The moon is made of cheese, gtk books/03 by Gestalt Therapy kairos Institute

Gestalt Therapists Translate The Borderline Language

/03

by Giovanni Salonia (Ed.)

september 2016/03

Gestalt Therapy Kairos Institute ISSN 2039-5337

THEMOON ISMADEOF CHEESE

GESTALT THERAPY KAIROS

/03

Gestalt Therapy hcc Kairos Institute Post graduate school in Gestalt Psychotherapy

In its quarter of a century, the institute significantly contributed to the history and progression of Gestalt psychotherapy, forming about a thousand psychotherapists and intersecting various and fruitful relationships of cooperation and affiliation with many national as well as international corporations and bodies directed to scientific exchange and the research in the specific field of psychotherapy and treatment connections. From the beginnings, the institute has been in contact with Gestalt psychotherapy founders that were living at that time – Isadore From, Jim Simkin – and handled to start didactic and scientific exchanges with the most illustrious representatives of second generation Gestalt therapists – E. Polster, M. Polster, S.M. Nevis, Ed Nevis, R. Kitzler and others – committing themselves to international research projects about Gestalt psychotherapy theory and therapy. The institute weaved didactic and scientific exchanges with the most prestigious Gestalt therapy institutes in Italy and abroad, as well as with the most qualified Gestalt Therapy associations worldwide, maintaining relationships of cooperation. In 2001, the institute started a collaboration with the Università Cattolica del Sacro Cuore, establishing second level Master courses, arrived at its 16th edition.

THE INSTITUTE ORGANISES ■ Second level Master degrees in “Paths of prevention and treatment of sexuality. Gestalt Therapy and interpersonal relations” in cooperation with the Università Cattolica del Sacro Cuore, Faculty of Medicine and Surgery in Rome. ■ Second level Master degrees in “Family Mediation” in cooperation with the Università Cattolica del Sacro Cuore, Faculty of Psychology in Milan ■ CME Continuing Medical Education courses AFFILIATIONS EAGT (European Association for Gestalt Therapy) NYIGT (New York Institute for Gestalt Therapy) SIPG (Società Italiana di Psicoterapia della Gestalt) FISIG (Federazione Italiana Scuole e Istituti di Gestalt) CNSP (Coordinamento Nazionale Scuole Psicoterapia) FIAP (Federazione Italiana delle Associazioni di Psicoterapia). WEB www.gestaltherapy.it BLOG www.gestaltgtk.blogspot.it FORUM www.abusosessuale.forumattivo.it www.gestaltherapykairos.forumfree.it OFFICES RECOGNISED BY THE MIUR Sicily Ragusa / Latium Rome / Veneto Venice D.M. 9.5.94, D.M. 7.12.01 e D.M. 24.10.08 SCHOOL MANAGEMENT AND SCIENTIFIC COMMITTEE Giovanni Salonia Scientific responsible Valeria Conte Responsible of didactic Erminio Gius Member of scientific committee

GTK books of GESTALT THERAPY KAIROS journal of psychotherapy Scientific Director Giovanni Salonia Managing Director Orazio Mezzio Chief editor Laura Leggio Rosaria Lisi Law Office Silvia Distefano Scientific Committee Angela Ales Bello Vittoria Ardino Paola Argentino Eugenio Borgna Vincenzo Cappelletti Piero Cavaleri Valeria Conte Ken Evans Sean Gaffney Erminio Gius Bin Kimura Aluette Merenda Rosa Grazia Romano Antonio Sichera Christine Stevens Editing Sergio Russo Miriam Zahavi Translations and English Consultancies Gemma McGlue Luisa Pacifico Emilia Rizza Miriam Zahavi Graphic project Marco Lentini Pagination Paolo Pluchino Illustrations Angelo Ruta

The Texts of GTK Psychotherapy Review and GTK Books are subjected to a double-blind peer review system. Printed by Parentesi S.r.l. Ragusa GTK books of GESTALT THERAPY KAIROS International journal of psychotherapy Address for all correspondence: GESTALT THERAPY KAIROS journal of psychotherapy Via Virgilio, n°10 97100 Ragusa Sicilia Italia Enquiries: Editorial +39 0932 682109 Subscriptions +39 0932 682109 FAX +39 0932 682227 Email: redazione.gtk@gestaltherapy.it Website: www.gestaltherapy.it

The reports have been modified in order to guarantee the patients’ privacy.

To Isadore From, therapist and master

INDEX

Introduction............................................................................. pag. 9 In this issue............................................................................. pag. 13 The moon is made of cheese Gestalt translation of borderline language (GTBL).......................................................................................... pag. 17 Giovanni Salonia The relational borderline pattern Gestalt translation of the diagnostic criteria of the DSM-5 (‘Alternative’ model)........................................................ pag. 65 Gabriella Gionfriddo «…As if i was born ‘uneven’…» The Gestalt translation of the borderline language model (GTBL) clinical attestations............................................... pag. 95 Andreana Amato «If i am afraid to die, could i die?» Gestalt Therapy with a patient with borderline language....................................................... pag. 139 Valeria Conte References............................................................................... pag. 163

Journal of Psychotherapy GTK1

GTK2

GTK3

Index

Editorial

In this issue

Research The anxiety of acting between excitement and transgression. Gestalt Therapy with the phobic-obsessive-compulsive relational styles Giovanni Salonia

Research Gestalt Therapy and its serious patients Valeria Conte

Research The personality-function in Gestalt Therapy Antonio Sichera

The Perls’ Mistake. Perceptions and misunderstandings of the gestalt post-Freudianism Interview to Giovanni Salonia by Piero A. Cavaleri

Theory of Self and the liquid society. Rewriting the Personality-function in Gestalt Therapy Giovanni Salonia

Art and psychotherapy The recovered body. Writings and images of a therapy I can’t write it… Eva Aster

Art and psychotherapy Borderline Border-line Annalisa Iaculo

The borderline patient: an insistent, anguished demand for clarity Interview to Valeria Conte by Rosa Grazia Romano Art and psychotherapy To Alda Merini Paola Argentino Catch my soul Giuliana Gambuzza New clinical pathways Onotherapy and Gestalt Therapy: New Applications of Pet Therapy Silvia Zuddas and Francesco Padoan

New clinical pathways Narcissus: the reflex without water The myth according to bill Viola, reflections on the narcissistic experience Giovanna Silvestri Readings Aluette Merenda

Readings Aluette Merenda, Fabio Presti

Re-reading ‘the re-discovered body’ interview to Maurizio Stupiggia ed. by Elisa Amenta Society and psychotherapy The flight of Bauman in Siracusa. Interview to Zygmunt Bauman ed. by Orazio Mezzio Readings Aluette Merenda

English Scientific Journal P. 1/2

INTRODUCTION

INTRODUCTION Giovanni Salonia

A book written by therapists of the same school – in this case the Gestalt Therapy Kairos (GTK) – needs the right technical clarifications in order to avoid the risk of a self-referential semantics.

1. A gestalt work pattern The book’s basic preference is to provide a precise psychotherapeutic model placed in the theoretical framework of the Gestalt Therapy (GT). We have called it The Gestalt Translation of Borderline Language (GTBL). Therefore, it is not the book’s nor its author’s aim to present a systematic presentation of other treatment models.

2. How To Name The So-Called Borderline Patient The GT has been among the first psychotherapeutic approach to refuse to typologize diagnosis. Already in 1950 Goodman was wondering «how not to impose (a specific problem that the psychotherapy shares with pedagogy and politics) a standard on the other instead of helping him to develop his own potentialities?» and he suggested to speak about orientation, since «the therapist needs his conception in order to maintain an orientation and to know in which direction the therapist has to look». The diagnosis in the GT is therefore a theoretical and experiential background of information about the relational styles, to draw on and from which it comes from, for the therapist, the empathic understanding of the betweenness that occurs during the relationship between the therapist and the patient. In the GT there is talk of relational styles. They can be functional or not, according to the fact that they allow or interrupt the contact between Organism (O.) and Environment (E.): in this case it is preferred to talk about phobic relational style, dependent, narcissist, borderline rather than borderline subject, narcissist etc. In our specific case it is more rigorous

to refer to the patient’s language. Highlighting the ‘borderline language’ instead of the experience or the function means – for our School – to point out how the disorder manifests itself and how it is placed within the language that is the dwelling of contact. Borderline language as the borderline relational style. A language that requires and calls the therapist for a ‘gestalt translation’. In the pages of this volume we will talk about patients that use a borderline language (PBL: Patient with Borderline Language) and about the Gestalt Translation of Borderline Language (GTBL) as our treatment models.

3. What Are The Gt’s Bottom Lines? The GTBL model is based on two fundamental principles of the GT: the theory of Self and the theory of contact. The theory of contact describes the contacts that the O. lives with the E. It is the quality of these contacts that creates health or psychical disorder. The Gestalt Theory of contact analyses the path that O. and E. accomplish in order to achieve full contact, able to meet their intentionalities. When the path continuously gets interrupted, dysfunctional relational styles are generated and they take shape depending on the moment when the break occurs. The theory of Self describes the contact O/E focusing on what happens in the O. when it comes into contact. In the gestalt theory the three functions involved in the realisation of a contact O/E are: the Id-function (what is felt in the body: sensations, emotions, corporeal experiences); the Personality-function (who feels: the definition of oneself built in the body by the assimilated experiences); the Ego-function (in comparing the Id-function and Personality-function, a novelty emerges in a creative way: the choice to harmonise with ‘who I am’ and the acuity of ‘feeling’ the chosen path as ones very own belong to the Ego-function). Obviously, the psychical disorder takes place when the Id-function (the O. does not feel or distorts the bodily sensations) and/ or the Personality-function (which results as a lump of introjects and not of assimilations). In these cases every choice will be dysfunctional and not nutritious (the Ego-function has been lost). Enjoy the reading!

Journal of Psychotherapy GTK4

GTK5

Index

Editorial

In this issue

Research The moon is made of cheese. Exercises of gestaltic translation of borderline language Giovanni Salonia

Research Gestalt animal assisted psychotherapy: heterospecific encounters in psychotherapy Aluette Merenda

The relational narcissistic model in the post-modern world and therapeutic work in Gestalt Therapy Valeria Conte Beyond Oedipus, a brother for Narcissus Paola Aparo

Intersections. Gestalt Therapy meets Ethnopsychiatry Michela Gecele New clinical pathways With you, Iâ&#x20AC;&#x2122;m not afraid. For a re-reading of the script Panic attacks and postmodernity Annalisa Castrechini Society and psychotherapy Now moment or final contact? Meetings and comparisons with D. Stern, friend and teacher Giovanni Salonia Readings Aluette Merenda

English Scientific Journal P. 2/2

IN THIS ISSUE

Giovanni Salonia pag. 17 Psychologist, psychotherapist, already professor of Social Psychology at the University LUMSA of Palermo. He teaches at the Università Pontificia Antonianum of Rome. Scientific director of the School of Specialization in Gestalt Psychotherapy of the Institute of Gestalt Therapy hcc Kairos (Venice, Rome, Ragusa) and of the second level Master degrees co-managed with the Università Cattolica del Sacro Cuore di Roma. He is a teacher wellknown internationally and he is invited to several italian and foreign universities, he was the President of the FISIG (Italian Federation of Gestalt Schools). He wrote Interpersonal Comunication (with H. Franta), Kairòs, Odòs, Sulla felicità e dintorni and as co-author, Devo sapere subito se sono vivo and La luna è fatta di formaggio, as well as numerous articles published in national and international journals, they deal with anthropological and clinical themes. He founded and directed the journal Quaderni di Gestalt (1985-2002) and since 2008 he is the scientific director of GTK Journal on line of Psychotherapy. Gabriella Gionfriddo pag. 65 She graduated in Psychology at the University of Palermo, she is a Gestalt psychologist and psychotherapist. Currently, she performs a clinical activity and, in the role of a trainee teacher, she conducts research activities at the School of Specialization in Gestalt Psychotherapy of the Gestalt Therapy Institute hcc Kairos, Ragusa office. Andreana Amato pag. 95 Gestalt Psychologist and Psychotherapist, she specialized at the Gestalt Institute hcc Kairos of Rome. Since 2004 she works in a Psycho-Pedagogical Institute with patients with mental disabilities and psychiatric pathologies. She performs a psychotherapeutic activity as a freelance therapist with individual patients, couples and families. She graduated in Music Therapy at the ‘Glass Harmonica’ School of Rome and she works in the field of rehabilitation programs for disorders in developing age.

Valeria Conte pag. 139 Psychologist, executive of the Mental Health Department of the provincial ASP of Ragusa; psychotherapist and regular Supervising teacher recognized by the FISIG (Italian Federation of Schools and Institutes of Gestalt). Member of the scientific committee and teaching and clinic responsible of the Gestalt Therapy Institute hcc Kairos. Trained with the major national and international representatives of Psychotherapy of Gestalt, she has widened her specific background with specialization in family therapy and corporal therapy. She deepened the epistemological model of Gestalt Therapy in her work with psychiatric patients and in the work with couples and families, whereof publications in national and foreign journals.

Books of Psychotherapy Books 2

Books 3

Index

Editorial

In this issue

Oedipus after Freud. From the law of the father to the law of relationship Giovanni Salonia

The moon is made of cheese Exercises of gestaltic translation of borderline language Giovanni Salonia

From Freudian fracture to Gestaltic continuity: the epistemological gap of Gestalt Therapy Antonio Sichera

The relational borderline pattern. Gestalt translation of the diagnostic criteria of the dsm-5 (‘alternative’ model) Gabriella Gionfriddo

Letter to a young Gestalt therapist. Gestalt therapy approach to family therapy Giovanni Salonia

«…as if i was born ‘uneven’…». The Gestalt Translation of the Borderline Language Model (GTBL). Clinical Attestations Andreana Amato

The refund grandson Co-therapy carried out by V. Conte and G. Salonia

“If i was scared of die, could i die?” the gestalt therapy with a patient with borderline language” Valeria Conte

Giusy’s failed degree Therapy conducted by G. Salonia

English Scientific Books

GIOVANNI SALONIA

THE MOON IS MADE OF CHEESE EXERCISES OF GESTALTIC TRANSLATION OF BORDERLINE LANGUAGE Giovanni Salonia

1. A foreword like a dedication. Isadore From’s1 teaching Every borderline’s precocious experience is the denial of the possibility of experience itself: «Don’t say this», «Don’t think this». Since psychoanalytic technique is quite similar, it turns out to be intolerable for borderlines. Without telling lies, in Gestalt Therapy, it is possible to confirm the patient’s experience and, unless it is dangerous, never intervene by saying: «You don’t have to think about this» or «Don’t say so». A child could say, for example: «The moon is made of cheese», a somehow extremely poetic statement. However, an anxious mother could respond: «You’re wrong». Well, even a good Gestalt therapist knows that the moon is not made of cheese, but would not say to a borderline: «Yes the moon is made of cheese», but rather «They are both yellow». And that is it.

1 Isadore From (1918-1994) was one of the most esteemed didacts and therapists of the group of the seven founders (together with Fritz Perls, Laura Polster, Paul Goodman and others) of Gestalt Therapy. He did not write much: cf. Requiem for Gestalt, in «Quaderni di Gestalt» (directors and founders Giovanni Salonia & Margherita Spagnuolo Lobb), I, 1, 1985, 22-32; together with V. Miller the introduction of the 1994 edition of the text Gestalt Therapy by F. Perls, R. Hefferline and P. Goodman; an interview given to E. Rosenfeld on Storia orale della psicoterapia della Gestalt published in 1987 in «Quaderni di Gestalt», III, 5, 11-36. Among texts written on him, we remember: G. Salonia (1994), L’elogio della debolezza, in «Quaderni di Gestalt», X, 18/19, 53-57; A. Sichera (1994), Per una rilettura di Requiem for Gestalt, in «Quaderni di Gestalt», X, 18/19, 81-90; B. Muller, Il contributo di Isadore From alla teoria e alla pratica della Gestalt terapia, in «Quaderni di Gestalt», VIII, 15, 7-24; H. Cole (1994), In ricordo di Isadore From, in «Quaderni di Gestalt», X, 18/19, 5-20; M. Spagnuolo Lobb (1994), Da figlia a madre, in «Quaderni di Gestalt», X, 18/19, 45-52. Since 1981 and up to some years before his death, he taught in various HCC Gestalt Institute departments (Syracuse, Venice, Rome).

Be very careful with borderlines. Never tell them they are wrong; instead, listen to their experience of the world. If you observe the history of these patients, in their early years, they listened to the language used by the key people in their lives which sometimes negated their experience. They may have done it to protect them, but by doing it in this way, they confused them by creating conditions of disorder. Therefore, as therapists you should not allow history to repeat itself; you do not have to make things happen which have already happened. I do not care about truth in front of borderline patients. What interests me is protecting their experience, what they say they experience. If a borderline patient said to me: «You look sad», I would not simply respond, «I’m not sad» (I could do it with patients that are not borderline, highlighting the fact that it could be a projection), but I would add: «I’m very tired today». I would not negate what he told me, but I would not tell a lie: only in this way do I protect his experience2. This contribution ideally arises from Isadore From’s withering, very smart and pioneering intuition, trying to outline the hermeneutic figure of Gestalt Therapy (GT) approach with PBL (Patients with Borderline Language)3. Without discrediting («What you say is wrong»), without lying («What you say is true»), the therapist supports his patient and makes the intimate coherence of a statement emerge, which seems strange at first glance. Let’s proceed with our itinerary from this paradigmatic and poetic example and from some precious teachings on the topic by From4.

2 The text is an authentic translation of a seminary held by Isadore From in Venice, from 29/1 to 1/12 1990, at the HCC Gestalt Institute. 3 The term ‘borderline patient’ is used for practical reasons; however, it does not intend to label, but rather indicate a specific relational modality. 4 Every time I cite Isadore From, I remember that dinner in southern France, where I told him (almost joking menacingly) – he was still reticent to publish about Gestalt – that I would publish many seminaries he had held under his name. He looked at me with his warm, sharp and clever eyes and responded with precision, something along the lines of: «You cannot write ‘What From said’, but ‘What I understood from From’s lessons’». Remembering this fine precision each time I refer to what… I understood from his ideas is a duty and pleasure to me.

I do not care about truth in front of borderline patients. What interests me is protecting their experience, what they say they experience

This contribution ideally arises from Isadore From’s withering, very smart and pioneering intuition, trying to outline the hermeneutic figure of Gestalt Therapy (GT)

GT can give the world of therapy an original, approaching method of interpretation and clinical intervention even in the most difficult conditions and the most extreme psychic disorders

However, to me, starting with From also means expressing a sincere gratitude towards him as he was the one that first adopted GT at work with serious patients. As he knew and often reiterated, GT can give the world of therapy an original, approaching method of interpretation and clinical intervention even in the most difficult conditions and the most extreme psychic disorders. In this sense, the bipartition of my work will try to respond to two requirements: to clarify, to a certain extent, hermeneutic basics and gestaltic therapy with some of the most difficult and emblematic patients of our times; and to connect (and question) the ‘gestaltic way’ with some of the most successful and well known suggestions (from Gabbard to Kernberg, from empathy to mentalization) in the diagnosis and treatment with PBL, in order to first of all verify a diversity and distance that also signify a serene, respectful and decisive dissent in real therapeutic language.

