rejection by the stepmother. In a sense, the
stratagem of the scale was a sort of enactment on two levels: as a
young man in reality, somebody was checking on his diet and
physical well-being to maintain health and provide clear limitations to
his excessively impulsive addictive behaviors; also, implicitly and in
order to address an earlier part of himself in the complex body–mind–
brain system, I was concretely contributing to an early organization of
his image, identity, and sense of self through my concrete
involvement and empathic attunement. His body was the easiest
target to address and the most clearly deprived part of his being to
which I could direct my attention, so I did it instinctively but then
repeatedly to establish a pattern of primary care, attention, a routine
channel of reciprocal involvement. It was a sort of conscious
enactment of an implicit preverbal meaning that I put on between us
to create an interconnection that could physically bond us as we
proceeded with the taking in of his story and his pain at other levels of
connection and of understanding and elaboration or integration. To
use the powerful and synthetic definition by Lyons-Ruth (1999), it was
a way to construct a channel toward a “two person unconscious,”
hinting at the implicit reparatory interconnection that comes together
with integration of new relational meanings and restorative
experiences. This two-person unconscious starts from bodily identity
and awareness as the body is felt in relation with the other.

NURTURING THE BODY IN THERAPY

The combination of attention to his body, empathic resonance with

his narrative, and care and concern for his words and the practical
and routine details of his life (as in primary care) soon gave fruit: after
3 months, he started coming to therapy smelling freshly showered,
which I took as a sign of the birth of some good narcissism (or love
for himself through the care and love of another). Also in beginning to
take care of himself, he was signaling his growing awareness that he
could become closer to another in a relationship; it was also a sign
that he had been totally abandoned and neglected in his younger
years, as clearly no one had been concerned with his consistency in
personal hygiene and bodily care.

FIRST YEAR OF THERAPY

For at least a year, the dynamics of the sessions remained almost the
same, and I was mainly, as I said, a container for his rage and a
primary caregiver for his most evident emotional needs, and I would
say I was primarily a soothing object (with the exception of touch, of
course, I tried to accept and respond to him with all possible care and
attention, through bodily posture, eye contact, especially responsive
facial expressions, softness of voice, timing and appropriateness in
response, meaningful nonverbal acts, and attention). I
accommodated his need to let out the rage and the anger and the
hate against the stepmother and for all the humiliation, the rejection,
the vulgarity of both his father and his stepmother and their constant
neglect, rejection, and abuse. I marked consistently and congruently
his rage and supported his sense that he had been deeply
mistreated. I felt that my role was to receive and respond in a
sensitive and attuned way to his affects, taking them in almost with
my body and giving testimony, almost an “embodied testimony,” to
his extremely miserable childhood, to the loss and the rejection and
the pain that had characterized his young life. In the sessions, he was
constantly rehearsing the scenes and the words of his stepmother,
making almost physical distortions of his body, almost hissing with his
breath as if he had to expel an alien self that tormented and tortured
him (a snake: he said his stepmother was like a snake). He seemed
to be in an almost dissociated state in which he sometimes would
stare into the void for brief moments, while with another part of
himself, his more developed representational connections, he was
always very present and even made very acute and smart, intuitive
comments (sometimes hilarious or ironic) about his past situation,
about the circumstances of his life, even his symptoms (he had
clearly read serious texts on psychoanalysis in the past), and showed
acute intuitions about his “illness” (some hysteric/histrionic elements
were also evident and he could recognize them).

VICTIM–PERSECUTOR DYAD

Fabian was the victim of a fiercely persecutory world, not in fantasy

but in reality, and his traumatizations made him literally relive his past
continually, to his own surprise. He was always the first to be aware
of how, as we read in manuals about reexperiencing PTSD and
trauma, the traumatizations are always present in their own physical,
sensorimotor, and emotional qualities, in an endless repetition, as if
they were happening again in that very moment. In all this, my
presence was that of a very available and concerned therapist who
did not interpret but just acknowledged and bore witness to the abuse
and to his need to physically relive, liberate, and rid himself of the
affects in his body that were always very present, while reinforcing
the positive qualities he had (intelligence, humor, perceptiveness,
sensitivity, kindness) in order to improve his extremely damaged self-
esteem.

WORKING AT REGULATORY EDGES

I suppose this was my part in helping him with affect regulation, which
I took as my role for more than a year in most of the sessions. I was
careful, as I always am with very severe patients, to always finish the
sessions with questions or indications that went in the direction of
restoring the patient to his normal everyday reality—questions like
“What are you doing now after the session? What do you have to do
now?” —to restore in him a sense of the limits of common reality and
to prepare the most mature part of the patient to reengage in real life
after the “working at regulatory edges” or at the “windows of affect
tolerance” (Schore, 2012); that is, the reconnecting in the patient of
the limbic–amygdalar emotional system to the orbitofrontal areas and