2. The gestaltic method: translating borderline language

Their words and behaviour may appear confusing, strange, accusing, but always include fragments of truth and coherence, from which one necessarily has to start

In my messy pockets I search for words never learnt And only see wrong words, Confused, intrusive, tangled I go back or I am absorbed by a reiterated deceit And so I feel myself thrown into the world In which I lose and confuse myself I hang onto the other to understand What happens to me, if I can feel. Annalisa Iaculo5

The Archimedean point of gestaltic clinical work with BLP is the certainty that their words and behaviour may appear confusing, strange, accusing, but always include fragments of truth and coherence, from which one necessarily has to start, in or-

5 A. Iaculo (2013), Border-line, in «GTK Journal of Psychotherapy», 3, 61-63. This poem accompanies us through the treatise.

der to trace the patient’s experience. Such a therapeutic gestalt model is called ‘Gestalt Translation of Borderline Language’ (GTBL). It is about avoiding the cognitive or emotional colonisation of the PBL, going back from his words – respected, even if totally idiographic – to the related experience. The use of the word ‘translation’ is not innocuous or accidental, but hermeneutically characterised. ‘To translate’6 means giving the PBL’s statements a dignified language. Indeed, in translation, both languages involved require and receive equal dignity. A translator cannot approach source and target language presuming implicit hierarchies of value7. It is a considerable aspect. In fact, in therapy with PBL, you often try to impose a language – the therapist’s one – considering the borderline language as ‘strange’ rather than ‘foreign’. The basic misunderstanding – according to the GTBL model – is due to the fact that PBL uses words of a language according to their idiographic meaning; hence it seems he speaks a different language. His semantic choice recalls the ‘false friends’ characteristic, which despite morphological and phonetical similarities, refer to dif-

6 For a new hermeneutics of ‘translating’ not any longer based on ‘sources-oriented’ and ‘target-oriented’ theories, but on the metaphor of the hotel, that is linguistic hospitality, basic text is A. Berman, L’epreuve de l’étranger, Gallimard, Paris 1984. Also cf.: M.J. Iglesias (2013), L’esperienza della traduzione. Verso un’ermeneutica dell’ospitalità e della reciprocità, in «Nuova Umanità», XXXV, 206, 177-192. Translating means reconfiguring both source and target language correlating them: cf. C. Hagège (1989) (or. ed. 1985), L’uomo di parole, Einaudi, Turin, quoted in S. Fontana, A. Zuccalà (2011), Tra segni e parole: Impatto linguistico, sociolinguistico e culturale dell’interpretariato lingua dei segni/lingua vocale, in «Rivista di Psicolinguistica applicata», XI, 3, 67-78. 7 It is interesting to notice how even a therapist with cognitive behavioural education compares such difficulty «with the arduous task to translate a book, in which Arab words alternate pervertedly with Chinese terms»: M.H. Stone (1987), Constitution and temperament in borderline conditions: biological and genetic explanatory formulations, in J.S. Grotstein, M.F. Solomon, J.A. Land (eds.), The Borderline Patient: Emerging Concepts in Diagnosis, Psychodynamics, and Treatment, The Analytic Press, Hillsdale, New York, 253-287, 253-254. Whereas the GTBL gestaltic model considers language coherent and independent.

It is about avoiding the cognitive or emotional colonisation of the PBL, going back from his words – respected, even if totally idiographic – to the related experience

Means giving the PBL’s statements a dignified language

The insuppressible and obstinate research for clarity and diversity from the PBL’s side will help the therapist to become conscious of his incoherence, clearer in his treatment relations and more precise in the use of his language

In the therapeutic path, it is essential identifying the (relational) experience of PBL and support the passage from his idiographic language to the shared one

ferent and sometimes even opposite meanings8. PBL language can be defined a ‘false friend’: in fact, it seems to be built on the semantic universe of the others, but is actually set on a different universe of meanings. Defining the present gestaltic working model with PBL actually means to acquire the epistemology of translation as a therapeutic task. Only if you know both languages appropriately, you can provide a correct translation. With such tools, translations feature the rich shades and sensitivity that each language owns. From such a perspective, the therapist is aware of the fact that you can learn a lot from PBL: the therapy will turn into an interesting and, to a certain extent, a fascinating trip towards the exploration of secret (but determining) trends of the human heart. The insuppressible and obstinate research for clarity and diversity from the PBL’s side will help the therapist to become conscious of his incoherence, clearer in his treatment relations and more precise in the use of his language. Let us go back to the translation process. Etymologically, ‘to translate’ (trans-duco) means ‘to lead’, ‘to carry across’, ‘to cross’. In gestaltic clinics, to translate means going through the PBL’s verbal and non-verbal communication, in order to identify the point where disorder was formed. In From’s example, the therapist finds the connection (surely idiographic and artistic!) that the patient established to put together moon and cheese: the colour yellow. As mentioned, borderline confusion comes from the fact that the PBL uses shared words (moon, cheese, etc.) with idiographic denotations, connections or connotations. In the example quoted by From, the subject acted out a different association criterion – but not less logical or coherent – from the one of common semantics: if both are yellow, it follows that they are connected and interchangeable (the moon is made of cheese and – why not? – cheese is made of the moon). In the therapeutic path, it is essential identifying the (relational) experience of PBL and support the passage from his idiographic language to the shared one.

8 For example, some foreign terms betray the assonance with the Italian: ‘to attend’ does not mean ‘attendere’ (to wait) but ‘frequent’, ‘delusion’ is not ‘delusione’ (disappointment) but ‘mistaken idea’, ‘déjeuner’ is not ‘digiunare’ (fasting) but ‘having breakfast’, etc.

GT offers a clear and interesting description of this process in two interpretations: the first one – evolutionary theory of the contact cycle – which analyses when and how PBL learnt words and grammar in the relationship with a parental figure. The second one – the theory of Self – analyses which function of the Self was involved in such learning: the Id-function, (corporeal experience) or the Personality-function (narration of the experience). Identifying the confusion in these phases and in these levels will allow the patient’s words to be traced back to a type of source-text. In this line of work, the Gestalt therapist is guided by questions such as: «What relational experience is the patient living?», «What difficulties is he facing in the experience, in understanding and telling us about the experience?», «How are his ‘strange’ words connected to such experience?», «What is happening between us, therapist and patient, in our contact border?». One day, Claudio, a patient, said to me as soon as he sat down: «Giovanni, I get the impression that you are mad at me today». I did not seem to feel such emotion, and thus I responded: «I don’t seem to feel this emotion, but if you say so, I want to listen to myself better. Give me some time to think about it». I pondered on it and said to him: «I don’t find anything against you in myself, but if you say so, such anger must be somewhere». A moment of silence and I added: «Maybe knowing when you’ve seen it and on which part of my body can help us. Try to remember». The patient: «I saw anger in your eyes». I asked: «When?». And he said, after a while: «Here you are, I remember it! Your eyes were angry when you opened the door». That day, the secretary was not there and I went to open the door. I responded: «Let me think...». At a certain point, everything became clear: «You’re right – I said to him – when I opened the door, my eyes were furious, but not with you. I was reading a letter about a colleague which made me furious and when I opened the door, my eyes were still in that emotional wave». «Thank Goodness – concluded Claudio – I’m not mad!». At the time my patient ended the interaction exclaiming: «Thank Goodness, I’m not mad!», he opened a gaping hole in the efforts he performs, telling himself and us about his experience without being misunderstood or seen as mad. If we

The GT’s identifying clinical factor with PBL is to make perceptive misrepresentation processes emerge, as well as the patient’s semantic field into certainty – as From insisted – that his statements, even the most incomprehensible ones for the therapist, tell a relational experience

had not found the reason for his feelings together, if we had not found a concrete explanation for my anger, even in that case I could have said to him: «You are telling me the that you sense anger in me towards you. I cannot see this and we cannot find a concrete explanation for this. If you say so, then it must be true in some shape or form. Let’s continue. Should you sense the same emotion or a similar one again, we will talk about it again: we will find out what it refers to...». It is obvious: respect and confidence in the truth of the PBL’s words do not intend to naively exclude the possibility that the patient could project his own experience onto the therapist. It becomes clearer and clearer how the GT’s identifying clinical factor with PBL is to make perceptive misrepresentation processes emerge, as well as the patient’s semantic field into certainty – as From insisted – that his statements, even the most incomprehensible ones for the therapist, tell a relational experience: this is why the patient anyway is always right (or at least he has a reason to be so). He anyway always and in any case wants to share his experience, but doesn’t know – and this is where confusion is! – that his words have ‘private’ meanings or connections, which are maybe not easily understood (this is what the therapist will have to comprehend), but not wrong. It’s the same dictionary, but meanings or reference grammar are different.

3. The imprinting of borderline confusion 3.1. Contribution of neurosciences As neuropsychological sciences have confirmed9, the development of an experience involves three levels (motor skills, the emotional and the cognitive sense), which in neuropsychology have been described as ‘triune brain’ by MacLean:

9 Cf. Wilber’s notion of hierarchic processing of information, which describes evolutional and functional hierarchy between three levels of experience organisation: cognitive, emotional and motoric sense. Cf. K. Wilber (1996), A brief history of everything, Shambhala, Boston.

«A brain with a brain within a brain»10. In the matter in question, the ‘reptilian brain’, the first one that developed according to an evolutional viewpoint, it controls the arousal, the organisms’ homeostasis, sexual impulses and it’s connected to the motor skills and the level of information processing, including impulses related to voluntary movements. Linked to the emotional process, the ‘paleomammalian brain’ or ‘limbic system’ present in all mammals, surrounds the reptilian brain and mediates emotions, memory, some social behaviours and learning11. Different types of knowledge originate from each of these brains12. The reptilian brain produces «innate behavioural knowledge: the tendency to carry out instinctive actions and habits linked to primitive survival needs»13. The limbic system is linked to «emotional knowledge: subjective feelings and emotional reactions to world events»14. Instead, the neocortex generates «declarative knowledge […] propositional information about the world»15. Indeed, the clinical work of GT tends to analyse the development process of Gestalt (a sort of Gestalt-analysis) to identify where borderline confusion is placed: it is a phenomenological-relational work, which reduces and does not intensify the patient’s confusion, avoiding any reference to frames of reference not related to his communication contents. The specific nature (and correlated severity) of any borderline disorder is established with the level of confusion in the patient. With this path, the therapist will understand (verbal and non-verbal) messages, which were first labelled as ‘strange’ and have now become only ‘foreign’, thus require

10 P.D. MacLean (1985), Brain evolution relating to family, play and the separation call, in «Archives of General Psychiatry», 42/4, 405-417. 11 Cf. L. Cozolino (2002), The neuroscience of psychotherapy: Building and rebuilding the human brain, Norton, New York. 12 Cf. P. Ogden, K. Minton, C. Pain (2006), Trauma and the body. A sensorimotor approach to psychotherapy, Norton & Company, New York-London. 13 J. Panksepp (1998), Affective Neuroscience: The Foundations of Human and Animal Emotions, Oxford University Press, New York, 43. 14 Ibid. 15 Ibid.

The clinical work of GT tends to analyse the development process of Gestalt (a sort of Gestalt-analysis) to identify where borderline confusion is placed

With this path, the therapist will understand (verbal and non-verbal) messages, which were first labelled as ‘strange’ and have now become only ‘foreign’, thus require a translator

a translator. I believe that understanding how borderline confusions happen and are structured along the patient’s evolutional learning paths is an essential, but not sufficient pre-understanding to approaching a PBL without any therapeutic prejudice.

3.2. Evolutional theory and psychopathology

In order to understand a PBL’s vocabulary and grammar, you need to go back to those imprinting processes, where the child is confused and/or misled without being aware of it Pathologically serious are those traumatic confusions that are produced in the stages where the child awakes to awareness and are placed at the level of corporeal sensations (Id-function of the Self)

In order to understand a PBL’s vocabulary and grammar, you need to go back to those imprinting processes, where the child is confused and/or misled without being aware of it. The evolutional stage16 in which this dysfunction happens is when he starts to become aware of experiences (sensations, perceptions, emotions, and intercorporeal feelings), his own ones and those of others, and of the words used when telling himself about and recounting such experiences. By describing confusion times and levels, it will then be possible to identify appropriate therapeutic paths for the different ways from which the borderline disorder arises.

3.2.1. Borderline learnings in the sensory-motor register (Id-function) Pathologically serious are those traumatic confusions that are produced in the stages where the child awakes to awareness and are placed at the level of corporeal sensations (Id-function of the Self). A mother starts to kiss her daughter on the face, then on the neck, in a crescendo that displays her affection more and more intensely and viscously, turning the kisses into bites. Despite the daughter’s verbal and nonverbal signals, the mother does not desist and continues sometimes using tender, and sometimes aggressive words. The daughter’s body is overwhelmed with opposite sensations at the same time (warmth, af-

16 Cf. in relation, G. Salonia (2013), Gestalt Therapy and Developmental Theories, in G. Francesetti, M. Gecele, J. Roubal, Gestalt Therapy in Clinical Practice, Franco Angeli, Milan, 235249.

fection, invasion, violence, annoyance). Confusion is inscribed in her body: each time she is kissed, mixtures of contrasting sensations and emotions will appear in this child’s body, which will produce confusion and disorientation. Another example: early in the morning, a father goes into his eleven-year-old daughter’s room, who is sleeping, speaking to her in an aggressive and confusing voice, saying vulgar words expressed with this terrible question: «What are you dreaming about? You are a tart! You belong to me!». A violent and mad intrusion that confuses and destroys the corporeal spontaneity of sleeping, dreaming and awakening in the girl. A lot of clinical work is required to restore such seriously destroyed spontaneity. However, the most serious experience of traumatic confusion is certainly incest17. In the variety of ways that this crime happens, from a clinical point of view, it is necessary to consider that the harm involves the Id-function of the Self (sensorial-motor level) decisively, if the abuse happened at a premature age, when a girl does not have the means to give this experience a name yet, since her body is overwhelmed and confused by contradictory and incoherent excitement and emotions (pleasure, warmth, pain, violence, bewilderment, proximity, passiveness, powerlessness and so on). When the body will feel sexual sensations and stimulations at any level in the future, it will at the same time and in the same corporeal space feel other emotions in an extricable way, such as uneasiness, violence, need, dis-

17 On abuse, cf. J. Kepner (1995), Healing tasks: Psychotherapy with adult survivors of childhood abuse, Jossey-Bass, San Francisco; M. Stupiggia (2007), Il corpo violato. Un approccio psicocorporeo al trauma dell’abuso, La Meridiana, Molfetta (BA). Touching, on incest, depositions of E. Aster: cf. E. Aster (2011), Letters, in «GTK Journal of Psychotherapy», 2, 75-78; Id. (2011), I can’t write it…, in «GTK Journal of Psychotherapy», 2, 79-81. Also cf. Elisa Amenta’s interview with prof. M. Stupiggia (2012), Re-reading The re-discovered body, in «GTK Journal of Psychotherapy», 3, 65-71, and the forum for sexual abuse of the GTK Institute edited by doctor E. Amenta: www.gestaltherapy.it. As for traumatic experiences in general, cf. P. Ogden, K. Minton, C. Pain (2006), Trauma and the body, cit., and in particular, the polyvagal theory: S.W. Porges (2001), The polyvagal theory: Phylogenetical substrates of a social nervous system, in «International journal of Psychopathology», 42/2, 123-146.

The most serious experience of traumatic confusion is certainly incest the harm involves the Id-function of the Self (sensorial-motor level) decisively, if the abuse happened at a premature age, when a girl does not have the means to give this experience a name yet

In the experience forming stage, the intrusive educational style can create confusion, and even different levels of severity (examples: «Go to bed, don’t you know that you are tired», «Eat, you are hungry», «Cover yourself, it’s cold», «I know what is happening to you now» and comparable), which interrupts spontaneity in the physiological process to go through and learn corporeal, emotional and relational experiences from life

gust, anger, with a deep sense of confusion and sensory as well as behavioural loss. In the experience forming stage, the intrusive educational style can create confusion, and even different levels of severity (examples: «Go to bed, don’t you know that you are tired», «Eat, you are hungry», «Cover yourself, it’s cold», «I know what is happening to you now» and comparable), which interrupts spontaneity in the physiological process to go through and learn corporeal, emotional and relational experiences from life. As if the names of emotions were learnt without experiencing them, as if that nomina nuda tenemus18 was achieved, which from time to time takes on different meanings. Even the educational style that verbally anticipates the paths and names of an experience that the child is starting to live and that has not yet reached its own form, seems confusing. Such confused timing imposes an external direction pre-established to sensations still in the early stages, which the child starts to feel, and so prevent the pre-learning-experience of those processes that follow when an emotion has to take form (for example: even ‘light irritation’ will be called ‘rage’). Conte summarises «Hence, the child has been prematurely hyper defined […] with a false and deceptive kind of empathy that does not allow him to learn the right name of his feelings. The child’s experience has been interrupted by establishing a difficulty in the symbolisation process and in the significance of the experience. [...] This misleading anticipation of experience offered by the parent in place of a respectful support of differences and a child’s regular experiences becomes a scam. As a consequence, the child grows up with confusing experiences»19.

3.2.2. To whom do the experiences belong? A second level of induced confusion does not actually concern the processes of formation of the experience, but their belonging, their assignment

A second level of induced confusion does not actually concern the processes of formation of the experience, but their belonging, their assignment. If the child asks his mother if she is sad

18 «Stat Roma pristina nomine, nomina nuda tenemus», in Bernardo Di Cluny, De contemptu mundi, I, v. 952. 19 V. Conte (2011), The borderline patient: an insistent, anguished demand for clarity, in «GTK Journal of Psychotherapy», 1, 63-77.

and the mother – not aware she is experiencing and showing this kind of emotion – responds in an intrusive way «What are you saying: me, sad? I am happy. You are the one that’s sad»; or if the mother responds to her child, who says she is sad «Come on, don’t say that. I’m the one that’s sad», the child remains disoriented with reference to identification and the correct distribution of experiences. Another situation: Anna, eight years old, is annoyed by her father’s caresses that she feels are, albeit not disturbing, but inappropriate. When she shows her annoyance, she is told that she is at fault, because she has strange thoughts: the father is not aware of the corporeal borders between himself and his daughter and attributes it to a mistaken emotion. The girl gets confused, because she does not know whether to allocate the ‘inappropriate’ experience to her father’s behaviour or to her own reaction. When she attends the therapy, she talks about her confusion, about the fact that she feels hurt when she feels unpleasant reactions in relation to the behaviour of others. In order to rediscover the limpidity in relationships with others, she will need to learn that it is her body and that nobody has the right to touch her without her permission.

3.2.3. A third level of borderline learning: names of the experiences (Personality-function of the Self) Another form of confusion that can be caused in children has to do with incorrect names given to the emotions they experience or see in the body of others. Confusion has been caused at the moment when the Personality-function20 comes out and the learned words do not correspond to or distort the experience one goes through. In a training group, at the end of a project, Anna shows that she is relaxed and tranquil. I ask her: «How do you feel?». And she replies: «I feel anxious». The participants and I are surprised: her answer seems to be

20 On the Personality-function of the Self, cf. G. Salonia (2012), Theory of Self and the liquid society. Rewriting the Personalityfunction in Gestalt Therapy, in «GTK Journal of Psychotherapy», 3, 29-57.

Another form of confusion that can be caused in children has to do with incorrect names given to the emotions they experience or see in the body of others. Confusion has been caused at the moment when the Personality-function comes out and the learned words do not correspond to or distort the experience one goes through

From a clinical point of view, it is necessary to make a differential analysis of confusion types and levels: distinguishing if it concerns the Id-function (formation of experience in sensations and emotions) or the Personality-function (telling oneself or recollecting an experience)

Using wrong names to define one’s own experiences does not only create confusion at a cognitive and narrative level, but also harms other levels of the experiential-relational world

too discordant with what her body communicates and with the work we have done. So, I ask her to explain to me in more detail what she feels in her body, which sensations she perceives, and above all, where the perception of anxiety comes from. She responds: «I feel my body vibrating. I feel energy flowing through me. I want to move my body… I feel anxious!». «If that word did not exist – I ask her – what would you say?». Surprised, she tells me: «Is this not anxiety?». Then she tells me that each time she feels the desire to move her body, she remembers her mother saying in similar circumstances: «What is wrong with you? Why are you so nervous? Why don’t you stand still?». In such a situation, experience has been formed and has been seen as one’s own, but the name given is ‘wrong’ (according to a shared vocabulary). Wrong names of experience refer to the cognitive and narrative experience level, which GT defines as Personality-function of the Self. As shown, from a clinical point of view, it is necessary to make a differential analysis of confusion types and levels: distinguishing if it concerns the Id-function (formation of experience in sensations and emotions) or the Personality-function (telling oneself or recollecting an experience). This analysis becomes particularly necessary in incestuous situations: indeed, the severity is qualitatively different to when a girl clearly distinguishes what happens – the violation of her body and related reactions – but she does not know if she has the right to say it, how to say it, if she is responsible as well, if they will believe her, if it is right to create other problems between parents or at home. In such a situation, confusion refers to the words used to define, understand and retell the experience, which the girl has, however, clearly undergone. Using wrong names to define one’s own experiences does not only create confusion at a cognitive and narrative level, but also harms other levels of the experiential-relational world. For children, in fact, learning to talk does not only consist of finding words to be filed in their memories and then mechanically repeated with their lips, but it coincides with the growth of linguistic ability that progresses with age and practice. The words children learn not only increase their information, but also prepare their intellect to understand with higher alacrity what they have not yet heard, to clarify what they have al-

ready heard a long time ago and only understood half of it or not at all, and to tidy up the world21. This confusion can also refer to the names of the emotions of others. Angelo answers the phone and his aunt asks if she can speak to his mother. At the end of the conversation, he asks: «Mum, aunty was speaking strangely. What is up with her?». His mother – lying (the aunt was in hospital because her husband had had a heart attack) – responds: «She was just a bit tired». The son replies: «Well, she did not seem tired to me, but very worried». Age allowed the boy to learn the right words in identifying an emotion through the tone of a voice. If children do not learn the correct names to identify the experiences of others, they are doomed to have confusing and conflicting relationships: if they wrongly learn to define a ‘sad’ face with an expression of disgust instead, this would give rise to misunderstandings and disagreements that nobody would understand the reason for at that moment in time. It is the repetition of similar situations that creates, in the long term, the definition of ‘strange’ that characterises the borderline.

If children do not learn the correct names to identify the experiences of others, they are doomed to have confusing and conflicting relationships

3.2.4. The ‘double bind’ theory A widely studied scam has been the one defined as the ‘double bind’ theory in literature. The mother gives two T-shirts to her son: a red and a white one. When she sees her son with the red T-shirt, she cries out: «You don’t like the white one». And vice versa in the case of the white T-shirt. In other words, ‘double bind’22 is a situation in which the communication between two individuals connected by an emotionally relevant relationship shows an inconsistency between the level of clear conversation (verbal) and the one of meta-communication (nonverbal: gestures, attitudes, tone of voice, etc.). However, in order to have a double bind, the situation has to be like this: the recipient of the message shall not have the

21 W. von Humboldt (1989) (or. ed. 1988), Scritti sul linguaggio, Guida, Naples, 51-52. 22 C.E. Sluzki, D.C. Ransom (1979) (or. ed. 1976), Il doppio legame, Astrolabio, Rome.

‘Double bind’ is a situation in which the communication between two individuals connected by an emotionally relevant relationship shows an inconsistency between the level of clear conversation (verbal) and the one of meta-communication (nonverbal: gestures, attitudes, tone of voice, etc.).

chance to decide which of the two levels is valid, nor to make the incongruence explicit. Bateson’s23 example is the mother, who sees her son again after a long period of time, because he has been in care due to mental illness. As a fond gesture, the son tries to embrace his mother, who freezes; at this point, the son pulls back, and the mother says: «You don’t have to be afraid of showing your feelings». At an implicit communication level (freezing), the mother expresses rejection against the son’s fond gesture, while at an explicit communication level (the sentence said immediately after), she denies being responsible for the estrangement: it is the son who is stopped in expressing his feelings. They make him feel guilty, and he is unable to respond. Referring to his studies on learning levels, Bateson suggests that the cause of schizophrenia is the chronic exposition to double bind family situations. In reality, the Palo Alto school has already responded extensively to similar theories, for example in the Pragmatics of Human Communication24, where it is clear on the one hand with lucid simplicity that, even if most people are subjected to double bind experiences in their lives, these are «isolated and spurious [...] A different situation is shown, when one is exposed to double bind for a long time and gets used to it gradually and expects it, with particular attention to childhood, where children have few defences and think, which leads them to establish that such communication happens all over the world»25. On the other hand, in keeping with a model that distances itself from the identification and theorisation of a single cause (linear causality), in favour of multifactorial causes and effects that retroact (circular causality), Watzlawick and his

23 Cf. G. Bateson (1976) (or. ed. 1972), Verso un’ecologia della mente, Adelphi, Milan. 24 P. Watzlawick, J.H. Beavin, D.D. Jackson (1971) (or. ed. 1967), Pragmatica della comunicazione umana, Astrolabio, Rome, also cf. with regards to the paradox communication style: L. Lumbelli, D. Parisi, C. Castelfranchi (1977), Sulla comprensione nelle situazioni comunicative di doppio vincolo, in «Lingua e stile», XII/3, 369-383. 25 P. Watzlawick, J.H. Beavin, D.D. Jackson (1971) (or. ed. 1967), Pragmatica della Comunicazione umana, cit., 2013.

colleagues explain «the double bind does not cause schizophrenia. All that can be said is that where the double bind has become a predominant communication model [...] it is evident that the behaviour of this individual meets the diagnostic criteria of schizophrenia»26.

3.2.5. The insurgence and arising of borderline relational mode When and how is the relational mode of borderlines determined? In the evolutionary Gestalt theory it is about a primary relational experience where a merging, warm and intrusive parental figure doesn’t tolerate that her son may have perceptions, emotions and experiences that are different from hers. To appease such distress, she imposes her son perceptive schemes and words that don’t coincide with her son’s experiences. As an example, she will call her son’s vivacity ‘anxiety’. Such etiologic supposition collocates the relational mode of borderline in the phase of confluence and introjection, anticipating the theories of Mahler27, which place the emerging of borderline disorder in the ‘reconciliation’ phase. The different collocation is given by the fact that the gestaltic theory focuses on the moment where the preconditions of the actual disorders are, while Mahler looks at the behavioural appearance of the disorder: when you learn how to look onto the (internal and external) world, and how to call it (around the 5th or 6th month). In the initial stages, children do not experience such semantic confusion, because their world is shared with the mother, who is confused as well. Only at the stage where they distance themselves from the mother by walking, giving rise

26 Ivi, 204. 27 Cf. M. Mahler, F. Pine, A. Bergman (1975), The psychological birth of the human infant: symbiosis and individuation, Basic Books, New York; G. Salonia (2013), Gestalt Therapy and Developmental Theories, cit. Also cf. M.S. Mahler, L.J. Kaplan (1977), Developmental Aspects in the Assessment of Narcissistic and So-called Borderline Personalities, in P.L. Hartocollis (ed.), Borderline Personality Disorder: the Concept, the Syndrome, the Patient, International Universities Press, New York, 71-85.

In the evolutionary Gestalt theory it is about a primary relational experience where a merging, warm and intrusive parental figure doesn’t tolerate that her son may have perceptions, emotions and experiences that are different from hers

In practice, a borderline acquires a differentiation of identity, not of experiences. His relational scheme can be defined like this: «I know who I am and who you are, but I don’t know to whom the experiences belong»

to their own adventure in the world, these first difficulties will emerge more and more evidently: they will neither be able to understand the others, nor have the feeling that they can be understood. By calling vivacity (one’s own and that of the other’s) ‘anxiety’, step by step, they will be perceived and slightly perceive themselves as ‘strange’, starting to deposit experiences of aggression, anger and confusion. It is useful to bear in mind that, while you can confuse the names of concrete things, you can be denied immediately (if a child calls the ‘table’ bread, he is experimenting by mistaking the term used), it is rather complicated to experiment with denial and identify mistakes in the world of corporeal and relational experiences. These features make the child’s separation path towards his mother complex. It is true that from a certain point of view, the parental figure and the child split in a primary borderline relationship, but they actually remain united in the confusion that combined them as far as sensations, perceptive structures, emotions and words are concerned. A specific ambivalence is developed in the patient, so the more he approaches the other and feels warmth (his own and the warmth of others), the more he gets confused and does not know what he wants. If he walks away and distances himself, then his confusion decreases but his sense of solitude increases. In practice, a borderline acquires a differentiation of identity, not of experiences. His relational scheme can be defined like this: «I know who I am and who you are, but I don’t know to whom the experiences belong». The patient develops a specific bivalence («I can’t stay with you/I can’t stay without you»): the need for emotional warmth leads him to get closer, but the heap of misunderstandings – and anger – make him get away. As we will see, he feels confusion and distress in not knowing what he wants, as he experiences the emotional warmth of a relationship, and therefore needs to distance himself to find himself again. If he gets away, his confusion gets less, but the sense of loneliness increases. We will see that many typical difficulties (‘strangeness’) of PBL come from such confusion.

3.2.6. Borderline relation mode between theory of Self and theory of contact To recap, hermeneutics collocation of borderline confusion in the theory of Self28, or better in the Id-function or Personality-function, has a clear clinical consequence. For example, if the therapist shakes the patient’s hand, and the latter pulls back immediately, saying that he feels embarrassed, the first clinical intervention will be to verify in which function this embarrassment is positioned. This means asking the patient if he feels embarrassment in the hand, the body or if it is connected to certain thoughts («You don’t do it», «it’s not fair» and similar). Differentiating confusion by positioning it in the body or narration is a required, irreplaceable presupposition for the following clinical work. The confusion concerning the Id-function requires a long and delicate intervention, a slow process of progressive clarification of the range of contradictory and disordered sensations emerging altogether. As for the contact cycle theory29, the therapist has to consider that the PBL starts every experience in a confusing Stimmung, because he does not have any adequate semantic tools to decipher and recollect his experiences and the ones of others. From his (already confused) background, his needs emerge inevitably confused. In fact, as it gradually takes form, he amasses more confusing elements, instead of clarifying them, and thus a contact experience can never happen. At this point, it is important to distinguish the borderline confusion between the one of neurotic or psychotic30. Indeed,

28 Cf. F. Perls, R. Hefferline, P. Goodman (1994) (or. ed. 1951), Gestalt Therapy: Excitement and Growth in the Human Personality, The Gestalt Journal Press, New York; G. Salonia (2012), Theory of self and the liquid society, cit. 29 Cf. F. Perls, R. Hefferline, P. Goodman (1994) (or. ed. 1951), Gestalt Therapy, cit.; G. Salonia (1989), Tempi e modi di contatto, in «Quaderni di Gestalt», V, 8/9, 55-64. 30 I do not think that one can speak about borderline confusion in the situation described by Dreitzel, where the child is confused by the diversity between father and mother. I do not agree with this definition: «From the point of view of Gestalt therapy, we must first be aware that borderline experiencing derives from schizoid and narcissistic modes of experiencing, in changing

The therapist has to consider that the PBL starts every experience in a confusing Stimmung, because he does not have any adequate semantic tools to decipher and recollect his experiences and the ones of others

The PBL’s disorder is not a lack of awareness of what happens to him, which is typical of the neurotic, and not the psychotic’s lack of identity, but rather the lack of clarity about what is happening in his intrapersonal and interpersonal world

borderline confusion is more intimate: in a certain sense, the patient is conscious of what he is doing, but is not able to distinguish confused sensations, or better still, he tells them with words right for him, but wrong for the others. The PBL’s disorder is not a lack of awareness of what happens to him, which is typical of the neurotic, and not the psychotic’s lack of identity, but rather the lack of clarity about what is happening in his intrapersonal and interpersonal world. Because the PBL’s confusion is placed right at the beginning of the formation of the experience, from a contact cycle point of view (in other words, the stage where the relational experience block occurs) his troubles lie in the pre-contact phase31.

4. Therapeutic paths

A phenomenological-gestaltic methodology, respectful of the patient’s perceptions (even if complicated), allows the therapist to enter into his account and to translate it in common language

In a certain sense, the therapeutic work has to retrace the passages of the development process of experience the PBL undergoes, in order to grasp the cores of confusion. A phenomenological-gestaltic methodology, respectful of the patient’s perceptions (even if complicated), allows the therapist to enter into his account and to translate it in common language. Every other intervention that bypasses this preliminary path proves to be ineffective and maybe even iatrogenic: like an intervention whereby two partners are in conflict, because they do not realise that although they are using the same language, they are assigning different meanings. If one person states that an hour is a very long time and the other instead maintains that it is a very short time, the two will be in (quite useless!) conflict, until it emerges that they have different reference backgrounds (the first one may compare hours with minutes, the second one hours with years!).

constellations», in H.P. Dreitzel (2010), Gestalt and Process. Clinical Diagnosis in Gestalt Therapy. A Field Guide, EHP Andreas Kohlhage, Bergisch Gladbach, 116. 31 Excellent contribution of A. Fabbrini (1997), Le radici corporee dell’esperienza emotiva nella psicoterapia della Gestalt. Per una lettura gestaltica degli stati limite, in C. Maffei, L. Baroni (eds.), Emozione e conoscenza nei disturbi di personalità, Franco Angeli, Milan.

4.1. Hermeneutical horizons 4.1.1. The horizon of clarity (rather than awareness) Such assumptions explain the reason why some approaches, such as not taking care when identifying precisely and respecting the patient’s experiences, are ineffective and maybe harmful. Indeed, it is epistemological and clinical nonsense in the treatment of a PBL: – Intensifying the patient’s level of emotion (their confusion would be increased); – Suggesting interpretations (this would create anguish, because it would repeat an archaic scheme where the parental figure states: «Don’t trust what you hear, because it’s not true, it means something that you don’t know»); – Exploring past experiences in the search of the meaning of the actual disorder (would enhance the confusion of the present experience); – Working in view of an insight (this would be a signal for a wrong diagnosis: the PBL is not missing awareness, but clarity); – Verbalising the emotional content (this would sound like limiting and defining the patient’s experiences); – Showing the patient his inability to ‘represent himself within mental systems referring to himself or to others’ (such intervention – which reveals a precise disturbance of the therapist – ignores the rule in which you can open yourself to the world of the other, only after you have created clarity in his own world); – Coming into the escalation of ‘who is right’ (non-therapeutic intervention, since it would turn the relationship into an equal one and repeat the primary relational modes that created the BL disease). In other words, the therapist has to totally rely on the patient’s affirmations, even if they sound incomprehensible and very strange: once explained, they reveal intimate and coherent truths. Many behaviours are actually clarified in this path of translation from strangeness to imprinting-experience.

The therapist has to totally rely on the patient’s affirmations, even if they sound incomprehensible and very strange: once explained, they reveal intimate and coherent truths

As a final analysis, one can affirm that in therapy with PBL, the therapist (!) is asked for a surplus of awareness that facilitates the processes of clarity (rather than of awareness) in the patient.

4.1.2. Horizon of cordiality (rather than warmth)

A distinctive feature of the PBL is to come to sessions irregularly

In the growth of the PBL, confusion or cheating happened in the stage of confluence with the maternal figure within a relationship full of warmth and attention. Only after it emerges that learning in those phases were inadequate or wrong (creating confusion and bewilderment). A similar situation as the one of a child drinking breast milk and then has stomach ache because the milk was spoilt. When he realises that what he has learnt from his maternal figure does not correspond to his interior world, he feels molested by such intrusion, so much so that an implacable anguish is aroused in him. His interior will develop a sort of fracture between truth and warmth: he will persistently search for the truth and develop a sense of intolerability of the relational warmth. Phobia of warmth is another feature that characterises the PBL: since he has experienced being cheated on from the point of view of affective warmth, he enters into anguish and confusion when he feels warmth in affective relationships. If possible (and giving him such a chance is therapeutic), he has to distance himself, because he risks being sucked up in psychotic fusion, losing his identity, not being able to distinguish what he wants compared to what others want. Differentiating the borderline from the narcissist distancing can be useful: from a behavioural point of view, it is the same movement, but whilst the borderline distances himself in order to understand what he wants, because he is confused in relational warmth, the narcissist distances himself and retroflects for fear of being scarified in a possessive confluence. The fight between autonomy and dependence can be understood in this relational frame. For example, a distinctive feature of the PBL is to come to sessions irregularly. From was very clear on this point: «Let the PBL decide on the rhythm of the sessions». What others define ‘irregularity’ is a self-regulated system to him. When the patient

feels affective warmth in a relationship, at the same time he perceives an intensification of confusion: he needs to keep his distance and spend some time alone in order to understand what really interests him and what is instead induced. After sessions where I experienced a very fluid understanding with the patient, she seemed distant and aloof during our following session, as if she had forgotten the previous one. However, the meaning is very clear: the previous session’s warmth was perceived as excessive and had confused her. Now she wanted to be on her own, in order to find some clarity. This relational style descends into an alternation of «I cannot live with you» and «I cannot live without you» in the affective experience of a PBL. For this reason, cordiality is the required emotional climate in treatment with a PBL. It is necessary for the therapist to avoid any invitation to closer proximity or any expression of warmth. For example, it is good to use the formal form to address the patient rather than being on first name terms. We can finish by stating that for a PBL, clarity is more important and significant than reception in a relationship.

4.1.3. Horizon of climate/background (rather than figure) The therapist’s attention has to aim at creating a climate of trust. The purpose of therapy with a PBL is not to unveil something unconscious or to arrive at some particularly illuminating and determined insight. On the contrary, a single session sometimes seems to produce no results. In fact, the purpose of therapy is to create a trusting and protective climate for the patient in the medium and long term, since confusion has to be cleared up gradually. In other words, the principle that therapeutic work must focus on the Personality-function32, or the

32 I do not agree with Muller’s statement – cf. B. Muller (2013), Comment to G. Salonia, From the greatness of the image to the fullness of contact. Thoughts on Gestalt Therapy and narcissistic experiences, in G. Francesetti, M. Gecele, J. Roubal (eds.), Gestalt Therapy in clinical practice, cit., 643-659, 660 – that you can

Cordiality is the required emotional climate in treatment with a PBL. It is necessary for the therapist to avoid any invitation to closer proximity or any expression of warmth

It is evident that you need to work on the background rather than focus only on the figure

therapist-patient relationship first, has a determining meaning for the PBL, given that he was actually hurt in trusting his significant primary figures. In this sense, it is evident that you need to work on the background rather than focus only on the figure. In my experience, a sign that a ‘fit’ climate for the therapy has been created – where the patient does not have to defend himself, because he does not feel threatened by any kind of misunderstanding – is the progressive relaxation in the way he sits during the session. Working with a reasonably serious patient, I remember that a sign for the fact that the therapeutic process was going on, in spite of everything, when progress seemed to be very slow, was the much more relaxed and tranquil way the patient sat down in the armchair.

4.2. Translation exercise of borderline language PBL behaviour in everyday life, explained in psychopathology manuals, is described in the DSM-533 with a hint of ‘strangeness’ and almost ‘incomprehensibility’. The manual cites: idealisation-devaluation, vicinity-distance, obsession, viscosity, control, manipulation, promiscuity, hallucination, dependence, incoherence, confusion, uncontrollable anger. This target-quality of characterised strangeness is so specific that it assumes a diagnostic value to distinguish PBL from psychotics and neurotics.

indifferently work on the Id-function or on the Personality-function without priority. If I ask a narcissist «What do you feel?», I will get this response, before he even defines himself a ‘patient’: «What should I feel?». The attention to Personality-function is priority and represents the therapy’s background for efficient therapeutic work. Cf. G. Salonia (2013), From the greatness of the image to the fullness of contact. Thoughts on Gestalt Therapy and narcissistic experiences, cit. 33 Cf. American Psychiatric Association (2013), DSM-5. Diagnostic and Statistical Manual of Mental Disorders, American Psychiatric Publishing, Washington. For an up to date gestaltic key of the DSM5 pages on borderline personality diseases, cf. the considerable work of G. Gionfriddo, La trama relazionale borderline: lettura gestaltica dei criteri tra corpo e parola, spazio e tempo, Postgraduate School, HCC Kairos Gestalt Institute, academic year 2012-2013. Cf. also, G. Gionfriddo, infra..

When reading (or translating) ‘strange’ PBL words and behaviours, various psychotherapy models can be separated. For example, Gabbard writes: «[Borderlines] often attach themselves to their perception just as to an absolute fact, rather than seeing it as one of various, possible alternatives»34. This ‘attachment of patients to their perception’ loses its pathologic connotation if you read it as the unique certainty the PBL hangs on, avoiding feeling overwhelmed by psychotic confusion (he experienced this at the beginning of his story and is afraid of repeating it again with the therapist!). For GT, the ‘strange’ behaviours of the PBL come from a relational experience he does not manage to understand, to tell himself or others, because of missing common instruments, or better still, different from the common ones. Words and behaviours of BLP are real language to communicate their own experiences, corporeal and relational meanings (feelings, emotions, perceptions) which the subject lives in the being-inthe-present-of-the-relationship. In the register of experiences, our identity takes form and you can experience real relationships. Diagnostic and gestaltic psychopathology establish the patient’s (and therapist’s) bodily-relational experiences as a place of psychic disorder, and therefore of treatment. Separating behaviours from experiences is the guiding light that permeates and guides clinical work. Elena, a PBL, also presented the symptom of alcohol dependence. When her parents, unsatisfied by the slow recovery, sent her to therapeutic heavy drinker groups, the symptom got worse: treating dependence (from alcohol or other) without considering that PBL experiences are very different from the ones of heavy drinkers, only created confusion and damage in the patient. Translating PBL’s behaviours (or their language) into common language of experiences is, for GT, a starting point and end point of clinical work. It is acknowledged that the actual Stimmung of a PBL is confusion. Besides noticing little clarity within one’s own emotional world, they feel confused in a relationship with others:

34 Cf. G.O. Gabbard (2006), Mente, cervello e disturbi di personalità, in «Psicoterapie e Scienze Umane», XL, 1, 9-24.

Diagnostic and gestaltic psychopathology establish the patient’s (and therapist’s) bodily-relational experiences as a place of psychic disorder, and therefore of treatment

It is obvious that as soon as they perceive confusing or manipulative communications from others – thanks to their strong awareness of misleading elements, although subtle – they feel like going insane, not being able to give a name to the disorder and anxiety they feel

they feel out of place35, unable to understand and be understood, though speaking the same language that the others do. They are not aware (and neither are those who interact with them) and unable to use an idiographic corporeal-cognitive vocabulary, which makes them incomprehensible to others and the others incomprehensible to them. Their interactions are continuously seen as disastrous and produce (additional/ secondary) experiences of aggression and failure, with the risk of strange or dangerous behaviours. Since they live in an intricate net of confusion (what happens to them is interpreted as fragments and misunderstandings), their relational lives often register an intertwining of confusing situations. At this point, it is obvious that as soon as they perceive confusing or manipulative communications from others – thanks to their strong awareness of misleading elements, although subtle – they feel like going insane, not being able to give a name to the disorder and anxiety they feel. And in order to appease the unbearable anguish, they can use auto or hetero damaging behaviours (acting out).

4.2.1. From ‘strange’ behaviours to bodily-relational experiences – A patient with borderline language does not accept apologies When I admitted to Giada that I had finished our previous session abruptly and apologised by offering her my reasons, I was surprised by her negative reaction and her intensifying irritation. I apologised again, explaining my reasons again (I did not have any negative feelings towards her), but her anger did not decrease; on the contrary, it seemed to get worse. I removed the predicted, useless thought ‘borderlines are really strange’ and tried to understand Giada’s logic. At a certain

35 Cf. in relation to the excellent work of A. Amato, Il mondo è fuor di squadra. Che maledetto dispetto esser nato per rimetterlo in sesto! (Amleto). Gestalt Therapy e stile relazionale borderline, Postgraduate School, HCC Kairos Gestalt Institute, academic year 2011-2012. Cf. Cf. also, A. Amato, infra.

point, I realised the slightly hidden manipulation in my excuse. Giada was right: as a first step, I wanted to calm her down by apologising. I thought of a partner that asks for forgiveness after having been unfaithful and expects the other to stop being furious about it. Just when she managed to understand and express her anger to me, she felt – and rightly so! – that it was a way to calm or diffuse her anger (e.g. series that is to say: ‘You can be angry, but not too much, unless I allow it’). Her behaviour (not accepting my apologies) revealed my unconscious attempt of manipulation (‘Don’t leave me feeling the embarrassment of being accused for long’, ‘Stop being angry with me at once’). I learnt from her to say to PBL: «You are right. Tell me about your anger in full. If you want, I will also tell you the reasons for my behaviour». The therapist needs to realise that those who need clarification go haywire if compelled to put together opposite reasons. Putting together two emotions of an opposite sign is a very complex, emotional process for a person with a confusing Stimmung and who is trying to express one emotion at a time with clarity. When, six months after, in quite a similar situation, I suggested to Giada to hold the legitimacy of her anger together and my possible reasons in her heart, she learnt to express her reasons and to also include mine in a clear and assertive way. – Patients with borderline language do not tolerate any mistakes A PBL operates what is called a ‘borderline split’ to protect himself from further confusion: the world is either black or white, with unavoidable, seesawing passages from moments of idealisation to stages of disqualification. From taught that therapists sometimes can split the process that for PBL is a quick passage (shift) from the Id-function to the personality function instead. It is well known that PBL are unable to tolerate mistakes (and sometimes even one simple mistake) even in therapists. And often a mistake of the idealised person becomes unbearable for the PBL: the mistake becomes so intolerable that he chooses the passage from idealisation to denigration. Here is a description in verses of this kind of experience lived from within:

A PBL operates what is called a ‘borderline split’ to protect himself from further confusion: the world is either black or white, with unavoidable, seesawing passages from moments of idealisation to stages of disqualification

and now that you meet and cross me Now a devil, now a god I paint you with white, with black And if my god dresses in black I dirty the whole world with anger

Those who are very anxious and confused are not able to support further, unclear messages from the outside and are instead calmed down by clear and univocal messages. The PBL feels like going crazy when he receives confusing messages that he is unable to decipher. He prefers, by far, to be in a situation of clear pain (caused by others and even by himself) rather than to be in an ambiguous situation. A patient told me that, when she was in conflict with her partner, she felt like going crazy after moments of great vicinity and she had to go back to brutally clear situations, in order to calm herself down: either the warmth of a beer or the physical relation with a guy she despised. The PBL can only hold one emotion: it is easier for him to tolerate a negative emotion rather to than put together and hold two emotions of opposite value. If you keep in mind this dynamic, even the possible mistake of the therapist can be recovered as a moment of growth, as long as the latter does not stand up for himself, does not apologise, is able to respect the patient’s experience and the time he needs to put together confusion and anger, anger and understanding (black and white). – The PBL has phobia of introjection In the same dynamic, or better, the same logic, another demanding feature – is part of the PBL – and that is the phobia of introjection, or the inability and unavailability to listen (even to what the therapist says during a session). Such modality causes problems in the therapy, but has to be deeply respected and supported. The patient cannot be opened up to other inputs, if he has not cleared his interior world first. He protects himself against increasing confusion with regards to the relationship. The therapist shall never push the patient in a direction that the other does not feel as his own. In front of such perceptive differences with the patients, the therapist has to search for an increase of his own awareness, considering that the one who is

confused does not tolerate other information, but first of all wants help in clarifying the confusion in himself. Essential principle of the therapy with PBL: the therapist has to increase in clarity. The insuppressible need for clarity and truth of the PBL becomes the direction for his growth: the borderline’s experiences will restore the sense and coherence of his words and behaviours. – The PBL is obstinately attached to details When a contrast of opinions with the PBL emerges, the latter, to defend his thesis, puts forward one or more details that he repeats obstinately. The obsessive attachment to detail and inferences (sometimes even arbitrary) can cause annoyance in the therapist, but corresponds to the logic of whom, being cheated, manipulated or confused in the past, needs to continuously verify truthfulness in the words of others. It is known – as an old saying cites – that God or the devil are hidden in details. The research and fixation on detail reveal a skepticism in words. In the PBL’s mind and body, these kinds of thoughts are present and active: ‘Who knows if what he is telling me is true’, ‘I can’t relapse by trusting again’, ‘Let’s check in detail the truthfulness of what he is saying to me’, ‘If I find something that confirms my suspicions, I’m calm: I know how to protect myself… and I’m not going to be cheated on again!’. – The PBL has the phobia to be defined, even if positively One of the ways of intervention that the PBL perceives as violent is sensing the definition of himself. I don’t look for excuses, I don’t want torts Everything seems like a scam to me I can neither hear nor tell myself But I won’t allow you to define me If what I say seems unusual to you Don’t pay attention to it, it’s my alphabet Confused, senseless, incoherent

Each time they are defined by others, PBL fears a new scam. Besides the risk that the definition could be wrong, each defini-

Essential principle of the therapy with PBL: the therapist has to increase in clarity

tion has a limit and a pretension. Even a compliment (‘You are very kind’) can cause unpredictable reactions, since it can be perceived (in reason!) as subtle manipulation: ‘I tell you that you are kind with the hope that you continue to be so’. It is interesting to note how, in an ironic way or by fate, even the names of those patients are defined and remain in a limbo of non-definition. ‘Border-line’ or: at the border, neither psychotic nor neurotic, undefined. Each label (heavy drinker, depressed, dependent and others) added to borderlines, turns into a diagnostic and therapeutic mistake. – The PBL has his own verbal language

The first step of a therapist is the path from external dialogue to internal dialogue . It is very useful to bear in mind the rules of transformational grammar, which allows the deep structures of language to emerge, going through distortions, such as generalisation, nominalisation and cancellation

The borderline verbal language is intriguing. In a supervision group for professionals of a CMHC (Community Mental Health Centre), we had discussed their guests’ language (serious patients), distinguishing the psychotic language from the borderline one. An operator objects: «I share the importance of trying to understand the patients’ language, but sometimes they become unbearable… they keep on repeating the same sentence like a broken record». The co-therapist asks her to give an example: «While I was accompanying a guest to town – the operator says – he repeated the same hammering complaint during the whole trip: ‘Why don’t women stay at home instead of going to work?’ There was no reason that could calm him down. Really unbearable». The co-therapist asks: «How were you doing that morning? How was your driving?». «The day started badly. His complaints made it even worse. I was really nervous even in my driving». Raising smiles among participants, the colleague says: «Don’t you think he wanted to say: drive more calmly?». She gives the others a smile and understands how important it is to help the patient with clarity, but the operator needs to achieve more awareness. The first step of a therapist is the path from external dialogue to internal dialogue36. It is very useful to bear in mind the rules of

36 H. Franta, G. Salonia (1979), Comunicazione Interpersonale, LAS, Rome; G. Salonia, C. Di Cicco (1982), Dialogo interno e

transformational37 grammar, which allows the deep structures of language to emerge, going through distortions, such as generalisation, nominalisation and cancellation. – The relational acting out of a PBL Considering such a relational background, you can also understand the acting out that represents a serious risk of therapy with PBL. They are gestures, which aim to calm anxiety, the explosive sense of craziness when there is no accessible emergency exit: you feel cheated, you cannot come out of it and you are unable to express the furor imploding inside. You come to extreme violence, if you feel that you cannot move away from the scam: feeling like going crazy because someone important to you makes you feel crazy, incites a violent rage, a sometimes uncontrollable fury. If acting out happens in therapy, it can refer to the relationship between PBL and therapist, who has become a significant person to him. It is self-harming gestures that happen when the experience of exploding is connected to guilt (‘I am bad’) and the person in the up position is inacceptable or irreplaceable (a borderline attempt suicide has particular connotations and requires interventions that are very different compared to neurotic or psychotic). When these features are missing, the explosion will be hetero-direct. In both violent gestures, therapeutic work that tries to let the core of the confusion emerge, causing explosive anguish, is crucial. At seven o’clock in the morning, my mobile phone rings. It is Luisa, who is telling me in an agitated and controlled voice that she is slashing her wrists. We talk. I verify the non-seriousness of her gesture. She slowly calms down. Afterwards, once I have cheered her up, I hang up and wondered what I could have done in my last session (of this therapy that started a couple of months ago) that had confused and annoyed Lu-

Dialogo esterno: contributo per un’integrazione della Terapia Cognitiva con la Comunicazione Interpersonale, in «Formazione Psichiatrica», 1, 179-194; R. Bandler, J. Grinder (1981), La struttura della magia, Astrolabio, Rome. 37 On generative grammar cf. N. Chomsky (1968), Language and Mind, Harcourt Brace, New York, 24.

If acting out happens in therapy, it can refer to the relationship between PBL and therapist, who has become a significant person to him

isa. Suddenly I realised: I made a mistake. I had to leave the room for some time and I gave Luisa my mobile phone without specifying that this was not an affective gesture of vicinity (in those days, only a few had mobile phones and you gave your number only to family and those people close to you), but a working requirement, because the mobile phone was my office number, given that I was always out of the office. How does a girl, who receives such an intimate gesture, explain this to herself? If she doubts the therapist’s competence (she talks well of him and sees him for a long time), she can only think badly of herself (‘What did I do?’). Confusion becomes explosive and she calms down with a gesture that hurts me and allows me a ‘medical’ use of the phone.

5. Learning from a borderline patient 5.1. Secret knots of relationships The gestaltic approach of GTBL turns therapy with PBL into a compelling experience. It becomes a unique occasion to explore and enlighten hidden and decisive meanders of human relationships; in particular, hidden and not listened pain and discomfort emerge, which are expressed in uncommon languages. The two coordinates of borderline experience – language that seems to be strange, but is foreign (within the relation and in the moment of narration) and the aware or unaware scam, but still present in the relationships (above all in the asymmetric ones) – can be found in all human relationships with different shades and registers. Working with PBL from a gestaltic viewpoint enriches the therapist by not only turning his listening very sensitive and careful even with regards to shades of confusion and manipulations, but also giving his language major clarity, higher accuracy, and a particular attention to ambiguities and confusions emerging from implicit background of language. One of the qualities that struck me the first time I saw From working had been the essential, clear and rigorous use of his words: not one in excess, not one out of line. I jokingly said: «You seem to have the delicacy and precision required by a

micro-surgeon». Hereafter, I was under the impression that he gained such mastery by using specific words in working with PBL. For example, the implicit, egocentric apologies. The ambiguities of therapy, intended as an attempt to colonise the patient’s world, impose one’s own semantic and perceptive schemes to help him. Subtle and hidden violence in defining the other also positively avoids calling oneself into question in front of the patient’s disorder… Training to GTBL entails a learning of clarity and awareness of places and anxieties where languages are confused and swindles are hidden.

5.2. From narcissistic society to borderline society When Adolph Stern38 introduced the diagnostic category of ‘borderlines’ for non-psychotic and non-neurotic patients in classical psychiatry in 1938, he could not foresee that such a diagnosis would have been extended so much, that it has become one of the most common ones today. From diagnosis of socialised psychotics, it turned into trash-diagnosis (or rubbish) for all marginal pathologies that were hard to diagnose as for that name or seriousness. It was as if the awareness suddenly aroused the personal and relational borderline style that was present in a lot of psychic pain and not only in serious cases39.

38 A. Stern (1938), Psychoanalytic investigation of and therapy in the borderline group neuroses, in «Psychoanalytic Quarterly», 7, 467-489. 39 Literature is vast. I only mention some of the most significant italian authors: P. Migone (1995), Terapia psicoanalitica, Franco Angeli, Milan, (in particular chapter 8); L. Cancrini (2006), L’oceano borderline, Raffaello Cortina, Milan; M. Rossi Monti (ed.) (2012), Psicopatologia del presente. Crisi della nosografia e nuove forme della clinica, Franco Angeli, Milan. I find the DBT model (Dialectal Borderline Treatment) of Marsha M. Linehan close to the GTBL gestaltic model, which arrives at a model, starting from the limits of cognitive-behavioural approach, that is in close to GTBL in some aspects, but in my opinion, with unresolved knots from an epistemological and clinical point of view (I’ll talk about the topic in a future work discussion between GTBL and DBT). Cf. M.M. Linehan (2011) (or. ed. 1993), Trattamento cognitivo-

Training to GTBL entails a learning of clarity and awareness of places and anxieties where languages are confused and swindles are hidden

Family therapy is, a litmus test: if in the past you went to sessions where partners exploded in an aggressive rage and then you went to those where narcissistic modes of relationships prevented you from opening yourself to alterity, then over the last ten years a new relational disorder has arisen

As always, the emerging and spreading of psychic pain are closely connected with the socio-cultural context. We are transiting from a narcissistic society to a borderline one. From the overbearing emerging of subjectivity and cult of image, we are arriving at a society where individuality is more and more highlighted, language more and more idiographic, logic less and less shared. In a narcissistic society, ambivalences, scams, incomprehension usually hushed in oligarchic societies explode40. In other words, if the comparison was between subjectivity and alterity, between two grammars (‘Only my point of view is valid’) in a narcissistic context, in borderline society we face a decline of subjectivity41 and grammar. If autoreferentiality caused a relationship crisis in narcissistic society, in borderline society then relationships are missing, because you are not only uninterested, but also show an inability to dialogue and compare means. Family therapy is, in this sense, a litmus test: if in the past you went to sessions where partners exploded in an aggressive rage and then you went to those where narcissistic modes of relationships prevented you from opening yourself to alterity, then over the last ten years a new relational disorder has arisen, which can be formulated as follows: «We don’t talk, we don’t understand each other, as if we were speaking two different languages. We seem to go crazy when we listen to each other». It is the icon of relational disorder from a social viewpoint: unable to understand the other, and therefore not even yourself. As a consequence, one can state that in borderline society, the careful listening to PBL offers interesting prospects to recover opportunities of encounters and relational bonds, for a more

comportamentale del disturbo borderline, Raffaello Cortina, Milan, and the TMI model – in G. Dimaggio et alii (2013), Terapia metacognitiva interpersonale dei disturbi della personalità, Raffaello Cortina, Milan – where for example therapy verbatims with Giulia (pp. 112-136) seem to be quite in line with GTBL principles. 40 For the importance of a social contextuality of any relational form and for the different declinations of the Basic Relational Model (MRB), cf. G. Salonia (2013), Psicopatologia e contesti culturali, in G. Salonia, V. Conte, P. Argentino, Devo sapere subito se sono vivo, cit., 17-32. 41 G. Vattimo (1981), Al di là del soggetto, Feltrinelli, Milan.

accurate comprehension, sometimes, of present chaos in human relationships in postmodernity. Their strangeness, when not quietened by descriptive or interpretative diagnostics, helps us to understand how coexistence is possible, when the comparison of diversity does not take place on the ‘right or wrong’, sanity or madness’ axis, but the one of translation. Giving every language dignity. Not renouncing dialogue, but renouncing the obsession to understand the other42 that is controlling him. Learning to coexist without understanding each other, but in respect of the different languages. Therefore, dialogue that shall invent new conditions: translating the language of the other without discrediting him (in stages of conflict) and without confirming to him by telling him a lie (in neurotic confluence) but recognising the fragment of truth that he is the bearer of. Willing to reconsider one’s own language with the rigour (a sort of Ockham razor) of who is aware of ambiguity, manipulations, implicit confusions not only in the polysemy of words, but also in the variety of implicit backgrounds. Serenely recognising that the confusing fragment in one’s own language opens itself to suggestive spaces of sharing and encounter. I was astonished when a former patient made me read one of my text message that she treasured for years, as she came back after ten years because of a problem of her daughter. «Hi. I feel like my language was rude and created misunderstandings this evening. I’d like to reiterate my deep esteem for you and your paths and your Buddhism. Sorry. When the right time comes, we can clarify, if you wish». In the period of narcissist society, spaces have been created, in order to give word to everybody. You went from fighting for legality to fighting for legitimacy: from respecting/not respecting law to the questions ‘Who are you to give orders?’43. Authoritativeness can become a borderline alternative (and thus con-

42 Cf. G. Salonia (1999), Dialogare nel tempo della frammentazione, in F. Armetta, M. Naro (eds.), Impense adlaboravit. Scritti in onore del Card. Salvatore Pappalardo, Pontificia Facoltà Teologica di Sicilia - S. Giovanni Evangelista, Palermo, 571-595. 43 In relation to cf. G. Agamben (2013), Il mistero del male. Benedetto XVI e la fine dei tempi, Laterza, Bari.

The PBL’s obstinate research for truth and clarity suggests that the integrity of a rigorous communication logic can be a meeting path. Democracy avoids the drift of fragmentation; not with nostalgic comebacks to indisputable authority or recourse to frail and questionable authoritativeness, but maybe by facing the task of rewriting the rules of dialogic starting with the peculiarity of each language, translated and shared.

fusing) to authority. Authority cannot be legitimated by authoritativeness: the first one is linked to objectivity of a context, the second one subject to the precariousness of a subjective judgement. In order to step out of Scilla’s subjectivity and Cariddi’s institution, maybe a common rewriting of communicative rules of logic is needed – as the attendance of a PBL teaches. The PBL’s obstinate research for truth and clarity suggests that the integrity of a rigorous communication logic can be a meeting path. Democracy avoids the drift of fragmentation; not with nostalgic comebacks to indisputable authority or recourse to frail and questionable authoritativeness, but maybe by facing the task of rewriting the rules of dialogic44 starting with the peculiarity of each language, translated and shared.

6. Gestalt Therapy and other approaches The hermeneutic translation model, with its serene, careful and never prejudiced potential to the implicit research in borderline language, seemed to be the most coherent with the theoretical prerequisites of GT45 so far; all focus, in their approach, on

44 A contribution to start thinking with logic again is: P. Cantù (2011), E qui casca l’asino. Errori di ragionamento nel dibattito pubblico, Bollati Boringhieri, Turin. 45 Among significant contributions of Gestalt work with PBL, I refer to: E. Greenberg (1989), Healing the Borderline, in «The Gestalt Journal», XII/2, 11-55; Id. (1999), Love, Admiration or Safety. A System of Gestalt Diagnosis of Borderline, Narcissistic and Schizoid Adaptations that Focuses on What Is Figure for the Client, in «Studies in Gestalt Therapy», 8, 52-64; N. Janssen (1999), Therapie von Borderline - Störungen, in R. Fuhr, M. Sreckovic, M. Gremmler-Fuhr (eds.), Handbuch der Gestalttherapie, Hogrefe, Göttingen, 767-786; G.M. Yontef (1993), Awareness, Dialogue and process. Essays on Gestalt Therapy, Gestalt Journal Press, Gouldsboro, in particular pp. 456-488; M. Spagnuolo Lobb (2013), Borderline. The Wound of the Boundary, in G. Francesetti, M. Gecele, J. Roubal, Gestalt Therapy in Clinical Practice, cit., 609-639. In my opinion, it is about attempts, maybe a bit taken for granted, to reread borderline patients with theoretical-clinical categories of Gestalt Therapy. Original and stimulating is Anna Fabbrini’s contribution: A. Fabbrini (1997), Le radici corporee dell’esperienza emotiva nella psicoterapia della Gestalt, cit.

the seriousness of the therapist-patient relationship, on the authentic man to man comparison, on the need for a radical acceptance of the surface and therefore of the other’s words and gestures in the setting, without shortcuts, without any presumed interpretations given, which turns the patient in principle into a ‘subordinate’ (very different from considering him in need of treatment in a clear distinction of roles). We have seen how such a firm choice entails a sort of ‘conversion’ of the therapist to listen and the equal consideration of the existence of the other. But not only that. The consequences of this setting leapt out very clearly. It was about putting the therapist in the inconvenient but intriguing position of ‘translator’, who dedicates himself completely to clarifying, aiming to return to the other language, trying to catch the spirit through grey areas, focusing on detail, educating his gaze and wording to acute understanding and infinite discovery of the ‘thing’ hidden in the other language, who turns it into a different way of telling the world about himself in the incomprehensible context of a common substance. Now it is time to introduce to the dialogue this suggestion with some of the current and most influent approaches in the field of therapy with PBL, in order to clarify the position and difficulties of one’s own view, by renouncing a fruitless contrast of models in principle and rather putting the different settings on probation and delving into the heart of therapeutic languages, or in the concreteness of verbatim offered by the authors. It is obviously not about expressing valuable judgments, but only about undertaking a prolific and concise debate in the common research of a key in front of a form of disorder that is emblematic of our times and therefore of our own lives. However, it is worth starting by giving a brief history. You need to operate from comparisons, in order to catch the identifying factor of every psychotherapy model.

6.1. In principle. Freud’s misunderstanding «One fine day – Freud narrates – I had clear evidence that what I suspected corresponded to truth: one of my quietest patients, with whom I got excellent results in hypnosis, one day put her arms around my neck, as soon as she woke up from a hypnotic

If the therapist had read the patient’s gestures as asymmetric from a gestaltic point of view (the context required it), he might have welcomed and reciprocated it: in fact, in an asymmetric context – like the one of therapy and hypnosis – the patient’s embrace only expresses the, maybe clumsy, attempt of a physical, affectionate contact with a man that is taking care of her and does not have (cannot have) equal seductive intentions

sleep, as I relieved her from her pain, relating her painful attack to the reasons that provoked it. The unexpected entrance of a servant spared us embarrassing clarification, but we renounced with a tacit agreement to continue the hypnotic treatment from that moment on. I had enough wisdom to avoid ascribing such an event to my personal irresistibility and therefore reckoned that I had finally understood the nature of the mystic element (Mystich) that acted beyond hypnosis; I needed to renounce hypnosis, in order to eliminate or at least isolate it»46. As we know, this ‘embarrassing’ episode was at the origin of the invention of transfer and its correlations (theory of the patient that seduces and countertransference as a possible response from the therapist’s side). Besides stopping hypnosis, a third person (the father) was introduced into analytic therapy as not present, but as the real addressee of the seductive embrace. Such stratagem was necessary to avoid therapy failure (which would have happened, if the therapist had responded to the embrace or interrupted his sessions). Two logical mistakes are implicit in this story: the patient’s point of view is missing (the tacit agreement does not guarantee reciprocity) and a seductive intention (erotic and equal) is assigned to the patient’s embrace. Freud’s comment («I had enough wisdom to avoid ascribing such an event to my personal irresistibility») shows honesty on one hand, but on the other hand confirms his embarrassment and related misunderstanding of the patient’s gesture. If the therapist had read the patient’s gestures as asymmetric from a gestaltic point of view (the context required it), he might have welcomed and reciprocated it: in fact, in an asymmetric context – like the one of therapy and hypnosis – the patient’s embrace only expresses the, maybe clumsy, attempt of a physical, affectionate contact with a man that is taking care of her and does not have (cannot have) equal seductive intentions. Indeed, seduction represents – the ‘Stockholm syndrome’47 proves it further – one of the many ways to protect oneself from fear and from the refusal of those who are in the up position. A

46 S. Freud (1989), Autobiografia, in Id., Opere, vol. X, Bollati Boringhieri, Turin. 47 For a critical story of transfer in the analytic perspective cf. A. Carotenuto (1986), La colomba di Kant, Bompiani, Milan 1986.

therapist ascribing erotic-equal intentionality to a patient would show a precise disorder in his Personality-function of the Self, since he would place himself in another context (equal partner). Paradoxically, as GT sustains, if the patient’s embrace had been welcomed in an asymmetric way and possibly returned, the therapy would (finally!) have made considerable progress. According to GT, the task of the therapy is concluding the interruptions of bodily-relational experiences which create psychic disorder: the welcomed patient would have taken the road of completion of a relational gesture that, being interrupted, then created many psychic and relational disorders, since that patient – it is good to remember – did not want to embrace her father, but actually the therapist, the man that was taking care of her ‘paternally’ in that precise context. The desire to embrace him was completely spontaneous, even if recalled from and by the corporeal memory of an activated but blocked (or interrupted) movement towards her father. After having embraced the therapist, the patient could possibly also have gone to her father and embraced him: like another experience, on the register of fullness and no longer on the one of integrity. When the therapist backs out of the patient’s embrace, defining it as seductive (and therefore symmetric), he reiterates the experience that had been interrupted between father and daughter, and makes the therapeutic path48 more complicated and maybe confused:

48 See: H.S. Krutzenbichler, H. Essers (1993), Se l’amore in sé non è peccato... Sul desiderio dell’analista, Raffaello Cortina, Milan. The story this book tells of the various abuses of psychoanalysis should be reinterpreted within the framework of ‘dysfunction of the therapist’s Personality-function’, which loses the asymmetric dimension of therapeutic relation. In this perspective, two theoretical and clinical points are implicit. Firstly, the interruptions of relational gestures in early childhood cause corporeal and emotional anxieties that determine relational blocking: cf. G. Salonia (2013), L’Anxiety come interruzione nella Gestalt Therapy, in G. Salonia, V. Conte, P. Argentino, Devo sapere subito se sono vivo, cit., 3353. Secondly, as a principle of emotional self-regulation, the child – like the patient – does not perceive the need for erotic-equal experiences in asymmetric contexts: any possible perceptions in this sense are ‘in the place of’ other emotions. In relation, cf. G. Salonia (2012), Theory of self and the liquid society, cit. In GT hermeneutics, the patient feels a corporeal impulse to express affection and thankfulness towards the therapist. However, image

Irrespective of the fact that the patient was maybe not part of a borderline diagnosis, I believe that the story shows very well the open possibility of therapists turning their disorders into pathology labels applied to patients. And this is a misunderstanding (or manipulation) risk that is presented most of the time in the work with PBL

indeed, once again, an affective push of the daughter/patient was seen as wrong due to the fear or embarrassment of the person that was taking care of her. What do I mean? Irrespective of the fact that the patient was maybe not part of a borderline diagnosis, I believe that the story shows very well the open possibility of therapists turning their disorders into pathology labels applied to patients. And this is a misunderstanding (or manipulation) risk that is presented most of the time in the work with PBL.

6.2. The therapist in the heart of the session: Gabbard’s example «Ms. A. was a 28-year-old patient with borderline personality disorder in dynamic psychotherapy. After 6 months of therapy, an apparently minor event in the therapy session triggered a major reaction in Ms. A. With about 5 minutes left of the therapy session, Ms. A. was talking about having visited her family during the Thanksgiving holidays. She felt unimportant to her father because he seemed much more interested in her brother’s activities than in hers. In the course of this discussion, I looked at the clock on my wall because I knew the time was running out and I wanted to see if I had time to make an observation about her assumption regarding her father’s feelings about her. Ms. A. stopped talking and looked at the floor. I asked her what was wrong. After a few seconds of silence, she burst into tears and said, “You can’t wait for me to get out of

and body will be blocked if his affective gesture has been interrupted as a child. At this point, it is as if the patient wanted to try the interrupted gesture with his therapist. Only with this interpretation does a therapeutic intervention makes sense. Cf. G. Salonia (1992) (or. ed. 1989), From We to I-Thou: A Contribution to an Evolutive Theory of Contact, in «Studies in Gestalt Therapy», I, 31-42; Id. (2013), Gestalt Therapy and Developmental Theories, cit.; Id. (2008), La psicoterapia della Gestalt e il lavoro sul corpo. Per una rilettura del fitness, in S. Vero, Il corpo disabitato. Semiologia, fenomenologia e psicopatologia del fitness, Franco Angeli, Milan, 51-71; Id. (2013), Oedipus after Freud. From the law of the father to the law of relationship, in G. Salonia, A. Sichera, V. Conte, For Oedipus a New Family Gestalt, GTK-books/02, Ragusa, 13-48.

your office. I’m sorry if I’m boring you! I’ve known for a long time that you can’t stand me, and you just do this for the money. I’ll leave now if you want me to.” I was taken aback and replied, somewhat defensively, that I was simply monitoring the time because I wanted to be sure I had time to say something before the session was over. Ms. A. replied by saying, “Nice try to get out of it. You think I’m going to believe that?” Escalating in my defensiveness, I stated emphatically, “Whether you believe it or not, that’s the truth.” Ms. A. was adamant: “I saw what I saw”. Placing her hand firmly on the wooden table next to her chair, she raised her voice: “It’s like you’re telling me that this table is not made out of wood!”. Feeling as misunderstood as she was, I continued: “All I’m saying is this: it’s possible that I looked at the clock for reasons other than the ones you attribute to me – just like you may make assumptions about your Dad”. Ms. A. became even more insistent in response to my efforts to offer other possibilities: “Now you’re trying to say I didn’t see what I saw! At least you could admit it!”». It is a very instructive conversation. Gabbard comments: «MS. A. One of the greatest challenges for a psychotherapist is managing this almost delusional conviction of some patients with borderline personality disorder […] I became a potentially malevolent and persecuting object for that patient; she became the victim; and a hypervigilant, anxious and humbled affective state had cemented the Self with the object. In this feeling of terror, you cannot think or reflect. Ms. A.’s intense accusations even eroded my ability to think»49. The point is: was it really just perceptive distortion of the patient, or was it something authentic, something deeply and truly involved in Ms. A’s disease and words, who called the therapist to a fruitful exercise of ‘translation’ of a language deserving consideration and equal? Was the interruption of therapy the fruit of a patient’s delirium or of missed benefit of hermeneutics of translation from the therapist’s side? A Gestalt therapist would have said, for example: «Ms A., you are right in a certain sense. While you were talking to me, I

49 G.O. Gabbard (2006), Mente, cervello e disturbi di personalità, cit.

In a gestaltic perspective, the effort is to find common ground, the humus that makes a translation possible and that detracts the other from a sense (lethal to him) of authoritative disconfirmation of experiences

The therapist even presumes she knows the patient’s family reality better than the patient herself, denying the possibility of existence to his perspective of the world of intimate relationships

was actually thinking of formulating an interesting comment which I could have used to reply to your words. I am sorry. I believe I missed some interesting things you were telling me… Maybe once again something happened between us that used to happen at home when you did not feel appreciated by your father...». In a gestaltic perspective, the effort is to find common ground, the humus that makes a translation possible and that detracts the other from a sense (lethal to him) of authoritative disconfirmation of experiences.

6.3. GT and method of Fonagy’s mentalization Patient: Yesterday, I had a bad anger crisis… Therapist: What happened? Patient: I argued with my mother. Therapist: Tell me… Patient: Nothing, as always… We agreed that she would wake me up to go shopping, but I woke up on my own and she was gone. As soon as she came back, I said all sorts of things to her, yelling at her that she was not interested in me, as usual. Therapist: Why did your mother not wake you up? Patient: As I’ve already mentioned, she is not interested in me! Therapist: And what if she only wanted you to have a rest, given that, if I remember well, this has been a very difficult week for you? Patient: No, doctor, I know my mother better than you do, sometimes she is mean! I’m sure she did it on purpose50! Even in this punctual verbatim of Fonagy’s approach, any effort of translation is missing. The therapist even presumes she knows the patient’s family reality better than the patient herself, denying the possibility of existence to his perspective

50 E. Prunetti, F. Mansutti (2013), La terapia basata sulla mentalizzazione (MBT) – caratteristiche distintive, Franco Angeli, Milan, 28; Cf. P. Fonagy (1991), Thinking about Thinking: Some Clinical and Theoretical Considerations in the Treatment of a Borderline Patient, in «International Journal of Psychoanalysis», 72, 1-18.

of the world of intimate relationships. Indeed, here the therapist’s comment: «In this communicative exchange, the patient’s conviction to be in the right is clear, blocking any possibility to be involved in a Socratic dispute. We can conclude by saying that the patient slides into an ‘excess of reality’»51 in this operation. If read from a gestaltic perspective, such verbatim seems to highlight how the therapist not only validates, but also (unconsciously!) reiterates a manipulating and confusing relational style, which is summarised in the statement: «I don’t keep a pact (waking you up in time) for your own good!». The therapist denies the patient’s experience here, imposes her perceptive inference (reading the mother’s mind): hence, the therapeutic intervention seems to validate the mother’s confusion who, beyond all (more or less valid) motivations, ‘cheats’ her daughter by not meeting the agreement. A Gestalt therapist would have said: «You are really enraged: the fact that your mother does not respect a pact makes you furious. How can you not feel hurt by this? Even if she did it for your own good, to let you rest, it would be a lack of agreement from your mother’s side… I believe you! You feel angry and confused».

6.4. The question of listening in a conversation with Kernberg In order to complete the picture, let us turn our attention to an account taken from another essential author in borderline treatment – Kernberg52. It is a very instructive case, given that, despite unconsciously, two approaching types are put side

51 Ibid. 52 Cf. O.F. Kernberg (1984), Severe Personality Disorders, Yale University Press, New Haven. Such verbatim is part of a research on confrontations among verbatim that is going to be published. I thank doctor A. Macaluso for this contribution. In relation, also cf. J.F. Clarkin, F.E. Yeomans, O.F. Kernberg (2000) (or. ed. 1999), Psicoterapia delle personalità borderline, Raffaello Cortina, Milano; O.F. Kernberg (1967), Borderline Personality Organization, in «Journal of the American Psychoanalytic Association», 15, 641-685.

by side: one, apparently passive according to the therapist, very close to a translation attitude that helps and releases the patient; the other one, far more active and orthodox, which, however, seems to be unable to guarantee results. Miss N. was a lawyer in her early thirties, presenting borderline personality organization with predominant obsessive and schizoid features. I saw her in psychoanalytic psychotherapy three times a week, for more than five yearsâ&#x20AC;Ś in the midst of my interpreting Miss N.â&#x20AC;&#x2122;s fears of sexual longings for me as father (because they were forbidden by her internal mother), a relatively sudden deterioration occurred53, and over a period of several weeks she seemed to regress to what had characterised the early stages of her treatment. At one point, Miss N. let me know that she wanted me to say only perfect and precise things that would immediately and clearly reflect how she was feeling and would reassure her that I was really with her. Otherwise, I should say nothing but listen patiently to her attacks on me. At times, it became virtually impossible for me to say a word because Miss N. would interrupt me and distort almost everything I was saying. I finally did sit back for several sessions, listening to her lengthy attacks on me while attempting to gain more understanding of the situation. I now limited myself to pointing out that I understood her great need for me to say the right things, to reassure her, to give her indications that I understood her almost without her having to say anything. Also, I pointed out that I understood that she was terribly afraid that anything I might say was an attempt to overpower, dominate, or brainwash her. After such an intervention, Miss N. would sit back as if expecting me to say more, but I did not. Then she would smile, which I privately interpreted as her acknowledgment that I was not attempting to control her

53 I underlined some words that are missing in the text, in order to highlight significant passages in comparison to the hermeneutics of our topic.

or say anything beyond my acknowledgment of this immediate situation. I must stress that in the early stages of this development I had intended to interpret the patient’s attitude as an effort to control me omnipotently and as a reflection of her identification with the attitude of her sadistically perceived mother (her Superego) toward herself (represented by me). But at this stage, any such efforts at interpretation exacerbated the situation and were not at all helpful (in contrast to similar interventions that had been very helpful months earlier). Surprisingly, after several weeks of my doing nothing beyond verbalising the immediate relationship between us as I saw it, Miss N. felt better, was reassured, and again had very positive and sexual feelings toward me. However, my efforts to investigate the relationship between these two types of sessions – those in which she could not accept anything from me and had to take over and those in which she seemed more positive but afraid of her sexual feelings – again led to stalemate. After a few more weeks, I finally formulated the interpretation that she was enacting two alternate relations with me: one in which I was like an affectionate, receptive, understanding, and not-controlling mother and another in which I was again a father figure, sexually tempting and dangerous. Miss N. now said that when I interpreted her behavior she saw me as harsh, masculine, invasive; when I sat back and just listened to her she saw me as soft, feminine, somewhat depressed, and somehow very soothing. She said that when she felt I understood her in that way – as a soothing, feminine, depressed person – she could, later on, listen to me, although I then made the mistake of becoming a masculine and controlling figure again54. So, the reiterated interpretation deteriorates the therapeutic relationship with the PBL, given that it tends to assert a model on the patients words and emotions. Noticing how the therapist

54 O.F. Kernberg (1987), Severe Personality Disorders, cit., 149151.

The patient asked for equal dignity, listening and ‘translation’. This is the road that leads to an ‘inexplicable’ improvement

is the one that has major difficulty in changing is intriguing: «Finally, I did sit back» (how much does a patient have to fight to make her-self heard!). Turned healthy, but theoretically unconscious. Indeed, later on the therapist states: «Surprisingly, after several weeks of my doing nothing beyond verbalising the immediate relationship between us as I saw it, Miss N. felt better». The adverb ‘surprisingly’55 seems to instil doubt that the therapist behaved how the patient requested (avoiding interpreting and only pondering) without understanding the deep reasons for that apparently imposed choice. The patient asked for equal dignity, listening and ‘translation’. This is the road that leads to an ‘inexplicable’ improvement.

6.5. The limits of empathic response with patients with borderline language A therapist asks for supervision for the fact that she feels discouraged in the work with a patient, who continuously protests her interventions, even when she limits herself to respond in an empathic way. I ask her to give me some examples of interaction in the session. Patient: My mother is sweet, but always misunderstands what I say. She makes me say things I do not think. Therapist: Do you feel misunderstood by your mother. Patient: What does that have to do with anything? It is well known that mothers are not able to understand their children.

55 It is interesting how there are moments in a therapist’s experience, where he becomes aware of the fact that his method could be modified and he perceives embarrassment. I studied this phenomenon in Horney: «... I think it is important to avoid overestimating emotional experience, as if such experience was the only thing that counts in analysis. I don’t think it’s right». Shortly before that, she said: «If such self-perception, such self-acceptance is so important, then we should maybe change good part of the therapy». Cf. K. Horney (1988) (or. ed. 1987), Le ultime lezioni, Astrolabio, Roma, 89. In relation, also cf. G. Salonia (1990), Karen Horney e Friederick Perls: dalla psicoanalisi interpersonale alla terapia del contatto, in «Quaderni di Gestalt», VI, 10/11, 35-41, 40.

Therapist: You do not feel understood by your mother. Patient: It is not like this. What a mess! After having carefully listened, my comment is: «Let us start from the point of view that the patient is not an opponent, but precise. Secondly, the PBL refuses empathic answers, because he perceives them as definitions. And he learnt in his story to perceive the definitions of his emotions and meanings as a way of having power over him and to limit his experiences. Rereading the text that way, you realise that the therapist is using the manipulation the patient fears, since she omitted some precious statements of the patient in her empathic responses, such as: ‘sweet mother’, ‘mothers don’t understand their children’. Therefore, I suggest a different hermeneutics, of the kind: «You feel confused when a mother is tender, but you don’t feel understood anyway. Any mother does not understand her children… it is very confusing. They love, but they don’t feel understood…».

6.6. From’s ‘yellow’: therapy as creative return that connect and colours This last example highlights the fact that translating does not mean emphatically reaffirming, but establishing a common understanding of space within that no-man’s-land, where each translator ventures in his effort of free and faithful diakonia of the words of others. «Thanks! – a patient said to me – how did you manage to understand, from what I said, what I meant but wasn’t able to say?». It is not about repeating, and maybe telling lies, and not about disconfirming by interpreting, but relying on the risk of the relationship, in order to give background and consistency to the fragments of truth of a language that is ‘divergent’ from the other, not asking for normalisation, but creative restitution. In other words, as the last analysis, poetry: «The moon is made of cheese». Isadore’s ‘yellow’, which connects and colours those fragments, is nothing else but aesthetic space, where words meet, renew and find themselves.

Translating does not mean emphatically reaffirming, but establishing a common understanding of space within that no-man’s-land, where each translator ventures in his effort of free and faithful diakonia of the words of others

GABRIELLA GIONFRIDDO

THE RELATIONAL BORDERLINE PATTERN GESTALT TRANSLATION OF THE DIAGNOSTIC CRITERIA OF THE DSM-5 (‘ALTERNATIVE’ MODEL) Gabriella Gionfriddo

A hungry Wolf was prowling around a cottage at the edge of a village, when he heard a child crying in the house. Then he heard the Mother’s voice say: «Hush, child, hush! Stop your crying, or I will give you to the Wolf» Surprised but delighted at the prospect of so delicious a meal, the Wolf settled down under an open window, expecting every moment to have the child handed out to him. But though the little one continued to fret, the Wolf waited all day in vain. Then, toward nightfall, he heard the Mother’s voice again as she sat down near the window to sing and rock her baby to sleep. “There, child, there! The Wolf shall not get you. No, no! Daddy is watching and Daddy will kill him if he should come near!” Just then the Father came within sight of the home, and the Wolf was barely able to save himself from the Dogs by a clever bit of running. Aesop1

1. Between feeling and saying: the illusion of warmth... the truth of a fraud The wolf goes away grumbling and confused. At this point one wonders: will the child understand the game or will he feel confused too? Children must trust what they are told, especially when they’re small. The Other’s words are special sounds for them, which accompanies their crying, their smile, kisses and caresses they receive; the child experiments on his own skin and body the Other’s word, the feeling and saying. The adults put body and word into the child’s experience: it’s in the mother’s answer

1 Aesop (1998), The Complete Fables, Penguin Books, London.

that the child has the occasion to start and build a memory – first of all corporeal – of his own perception and discovery, of himself. The thoughts of oneself (body) and the relational thoughts (between the bodies) emerge in the inter-corporeality, that is to say, the body interacting with other bodies2. In the experience of Us3, where the corporeality is vague and fluid and the boundaries between me and the other are not clear yet, the mother and the child’s experiment of bodily-relational past experiences of each other’s presence, namely words, looks, pauses that are accompanied by the nourishing and being nourished, by the caress and being caressed, forms the background from which the sense of boundaries will emerge. The child’s development proceeds from We to You where the experiences organise and the perceptions of differentiation mature: a You-nutritious that takes care, and an Ego-that-receives. The mother is able to harmonise not only with the child’s past experience, but also with her own personal one, she senses her child’s needs and discriminates against her own ones, she finds an appropriate rhythm of giving and respecting, of being present and absent, of rewarding and limiting4. «By means of introjection, the child receives and assimilates, among others, the first fundamental perceptive structures, language, the sense of belonging: in other words the instruments

2 According to a gestalt interpretation on Oedipus, it turns out that it is the bodily changes that activates the modifications of the relational modalities. Cf. G. Salonia (2008), La psicoterapia della Gestalt e il lavoro sul corpo, cit. For thorough examination of the gestalt interpretation of Oedipus, cf. Id. (2005), Il lungo viaggio di Edipo: dalla legge del padre alla verità della relazione, in P. Argentino (ed.), Tragedie greche e psicopatologia, Medicalink Publishers, Siracusa, 29-46; Id. (2009), Letter to a young Gestalt therapist for a GT approach to family therapy, in «The British Gestalt Journal», 18/2, 38-47; G. Salonia, A. Sichera, V. Conte (2013), For Oedipus a New Family Gestalt, cit. 3 For thorough examination of the evolutionary theory in GT, cf. G. Salonia (1992) (or. ed. 1989), From We to I-Thou. A contribution to an evolutive theory of contact, cit.; Id. (2013), GT and Developmental Theories, cit. 4 Cf. Id. (1992) (or. ed. 1989), From We to I-Thou, cit.

The child’s development proceeds from We to You where the experiences organise and the perceptions of differentiation mature: a You-nutritious that takes care, and an Ego-that-receives

to be able to define the boundaries of his own Ego»5. The child needs a parental figure able to help him to decode reality, respecting the child’s time limits, desire and fears. If the child is being listened to and supported in a respectable way, according to his differences and requests, the child learns to listen to himself and to express the needs in a fluid and natural way. In a rhythm of words and sounds accompanying the child’s experiences, it learns to recognise and name all the sensations that the body sends, and to distinguish between them and the ones perceived in the other. The child must be recognised and helped with the intimate evaluation capacity of the personal experience: «In becoming a critic of experience, the child forms an individual personality»6.

2. The distinction between past experiences and behaviours: Ariadne’s thread in the relational borderline pattern Starting from Isadore From’s intuition and entering the phenomenological-existential tradition, the Gestalt Translation of Borderline Language (GTBL) elaborated by Salonia, establishes a precise and unpublished translation model of the patient’s verbal behaviours with a Borderline Language (PBL, Patient with Borderline Language) in the shared language of past experiences. In GBLT, «words and behaviours of BLP are real language to communicate their own experiences, corporeal and relational meanings (feelings, emotions, perceptions) which the subject lives in the being-in-the-present-of-the-relationship»7. Words, gestures, unpredictable and contradictory behaviours that for a long time have been the source of diagnostic confusion8, but «always contain fragments of reality and coherence

5 Ibid., 50. 6 I. From, V. Miller (1994), Introduction to The Gestalt Journal Edition, in F. Perls, R. Hefferline, P. Goodman, Gestalt Therapy, cit., VIII-XXIII, XV. 7 G. Salonia, supra, 40. From here on in, unless otherwise specified, the translation is edited by the author. 8 Historically, the Borderline Personality Disorder (BPD) seems

from which one must start in order to track down the patient’s experience»9. Employing the logic of the ‘translation’, in order to adopt the GTBL, the first step to take is to distinguish between bodily-relational past experiences and the description of the behaviours that underlie the experiences. The DSM – The Diagnostic and Statistical Manual of Mental Disorder – as a nosographic system that describes the clinical aspects manifest of a disorder and the observable behaviours, establishes a descriptive approach to the psychopathology, a useful map. On the other hand, the Gestalt therapist is interested in the behaviours because they contain and express bodily-relational past experiences. «The feature of relationality – which for the Gestalt Therapy is very important and decisive for the onset, manifestation and the treatment of psychopathology – is gathered in the bodily-relational past experiences»10. It is a diversity of language. Salonia reminds us that Isadore From underlined the necessity of a precise language within the gestalt community, but flexible in the world of psychotherapy in order to be comprehensible11. In this sense, the most suitable model is the descriptive one. In the Gestalt Therapy, the diagnosis12 takes into account the DSM clinical model thematising the different psychopathologies, in respect of the definitions of classical psychiatry. Unlike the first definitions that put the accent on the boundary between neurot-

to have had the function of filling the ‘void’ between neurosis and psychosis, pushing for clinical considerations and articulate theoretical elaborations. 9 Cf. G. Salonia, supra. 10 Id. (2013), Psicopatologia e contesti culturali, cit., 31. 11 Cf. Id. (2013), Pensieri su GT e vissuti narcisistici, in G. Salonia, V. Conte, P. Argentino, Devo sapere subito se sono vivo, cit., 159-179. 12 Formulating a diagnosis means adopting one’s own model and at the same time assume a language shared by a scientific community in order to guarantee transfer and exchange of information, with an eye to practicality, cheapness and clarity. For a thorough examination on gestalt diagnosis, cf. A. Sichera, Ermeneutica e GT. Breve introduzione ai fondamenti di una diagnosi gestaltica, in G. Salonia, V. Conte, P. Argentino, Devo sapere subito se sono vivo, cit., 11-16.

Employing the logic of the ‘translation’, in order to adopt the GTBL, the first step to take is to distinguish between bodily-relational past experiences and the description of the behaviours that underlie the experiences

The aim of this work is to provide a gestalt interpretation of the diagnostic criteria of this disorder: to give a ‘relational pattern’ to symptoms through a bodily-relational interpretation of those criteria

ic aspects and psychotic ones, the nosographic system DSM13 – from DSM-III from 1980 to the present DSM-5 – focuses on the fundamental characteristics to put the diagnosis of Borderline Personality Disorder (BPD) in the area of «interpersonal relationships, loved ones, identity and impulsiveness»14. The aim of this work is to provide a gestalt interpretation of the diagnostic criteria of this disorder: to give a ‘relational pattern’ to symptoms through a bodily-relational interpretation of those criteria. It is noted that, in the making of this work, it was chosen to refer to the diagnostic criteria proposed in the Borderline Personality Disorder (BPD) model, presented in section III of DSM-5, in order to guarantee a major «continuity with the current clinical procedure»15 and with the new developments of research about this topic16.

2.1. The descriptive language As for the new diagnostic classification of the last version of the DSM-5, a modification17 of the Personality Disorder has been proposed, favouring a dimensional classification system while maintaining a descriptive structure. As mentioned above, in the DSM-5 the personality disorders are present in section II where the same diagnostic categories have been repurposed, present in DSM-IV TR, and also

13 Cf. American Psychiatric Association (1980), DSM-III. Diagnostic and Statistical Manual of Mental Disorders, American Psychiatric Publishing, Washington; Id. (1994), DSM-IV. Diagnostic and Statistical Manual of Mental Disorders, American Psychiatric Publishing, Washington; Id. (2013), DSM-5, cit. 14 V. Lingiardi (2001), La personalità e i suoi disturbi. Un’introduzione, Il Saggiatore, Milan, 206. 15 American Psychiatric Association (2013), DSM-5, cit., 761. 16 Cf. to this matter A. Frances (2013), Primo, non curare chi è normale. Contro l’invenzione delle malattie, Bollati Boringhieri, Turin; P. Coppo (2013), Le ragioni degli altri. Etnopsichiatria, etnopsicoterapie, Raffaello Cortina, Milan. 17 For an explanatory contribution of the diagnostic process in the DSM-5, cf. V. Lingiardi, F. Gazzillo, La diagnosi dei disturbi di personalità nel DSM-5, in Temi di politica professionale, on http://www.aipass.org/.

in section III where a hybrid model is proposed. The aim is to accustom the clinicians to a new classification, dimensional, trait-specified and orient the research towards this direction. The BPD, as well as the other disorders seen in this model (schizotypal, antisocial, avoidant and obsessive compulsive), is delimited by a set of criteria that indicates the presence of a significant compromise of the function of personality in the area of Self and in the interpersonal one and pathological specific personality traits of relatively stable personalities that are not linked to the socio-cultural conditions of the individual, nor are they linked to a general medical condition of the use of substances. In order to provide a precise analysis of the BPD, the diagnostic criteria present in the original text, the DSM-5, are shown below.

2.2. Borderline Personality Disorder ÂŤTypical features of borderline personality disorder are instability of self-image, personal goals, interpersonal relationships, and affects, accompanied by impulsivity, risk taking, and/ or hostility. Characteristic difficulties are apparent in identity, self-direction, empathy, and/or intimacy, as described below, along with specific maladaptive traits in the domain of Negative Affectivity, and also Antagonism and/or Disinhibition. Proposed Diagnostic Criteria A. Moderate or greater impairment in personality functioning, manifested by characteristic difficulties in two or more of the following four areas: 1. Identity: Markedly impoverished, poorly developed, or unstable self-image, often associated with excessive self-criticism; chronic feelings of emptiness; dissociative states under stress. 2. Self-direction: Instability in goals, aspirations, values, or career plans. 3. Empathy: Compromised ability to recognize the feelings and needs of others associated with interpersonal hypersensitivity (i.e., prone to feel slighted or insulted); perceptions of others selectively biased toward negative attributes or vulnerabilities.

4. Intimacy: Intense, unstable, and conflicted close relationships, marked by mistrust, neediness, and anxious preoccupation with real or imagined abandonment; close relationships often viewed in extremes of idealization and devaluation and alternating between over-involvement and withdrawal. B. Four or more of the following seven pathological personality traits, at least one of which must be (5) Impulsivity, (6) Risk taking, or (7) Hostility: 1. Emotional lability (an aspect of Negative Affectivity): Unstable emotional experiences and frequent mood changes; emotions that are easily aroused, intense, and/or out of proportion to events and circumstances. 2. Anxiousness (an aspect of Negative Affectivity): Intense feelings of nervousness, tenseness, or panic, often in reaction to interpersonal stresses; worry about the negative effects of past unpleasant experiences and future negative possibilities; feeling fearful, apprehensive, or threatened by uncertainty; fears of falling apart or losing control. 3. Separation insecurity (an aspect of Negative Affectivity): Fears of rejection by --- and/or separation from --- significant others, associated with fears of excessive dependency and complete loss of autonomy. 4. Depressivity (an aspect of Negative Affectivity): Frequent feelings of being down, miserable, and/or hopeless; difficulty recovering from such moods; pessimism about the future; pervasive shame; feelings of inferior self-worth; thoughts of suicide and suicidal behavior. 5. Impulsivity (an aspect of Disinhibition): Acting on the spur of the moment in response to immediate stimuli; acting on a momentary basis without a plan or consideration of outcomes; difficulty establishing or following plans; a sense of urgency and self-harming behavior under emotional distress. 6. Risk taking (an aspect of Disinhibition): Engagement in dangerous, risky, and potentially self-damaging activities, unnecessarily and without regard to consequences; lack of concern for oneâ&#x20AC;&#x2122;s limitations and denial of the reality of personal danger. 7. Hostility (an aspect of Antagonism): Persistent or frequent angry feelings; anger or irritability in response to minor slights and insults.

8. Specifiers. Trait and level of personality functioning specifiers may be used to record additional personality features that may be present in borderline personality disorder but are not required for the diagnosis. For example, traits of Psychoticism (e.g., cognitive and perceptual dysregulation) are not diagnostic criteria for borderline personality disorder (see Criterion B) but can be specified when appropriate. Furthermore, although moderate or greater impairment in personality functioning is required for the diagnosis of borderline personality disorder (Criterion A), the level of personality functioning can also be specified»18.

3. Criterion A and Gestalt Translation Description of criterion A. Significant compromises of the Self (Identity or Self-direction) and of the interpersonal function (Empathy or Intimacy). People with BPD have a very frail concept of themselves that can easily be fragmented or disintegrated under distress, provoking a sense of identity confusion or chronic feelings of emptiness. This unstable structure of oneself causes difficulties in maintaining close relationships stable. The personal valuation is often associated with feelings of anger and discouragement. Empathy for the others is seriously compromised.

3.1. The frail identity: separated at the border but melted together on feeling Gestalt interpretation of the ‘impairment of the Self (identity and self-direction)’ Identities are fruitful only if their diversity is respected Giovanni Salonia19

18 American Psychiatric Association (2013), DSM-5, cit., 766-767. 19 G. Salonia (2007), Odòs, la via della vita. Genesi e guarigione dei legami fraterni, EDB, Bologna, 98.

People with BPD have a very frail concept of themselves that can easily be fragmented or disintegrated under distress, provoking a sense of identity confusion or chronic feelings of emptiness

Borderline suffering starts ‘from’ and ‘in’ a disturbed and confused relationship at the level of body and word

In the gestalt perspective the primary relationship structures the relational modalities of Self20, functional and dysfunctional ways of getting in a relationship and are therefore vital in the creation and maintenance of meaningful bonds21. The child’s identity is developed starting from what the parents offer and tell him: it is the experience of primary relationships that gives substance and word to the child’s identity. Borderline suffering starts ‘from’ and ‘in’ a disturbed and confused relationship at the level of body and word. The two different registers22 in which confusion is placed, that is the sensorimotor level (the Id-function) and the cognitive narrative level (Personality-function), will lead to different ways and seriousness of the pathology: the specificity of the PBL, severe or less severe, is determined exactly by the level in which the patient has been confused. Id-function and borderline modality We build the Self from corporeal experiences: the Id-function is what is perceived within the skin. The corporeality is the constitutive dimension of the body identity that ourselves are, it is the place where we experiment our limits, at the contact

20 In GT, the Self is not a fixed entity, «it is not the self of the organism as such, nor is it the passive recipient of the environment». It is the system of contact present and the agent of growth, it is the way the Organism gets in contact with the environment. «In ideal circumstances the self does not have much Personality. It is the sage of Tao that is ‘like water’, assuming the form of the receptacle», in F. Perls, R. Hefferline, P. Goodman (1994) (or. ed. 1951), Gestalt Therapy, cit., 147, 206. The Self is the Organism in contact and, as a process of a continuous adaptation of the organism to the changing conditions of its internal and external environment, in GT we do not talk about characteristics but about the functions of Self: the Id-function (from the body emerges the ‘movement towards’: «what I feel»), Ego-function (to make one’s own or alienate what emerges: «what I want»), Personality-function (the assimilation after the contact: «what I have become»). 21 Cf. G. Salonia (2013), Psicopatologia e contesti culturali, cit. 22 For a thorough examination of the evolutionary theory and borderline psychopathology, cf. G. Salonia, supra; Id. (2013), Disagio psichico e risorse relazionali, in G. Salonia, V. Conte, P. Argentino, Devo sapere subito se sono vivo, cit., 55-67; V. Conte (2011), The borderline patient, cit.

border, and we recognise the differentiation from the other. The relationship is first of all corporeal23. The body repeatedly sends sensations, understood or not, but from which we gain experience anyway. The child feels something in his body and starts to give some coordinates (warmcold, pleasant-unpleasant etc.), but if the child is not given the possibility to find out what his body gives, and to evaluate his personal experience, which on the contrary gets confused, the child will lose the logical connections that give a framework to body and feeling. The ability to feel emotions, the emerging of needs requires a fluidity of the basic corporeal experience that is compromised in the PBL: the experience of one’s own body, the past experiences and the corporeal meaning are confused. In the borderline suffering, the disorder of the Id-function is not a problem of awareness but of clarity24: the experience is confused. Personality function and borderline modality The disorder of the Id-function is marked in the person’s difficulty to update his own Self, compared to what he has become, who he is in life. The acquisition of new skills, the roles played do not integrate in a unified way, they cannot be assimilated. In these persons there is autonomy, but at the same time an inability to separate themselves from the original family maintaining a never-completely-satisfied filial role. It is about a fused family, the boundaries are not outlined, no one really leaves25. The disorder of the Personality-function concerns, in particular, the thoughts linked to the experience, in other words, the corporeal thoughts. In a recent interpretation of the theory of the Self26, Salonia highlights how Gestalt Therapy authors de-

23 Cf. G. Salonia (2008), La psicoterapia della Gestalt e il lavoro sul corpo, cit.; Id. (2011), Sulla Felicità e dintorni. Tra corpo, parola e tempo, Il Pozzo di Giacobbe, Trapani. 24 Cf. also, V. Conte, infra; Id. (2011), The borderline patient, cit. 25 Cf. Ibid. 26 From a recent reinterpretation of the theory of the Self, the Personality emerges not only in the post-contact, but also at the beginning with the Id: ‘Who have I become, me feeling this’. The Personality is the created figure that the Self becomes and assimilates to the organism, combining it to the results of the

Tf the child is not given the possibility to find out what his body gives, and to evaluate his personal experience, which on the contrary gets confused, the child will lose the logical connections that give a framework to body and feeling

The boundary is created, but it is unstable, it allows past experiences to be wrongly assimilated as personal

scribe the Personality-function as the ability to respond to possible questions about personal experience, emotional stream that the body experiences: «Who am (became) I, that I feel this». In other words, every experience has to be expressible27. «The words have the task to name the experiences»28, but in the story of the PBL the apprehension of decoding personal experiences and naming personal sensations have been compromised. The PBL gives a wrong name to the feeling, the words don’t correspond to the past experience the patient experimented. The mother-child differentiation, I-know-who-I-am and I-knowwho-you-are, even though it has taken place, leaves behind traces of original confluence. The child, thus distinguishing himself from You, it is like he would say «I know that I am I, but I don’t know to whom these past experiences I perceive belong and, moreover, I’m not sure I’m able to recognise the experiences of the other: closeness with the other confuses me»29. The boundary is created, but it is unstable, it allows past experiences to be wrongly assimilated as personal30. The PBL turn out to be identified, strict and clear people, but they’re confused about their deepest and intimate experiences. In such confusion, it becomes difficult to understand, convey, express, narrate the most intimate meanings of the experience that they live. They will continue to fight in order to differentiate themselves and they won’t find the correct words to share their personal experiences.

previous growth. Cf. G. Salonia (2012), Theory of Self and the liquid society, cit. 27 Ibid., 50. In fact, the Personality-function is formed between two and three years of age, it is a period that corresponds to the birth of the language: during these years the words begin to connect with one’s own and the other’s body, they take shape and become narration. The sense of the narrative Self emerges, the child is able to give us a narration, to tell us who he is and what happens to him, what he does and why he does it: cf. D. Stern (1989), La nascita del sé, in M. Ammaniti (ed.), La nascita del sé, Laterza, Bari, 117-128. 28 G. Salonia (2011), Sulla Felicità e dintorni, cit., 124. 29 Id. (2013), Disagio psichico e risorse relazionali, cit., 60. 30 Cf. V. Conte (2011), The borderline patient, cit.

3.2 Permanently unstable relational modality31 Gestalt interpretation of the ‘impairment of the interpersonal function (empathy and intimacy)’ Understanding the instability and the ambivalence of the behaviours present in borderline modality means to draw on the background of contradictory experiences, tested and assimilated inside the primary close relationships. A relationship in which the child says «I’m sad…» and the mother answers «It’s not true!», the child says «You’re sad» and the mother answers «You are sad!», it’s a relationships in which the mother doesn’t listen to the child, she doesn’t «take a careful look» at him32 in order to hear and understand him. A relationship in which intentions, goals, desires, emotions and sensations are attributed and sent back, is a relationship that doesn’t allow differentiation. The developmental psychology teaches us that the child opens his eyes to the world starting from what he has experienced on his own skin: when drinking from the breast, the child tastes also reception, warmth, but sometimes even rejection and indifference33. This way, the warmth crosses the borderline experience: the warmth of empathy even though misleading. The child has tasted the warmth of being-us, but also ‘swallowed’ things that do not belong to him, so the illusion of being ‘I’ in front of ‘You’. The child introjects the mother’s experiences, without discrimination, and the incorrect names for what the child feels and what the other ones feel. This false and misleading empathy assumes the tones of an early hyper definition of the child («Surely you’re sad, let me cheer you up…») and it’s in the fact that one has repeatedly and systematically been defined by the other and without being seen and/or before completing the personal experience

31 Cf. M. Schmideberg (1969), I casi limite, in S. Arieti (ed.), Manuale di psichiatria, vol. I, Boringhieri, Turin. 32 D. Iacono, G. Maltese (2012), Come l’acqua. Per un’esperienza gestaltica con i bambini tra rabbia e paura, Il Pozzo di Giacobbe, Trapani, 48. 33 Cf. V. Conte (2011), Gestalt Therapy and serious patients, in «GTK Journal of Psychotherapy», 2, 17-48.

This denial of experience, presented as empathy instead of listening, supporting, respecting the differences and the child’s needs and body, it becomes a fraud. As an adult the suffering for that fraud will emerge, as well as the confusion as a frequent difficulty to place oneself in relationships

The patient with BPD does not tolerate opposite experiences, he cannot combine them: «If you love me so much, why do you get angry?». The inability to decode unclear messages leads the person to operate a split that is manifested in a form of dichotomous thinking and behaviour: all or nothing, good or bad, idealised or underestimated

that the Borderline Language has originated. This denial of experience, presented as empathy instead of listening, supporting, respecting the differences and the child’s needs and body, it becomes a fraud. As an adult the suffering for that fraud will emerge, as well as the confusion as a frequent difficulty to place oneself in relationships34. «The intolerance of the complexity in the PBL derives from the anguish being thrown back in confusing ‘confluence’»35, it is not easy to distinguish between who acts and who lives in tension: it is right here that the difficulty to stay close or distant from the other starts: the need of contact and the fear of being fooled. Belonging to and being separated become relational skills that are not fluid anymore, but ambivalent: unstable relational models, from extreme dependence to ephemeral superficiality, where the fear of depending and being abandoned coexist. Generally these fears can oscillate, but we can have patients centred on the fear of being abandoned (so they are addicted and they hold on to relationships with excessive request for affection, anguished by the feeling of being abandoned or rejected) or they can be more focalised on the fear of being swallowed up (where anguish is the elimination, the invasion of the other). The instability and the ambivalence of the behaviours that are frequently present in the relational borderline modality have an internal logic: appease the sense of confusion by having two opposite experiences at once. The patient with BPD does not tolerate opposite experiences, he cannot combine them: «If you love me so much, why do you get angry?». The inability to decode unclear messages leads the person to operate a split that is manifested in a form of dichotomous thinking and behaviour: all or nothing, good or bad, idealised or underestimated. Feeling at the same moment and with the same persons or situations opposite emotions or feelings, reminds of the relational fraud. Persons with BL can only have one emotion at a

34 Cf. Id (2011), Specific Didactics Lecture Notes, Academic Year 2011. 35 G. Salonia (2013), Disagio psichico e risorse relazionali, cit., 60.

time, otherwise they feel like going mad, they do not tolerate mistakes36: a wrong behaviour of that person they idealise «destabilized their world»37.

4. Criterion B and Gestalt Translation The criteria provided by the new formulation of the DSM for the classification of BPD outline the gravity of the traits in three specific dimensions or domains in a very descriptive way: negative affectivity, disinhibition and antagonism38.

4.1. Negative affectivity «Frequent and intense experiences of high levels of a wide range of negative emotions (e.g., anxiety, depression, guilt/ shame, worry, anger) and their behavioral (e.g., self-harm) and interpersonal (e.g., dependency) manifestations». As for the specific traits indicated by the DSM in the domain of the negative affectivity, I would like to start from the separation insecurity: «Separation insecurity (an aspect of Negative Affectivity): Fears of rejection by – and/or separation from – significant others, associated with fears of excessive dependency and complete loss of autonomy»39.

4.1.1. Gestalt interpretation: the relational borderline modality is manifested in separations The anguish of being left alone is one of the main fears that doesn’t allow separation and individuation, where the experience of feeling separated is a necessary precondition to dis-

36 Cf. G. Salonia, supra. 37 To this matter see V. Conte (2011), The borderline patient, cit. 38 American Psychiatric Association (2013), DSM-5, cit., 779-780. 39 Ibid., 767.

The anguish of being left alone is one of the main fears that doesn’t allow separation and individuation, where the experience of feeling separated is a necessary precondition to discover the personal uniqueness

cover the personal uniqueness40. The arrival point of the way to subjectivity is learning to walk, since it is an action, as Mahler reminds us41, that expresses and allows autonomy and that in a bodily-relational perspective, typical of the GT, «carries along another pleasure: the pleasure to decide the distance between the bodies (for example, to leave and return)»42. Walking means to gain the experience of being able to decide independently the distances. «The autonomy that the child experiments thrills and excites him, but at the same time the fear of being alone frightens him. So the child returns to the mother»43. Therefore, the child lives this ambivalence between addiction and autonomy, the need of the other and the excitement of doing things alone. The intolerance to loneliness as well as the comprehension of the BPD has been explained by Kernberg44, and by Materson and Risley45 with different shades, as the failure in the rapprochement sub phase of Mahler46, according to whom the child’s psychological birth coincides with the fulfilment of the separation-individuation process. In the gestalt comprehension of the PBL one must understand that in the separation time the inability to separate exists, but

40 Cf. G. Salonia (2011), Sulla Felicità e dintorni, cit. 41 Cf. M. Mahler, F. Pine, A. Bergman (1975), The psychological birth of the human infant, cit. 42 G. Salonia (2011), Sulla Felicità e dintorni, cit., 60. 43 Ibid., 19. 44 Cf. O.F. Kernberg (1975), Borderline conditions and pathological narcissism, Aronson, New York. 45 Cf. J. Masterson, D. Risley (1975), The borderline syndrome: Role of the Mother in the genesis and psychic structure of the borderline personality, in «International Journal of Psychoanalysis», 56, 163177. Opposite to Kernberg, for Materson and Risley emphasis is placed on the mother, instead of on the child’s aggressiveness. According to the authors, in fact, the borderline patients’ mothers send their children a message that they will keep the motherly love only remaining dependent (if they will remain dependent) while the growing and achieving autonomy will provoke the loss of bond with them. The mothers of these patients have initially obstructed the childrens’ separation and then they have provided little emotional availability towards their regressive needs. 46 Cf. M. Mahler, F. Pine, A. Bergman (1975), The psychological birth of the human infant, cit.

the reason why this happens is linked to a previous time. In the phase of rapprochement, what emerges is not the root of the disorder, but it is the result of a previous interruption in the evolutionary process. Before even learning to walk, to meet the others and to separate from them, every child needs to be understood where he is not able to understand. «The child needs to be listened to and accepted in the tumult of his emotions»47; the child needs help in order to give a meaning, a name to personal experiences and the ones of others. One cannot detach oneself from a relationship if it did not allow me to find the right words to say what I feel, if it did not provide me with the instruments to distinguish and differentiate what one feels in front of the other and what the other feels in front of us. In GTBL48, Salonia highlights how the fact of having wrong names for personal experiences not only creates confusion on a cognitive and narrative level, but also damages other levels of the experiential-relational world. Until the child is in the relationship with the mother, he is protected from this confusion, but once the child separates from the mother, he will have to face the world, he will be uncomfortable. Confusion will make its way and it is expressed through the recurrent difficulty to take place in a relationship because the child does not know the right words for the personal and the other’s experiences49; the consequence is that he will not be able to understand the other nor will he feel understood, often he will feel misunderstood, despite he speaks the same language with the others. Since this failure of learning process took place in an environment of trust, the child’s affectivity is imbued with ambivalence with regard to each relationships. The PBL has some difficulties to put together the complex aspects of the experience, he cannot stay with the uncertainty, he gets confused: the experience is that of feeling overwhelmed, deceived, betrayed. «Emotional lability (an aspect of Negative Affectivity): Unstable emotional experiences and frequent mood changes;

47 D. Iacono, G. Maltese (2012), Come l’acqua, cit., 29. 48 Cf. G. Salonia, supra. 49 Cf. Id. (2013), Disagio psichico e risorse relazionali, cit.

In GTBL, Salonia highlights how the fact of having wrong names for personal experiences not only creates confusion on a cognitive and narrative level, but also damages other levels of the experiential-relational world

emotions that are easily aroused, intense, and/or out of proportion to events and circumstances. Anxiousness (an aspect of Negative Affectivity): Intense feelings of nervousness, tenseness, or panic, often in reaction to interpersonal stresses; worry about the negative effects of past unpleasant experiences and future negative possibilities; feeling fearful, apprehensive, or threatened by uncertainty; fears of falling apart or losing control». Depressivity (an aspect of Negative Affectivity): Frequent feelings of being down, miserable, and/or hopeless; difficulty recovering from such moods; pessimism about the future; pervasive shame; feelings of inferior self-worth; thoughts of suicide and suicidal behavior»50.

4.1.2. The gestalt interpretation: dysphoria between body and time The sudden oscillation of the affective states is a typical feature of the borderline experience dimension51. Dysphoria52 (from

50 American Psychiatric Association (2013), DSM-5, cit., 766-767. 51 Cf. L. Cancrini (2006), L’oceano borderline, cit.; A. Correale et alii (2009), Borderline. Lo sfondo psichico naturale, Borla, Roma. 52 The term ‘hysteroid dysphoria’ was coined by Liebowitz and Klein in 1979: cf. M.R. Liebowitz, D.F. Klein (1979), Hysteroid dysphoria, in «Psychiatric Clinics of North America», 2, 555-575. This term, on the one hand was not so lucky on a nosographic level and on the other hand it takes the credit for bringing into focus a specific affective state extremely dependent on the relational variables: cf. R. Spitzer, B.W. Janet, D.S.W. Williams (1982), Hysteroid dysphoria: an unsuccessful attempt to demonstrate its syndromal validity, in «Am J Psychiatry», 139, 1286-1291. Berner, Musalek and Walter have tried to highlight the psychopathological meaning of dysphoria, identifying some specific qualities that allows to consider it as an affective state that does not correspond to the depressive affection. In this sense, it has been proposed to limit the use of the term dysphoria to those conditions characterised by an unpleasant feeling of tension, irritation, surly mood, with an increasing predisposition to furious acting out and affective rigidity with a reduction of the capacity of modulating affections: cf. P. Berner, M. Musalek, H. Walter (1987), Psychopathological concepts of dysphoria, in «Psychopathology», 20, 93-100; E. Gabriel (1987), Dysphoric mood in paranoid psychoses, in

Greek δυσ-φορία: intolerable suffering, anguish, distress, agitation), defined as intermediate experience between depression and mania53, as Rossi Monti recalls, it’s the signal of an affective state or condition that cannot find its own stability54. In BPD subject dysphoria has been interpreted as a result of a pathoplastic effect developed by the personality organisation that, just like a prism, filters the depressive experience distorting it. The dysphoric effect would point out an actual resistance to invasion by a more authentic sadness, an attempt to rebel against the depressive fate55. Dysphoria, from a gestalt point of view, expresses an intense reactivity/dependency to/on the environment: the PBL is extremely sensitive, vulnerable to the influences and the changes in the environment, he smiles if the environment does, but if the smile doesn’t occur, this will be enough to make the relationship fall apart. If the environment changes, experience will also change56. In this ‘dependency’, the diversity, inherent in oneself and the relationship, will be cancelled. The Other is a body that he cannot meet because the relational skills require the progressive changing of the way of seeing oneself in front of the other and the other in front of oneself57. The PBL cannot not tolerate the continuous changes that the human relationship requires, as he is trapped in confusion and the effort to differentiate his own experiences from those of the others, and deceived by words about experiences – which are ‘right’ for him, but wrong for the other.

«Psychopathology», 20, 101-106. 53 Cf. D.J. Smith, W.J. Muir, D.H. Blackwood (2005), Borderline personality disorder characteristics in young adults with recurrent mood disorders: a comparison of bipolar and unipolar depression, in «Journal of Affective Disorders», 87/1, 17-23. 54 Cf. M. Rossi Monti (2012), Borderline: il dramma della disforia, in Id. (ed.), Psicopatologia del presente. Crisi della nosografia e nuove forme della clinica, Franco Angeli, Milano, 15-63. 55 Cf. G. Stanghellini (1996), Phenomenological Psychopathology of Depressive Mood Spectrum, in «Fundamenta Psychiatrica», 2, 45-60. 56 Cf. V. Conte (2011), Specific Didactics Lecture Notes, cit. 57 «To be in front is a way to say that we recognise each other. Every identity is created by a relationship and it is defined in front of someone»: in G. Salonia (2011), Sulla Felicità e dintorni, cit., 106.

The PBL cannot not tolerate the continuous changes that the human relationship requires, as he is trapped in confusion and the effort to differentiate his own experiences from those of the others, and deceived by words about experiences – which are ‘right’ for him, but wrong for the other

The subject with BL lives in the present, because he cannot stay between the present moment and the following one

The relationship with the other, in a borderline mode, is characterized by the search for an impossible proximity. The proximity eventually becomes closeness, warmth that overwhelms him, confuses him, and recalls the fraud; too much distance and loneliness recall anguish, panic, rejection. In this way, the subjects with BL try to live in proximity with the other, fighting between «autonomy and dependency»58, having a hard time finding a space, a possible distance between the bodies, between the Self and the other. Greenberg recalls: «Every intimate thing is experiences as potentially threatening; they cannot find an adequate distance»59. A space – the PBL one – experienced as a place of presence or absence of the other. To this matter, Kimura writes: «The absence of an object of attachment means for the ‘limit-state’ person an immediate suspension of his present being-there, or of his present as such»60. This way, waiting becomes a pitiful and unbearable experience. Time and relationship intertwine in a unique way in the dimension of waiting. The first experience of time is waiting, and past, future and present gather around the act of waiting. The subject with BL lives in the present, because he cannot stay between the present moment and the following one. This would imply giving a name to what one is waiting for. The inability of maintaining a narrative plot of life and the affective continuity of the Self and of the other, the difficulty to elaborate the unsustainable feeling of confusion, explain the difficulty these subjects have to tolerate the waiting and the loneliness. Salonia underlines: «his actions continuously turn out to be a failure and they produce experiences (additional/secondary) of aggression and failure, with the risk of strange and dangerous behaviours»61.

58 Cf. also, V. Conte, infra. 59 E. Greenberg (1999), Love, Admiration or Safety. A System of Gestalt Diagnosis of Borderline, Narcissist, and Schizoid Adaption that Focuses on What Is Figure for the Client, in «Studies in GT», 8, 52-64, 60. 60 B. Kimura (2005) (or. ed. 1992), Scritti di psicopatologia fenomenologica, Giovanni Fioriti, Roma, 66. 61 Cf. G. Salonia, supra.

The depressive condition in PBL is followed by the sense of failure of reaching the other because incapable of moving well inside the experiences of feeling mislead and confused in a precise and current relational situation62.

4.2. Disinhibition «Orientation toward immediate gratification, leading to impulsive behavior driven by current thoughts, feelings, and external stimuli, without regard for past learning or consideration of future consequences». Trait facets: «impulsivity» and «risk taking»63. «Impulsivity (an aspect of Disinhibition): Acting on the spur of the moment in response to immediate stimuli; acting on a momentary basis without a plan or consideration of outcomes; difficulty establishing or following plans; a sense of urgency and self-harming behavior under emotional distress. Risk taking (an aspect of Disinhibition): Engagement in dangerous, risky, and potentially self-damaging activities, unnecessarily and without regard to consequences; lack of concern for one’s limitations and denial of the reality of personal danger»64.

4.2.1. Gestalt interpretation: the friable experience Kimura writes: «[…] the ‘limit-state’ patient tends to escape from the future […] looking for an immediate union with the

62 «It would be a relevant therapeutic mistake to cure/to work, for example, on the borderline patient with depression (with suicidal temptations) without first helping to elaborate the unsustainable feelings of confusion, of madness and of powerlessness, through a clarification of the concrete situation in which he is forced to interact even if he feels fooled» Hence the importance of the work on the present with borderline patients: Id. (2013), L’improvviso, inesplicabile sparire dell’Altro. Depressione, GT e postmodernità, in G. Salonia, V. Conte, P. Argentino, Devo sapere subito se sono vivo, cit., 181-192, 188-189. 63 American Psychiatric Association (2013), DSM-5, cit.,780. 64 Ibid., 767.

pure presence […] For this absorption in the present, the limit-patient way of being is distinguished not only by a schizophrenic one, but also by a melancholic one»65. The author speaks about punctiform temporal modality, minute by minute in the present, a being assimilated in the immediacy. It’s about a way to build experience in which the formal functions, through which time and space are structured, are distorted66. One of the GT’s key points is that the present cannot fill in the existence: every time one focuses on the importance of the ‘hereand-now’ will get confused if one doesn’t keep in mind the ‘nowfor-next’, namely, the experience that comes right after67. The time in the subject with BL is filled with not assimilated, emptied and impoverished experiences that do not allow to grow and don’t leave corporeal memory. These persons live in the immediacy, they look for body coupling, they tie themselves quickly, they have brief, quick and inconsistent contacts, they suffer from ‘tactile hunger’68, looking for the epithelial surface and an immediate satisfaction without a real contact; for example, they confuse intimacy with sexuality. Their way to live on the surface is characterized by a continuous need of novelty, something never experienced. They form fast but weak figures: moments of experience that do not represent the whole, dim and continuous needs of which one does not know the name nor the belonging. Their story is about anticipations, distorted time and experiences never completed, evaluated and interrupted by the mother.

65 B. Kimura (2005) (or. ed. 1992), Scritti di psicopatologia fenomenologica, cit., 64-65. 66 Cf. Id. (2000), L’entre. Une approche phénoménologique de la schizophrénie, Jerome Millon, Grénoble; Id. (2005) (or. ed. 1992), Scritti di psicopatologia fenomenologica, cit. 67 Cf. E. Polster, M. Polster (1986) (or. ed. 1973), Terapia della Gestalt integrata, Giuffrè, Milano; G. Salonia (2011), Sulla Felicità e dintorni, cit. 68 I used the term ‘tactile hunger’ present in the chapter on introjection, actually with the term ‘tactile hunger’ the authors do not refer explicitely to the ‘limit-state’, but rather to alcoholism and sexual promiscuity as unassimilated experiences: cf. F. Perls, R. Hefferline, P. Goodman (1994) (or. ed. 1951), Gestalt Therapy, cit., 433-454.

That way, every experience will always be new because the past ones were never assimilated. So the experience is not completely lived. The experience needs the assimilation and the meeting time with its novelty needs the pausing time69; the PBL cannot stay in the ‘pause’, in the silence to which comprehension and assimilation are assigned. In him the time is made of the consummation of moments that are the pauses that organise the rhythm of the lived time, without waiting and assimilation70. It’s the pause (Perls speaks about the ‘fertile void’) that brings us to the rhythm of life and relationship, at the same time it allows us to assimilate the experience and express our creativity.

4.2.2. The exhausting research of relationship between the need to appease oneself and the need to feel oneself PBL’s tend to immediately put into action self-destructive and impulsive behaviours, known in literature as acting-out. In a gestalt interpretation, the action is not seen as the execution of a thought, but as an autonomous experience that verifies and modifies the thoughts that precede the actions and in turn generates new thoughts. So, the action is like a place in which decisive elements of the personal identity are experimented and assimilated. In the borderline modality the action, as a continuous research of sensory experience, is not put into practice to reach a destination nor to achieve an aim, but to reduce and discharge the unsustainability of the internal tension, «they are gestures,

69 For details, cf. G. Salonia (1992), Time and relation. Relational deliberateness as hermeneutic horizon in Gestalt Therapy, in «Studies in Gestalt Therapy», I, 7-19; A. Sichera (2001), A confronto con Gadamer: per una epistemologia ermeneutica della Gestalt, in M. Spagnuolo Lobb (ed.), Psicoterapia della Gestalt. Ermeneutica e clinica, Franco Angeli, Milano, 17-41; G. Salonia (2012), Theory of Self and the liquid society, cit. 70 Cf. E. Minkowski (1933), Le Temps vécu. Études phénoménologiques et psychopathologiques, D’Artrey, Paris; G. Salonia (2011), Sulla Felicità e dintorni, cit.

The PBL cannot stay in the ‘pause’, in the silence to which comprehension and assimilation are assigned

The acting out, the self-destructive and impulsive behaviours are considered part of the patients’ need to appease themselves and their difficulty to contain and assimilate their own feeling

which aim to calm anxiety, the explosive sense of craziness when there is no accessible emergency exit»71. The impulsive action assumes the nuances of an excitement without orientation, an intolerable tension that pushes the person to act. In the borderline experience, there are no words to ‘say’. The words actually function only if they are a copy of the experience72, but in the BL the words for the personal experience are confused, vague, wrong, anticipated or limited to a sensory excitement instead of the experience itself. The communications are often oriented to the excess through dramatic expressions, imbued with anger. Through words the patients can express themselves in an ‘explosive’ way – from acting out – raising the voice or shouting. The intensity of the sound is the intensity that the person perceives on his own skin73. They do not know what name to give to the feeling or to define the things that happen, they do not have the ability to symbolize the experience. The distrust in the body is present in the possibility that the body has to contain the personal feeling, as can be seen from their difficulty to hold back and let go: there aren’t any logical connections that give a frame to the feeling, power to the body and the sensations, making them live the impulse as if it emerged from nowhere. The difficulty to act in full awareness indicates an unsustainable internal tension (to feel something without knowing what): in order to appease themselves they have to discharge the tension in action74. The acting out, the self-destructive and impulsive behaviours are considered part of the patients’ need to appease themselves and their difficulty to contain and assimilate their own feeling.

71 G. Salonia, supra, 46. 72 Cf. G. Salonia (2012), Theory of Self and the liquid society, cit.; cf. F. Perls, R. Hefferline, P. Goodman (1994) (or. ed. 1951), Gestalt Therapy, cit. 73 The sound is a constituent element of words. The sounds create the words and give relational value of closeness and distance. Cf. G. Salonia (2011), Sulla Felicità e dintorni, cit. 74 Cf. J.I. Kepner (1987), Body Process: A Gestalt approach to working with the body and psychotherapy, Gardner, New York.

4.2.3 From the difficulty of self-thinking to the pain of feeling The BPD, in DSM-IV, is the only personality disorder that, among the diagnostic criteria, foresees the presence of suicidal or self-harming behaviours. In gestaltic key, self-harm actions (without suicidal intention)75 can be understood on different levels. Self-harm as an attempt to appease the ‘sense of madness’. Self-harm gestures should be included in the attempt to appease tension, agitation, the sense of madness bound to the feeling of being deceived by an important person for them and not be able to come out from the fraud76. Self-harm as an attempt to ‘be confirmed as a presence in the world’. The tendency towards the mutilation of the body and the self-destructive behaviour provide the background of the story of the subject with BL, which is the story of a highly desensitized body. In the absence of a clear and accessible sensory perception of ourselves and of the environment, we lose contact with the needs and with our placement in the world77: the sense of our presence, of our physical boundaries. So the self-harm can be intended as the attempt to confirm that unstable boundary, that thin and permeable skin that every day questions the personal existence. A numb part wants to feel something through the confirmation of oneself and the touching of the wounded part provoking pain78; the GT founders, paraphrasing Aristotle, they write: «When the thumb is pinched, the self exists in the painful thumb»79.

75 A special reference needs to be made to the suicidal temptations in PBL: they are impulsive, unplanned, «in this way […] the aspiration for death accompanies necessarily the ‘limit-state’»: in B. Kimura (2005) (or. ed. 1992), Scritti di psicopatologia fenomenologica, cit., 64. 76 Cf. G. Salonia, supra. 77 Cf. J.I. Kepner (1987), Body Process, cit. 78 F. Perls, R. Hefferline, P. Goodman (1994) (or. ed. 1951), Gestalt Therapy, cit., 139. 79 Ibid., 180.

Self-harm as the pursuit of the other. A visible pain in the body is more likely to tolerate than the intolerable experiences in the soul, mostly invisible for the others. Those impulsive acts, even though they’re seriously distorted, are a way to relate to other people, to create an affective reaction in the other80. Considering this aspect, it is interesting the reflection on the fact that the impulsive behaviours have the sense of ‘testing’ the endurance (or the very presence) of an environment, able to act as an embankment to a subject in search for a function of limit and containment. In this sense, Zanarini proposes the definition of ‘limit-state’, used by the French psychopathology to indicate the borderline psychopathology, it’s particularly suggestive: states of mind searching for a limit81.

4.3. Antagonism «Behaviors that put the individual at odds with other people, including an exaggerated sense of self-importance and a concomitant expectation of special treatment, as well as a callous antipathy toward others, encompassing both an unawareness of others’ needs and feelings and a readiness to use others in the service of self-enhancement». Trait facets: «hostility»82. «Hostility (an aspect of Antagonism): Persistent or frequent angry feelings; anger or irritability in response to minor slights and insults»83.

80 Cf. J.G. Gunderson, P.D. Hoffman (1984), Understanding and treating borderline personality disorders, American Psychiatric Press, Washington; A.R. Favazza (1989), Why patients mutilate themselves, in «Hospital & Community Psychiatry», 40, 137-145, cit. in J.G. Gunderson (1984), Borderline personality disorders, American Psychiatric Press, Washington 81 Cf. M.C. Zanarini (1993), BPD as an impulse spectrum disorder, in J. Paris (ed.), Borderline personality disorder: etiology and treatment, American Psychiatric Press, Washington. 82 American Psychiatric Association (2013), DSM-5, cit., 780. 83 Ibid., 767.

4.3.1. Gestalt interpretation: the borderline anger, an obstinate pursuit of clarity84 The anger expresses the difficulty of the PBL to contain and assimilate his own feeling: there is a lack of connections that give power to body and feeling. ‘Explosive’ emotions, such as anger, cannot be supported by a body that is not fully perceived; for these reasons, the anger shall never be amplified but contained instead in such patient. He perceives full intensity of anger and tension on his skin, but he doesn’t feel it to the bottom, he doesn’t understand the reasons, the meanings. Anger is the most evident expression of confusion among experiences: it’s the pain of those who are not able to put together the complex aspects of personal experience, and it is the consequence of feeling deceived without knowing why. Anger is necessary to the person, so he does not turn mad in a relationship, in which the other does something intrusive or aggressive, denying or underestimating his perception; therefore it has to be seen as a pursuit of clarity85. If the PBL, for example, feels the rejection as something clear, then it is all right for him. On the contrary, the rejection makes him crazy not because he feels humiliated, but because he gets confused. For example, if his girlfriend prepares a romantic dinner and then she sexually rejects him, he will get mad, not because his girlfriend humiliates him, but because it confuses him. The rejection can be logical or not: regarding this, the subject with BL gets confused and many of his ‘odd’ behaviours are part of the need to appease between two opposing emotions (e.g. aggression and love are incompatible for him). Anger is what we see, it is the behaviour that comes out, but that not always corresponds to the real experience: it ‘takes the place’ of other experiences (fear, pain etc.) The experience is often depressive. Actually, the patient with BL has the strength to individuate himself, but he is not able to separate himself between the experiences, he feels this strength, but in an illusory way, he

84 Cf. V. Conte (2011), The borderline patient, cit. 85 Cf. Ibid.

Anger is what we see, it is the behaviour that comes out, but that not always corresponds to the real experience: it ‘takes the place’ of other experiences (fear, pain etc.)

feels strong, identified, but these things do not belong to him: he has been deceived to distinguish between the experiences.

5. Final remarks. GTBL86: A space with several voices

Feeling and saying: starting from this twist, the patient builds his own world, his own particular world that becomes comprehensive, logical and coherent, where there is availability of a therapeutic relationship in which the symptom of narration meets a respectful translation, a space with ‘several voices’, that allows to decode and recover the experience

The GT therapist, aware of the fact that each description of pathology risks to be transformed in ‘typology’, keeps in the background the diagnostic guidelines (whose function is to show the way and not to describe the patient), but he asks himself a question: what is the experience behind the word, the gesture or the behaviour? The specificity of hermeneutics of GT is to read the symptom as «a text that comes to the patient from the personal tradition that becomes problematic all of a sudden […] the patient brings the symptom in treatment so the therapist can accompany him in the pursuit of sense»87. In this interpretation the symptom is a text, an ‘appeal’88 that wants to be listened to: the symptom invites to a relationship. The PBL brings us in the patterns of a world where the effort of a foreign language is experimented, where the experience is expressed through an emotional and relational vocabulary, it’s not shared, not coherent, but that does not mean it is less authentic. GTBL allows the translatability of suffering that is not indecipherable if one is willing to give back destiny to the experience according to a logic of coexistence of truth instead of a reciprocal consistency, if one is willing to listen in a careful and respectful way, that goes beyond the behaviours and that gives saying to those words, to that vocabulary, that tell about feelings, emotions, perceptions and that if they are admitted in a careful and expert relationship, they will give back to the PBL the authenticity of his experience of the world and can avoid further injury of the experiences. Feeling and saying: starting from this twist, the patient builds his own world, his own particular world that becomes compre-

86 Cf. G. Salonia, supra. 87 A. Sichera (2013), Ermeneutica e GT, cit., 13. 88 Antonio Sichera says: «The symptom is an appeal to relationship». Cf. Id. (2001), A confronto con Gadamer, cit., 25.

hensive, logical and coherent, where there is availability of a therapeutic relationship in which the symptom of narration meets a respectful translation, a space with ‘several voices’, that allows to decode and recover the experience. You can’t change anything from the outside in. Standing apart, looking down, talking the overview, you see pattern. What’s wrong, what’s missing. You want to fix it. But you can’t patch it. You have to be in it, weaving it. You have to be part of the weaving. Ursula K. Le Guin89

89 Cf. U.K. Le Guin (1997), Four Ways to Forgiveness, HarperPrism, New York.

ANDREANA AMATO

«…AS IF I WAS BORN ‘UNEVEN’…» THE GESTALT TRANSLATION OF THE BORDERLINE LANGUAGE MODEL (GTBL) CLINICAL ATTESTATIONS Andreana Amato

I could not reconcile these two feelings. I can remember this sensation – this thought – very clearly. The realisation that sometimes, it is possible – even necessary – to entertain contradictory ideas; to accept the truth of two things that flatly contradict each other. I was only just beginning to understand this: only just beginning to acknowledge that this is one of the fundamental conditions of our existence. How old was I? I was thirty-three. So, yes: you could say that I was just starting to grow up. J. Coe1

1. Anthropological introduction: the anguish of confusion between vicinity and distance Integrity and wholeness are the two basic needs for development: the first one concerns the feeling of one’s own uniqueness and singularity, the second one with the audacity to express oneself to the fullest in front of somebody else

In the theory of Gestalt Therapy (GT), the two basic evolutional tasks of each human being – the ability to be completely yourself and the ability to be in relation with the other – necessarily go through two great types of existential anguish: the anguish of distancing oneself (distress of saying ‘I’) and the anguish of relying on someone (distress of the ‘us’)2. Integrity and wholeness are the two basic needs for development: the first one concerns the feeling of one’s own uniqueness and singularity, the second one with the audacity to express oneself to the fullest in front of somebody else3. The fluidity with which these two tasks can be followed through, and can continue to intertwine and unfold over the course of life, ‘describes’ the meeting between Organism (O.) and En-

1 J. Coe (2007), La pioggia prima che cada, Feltrinelli, Milan, 163164. 2 Cf. G. Salonia (2010), The anxiety of acting between excitement and transgression. Gestalt Therapy with the phobic-obsessive-compulsive relational, in «GTK Journal of Psychotherapy», 1, 21-59. 3 Cf. Id. (2013), Gestalt Therapy and Developmental Theories, cit.

vironment (E.), between myself and the other, as a mutually beneficial meeting, a source of growth and well-being of the entire relational field. In a certain sense, it is about crossing the border between one side and the other of ‘I-You’, feeling that the moment, the rhythm, the speed of such a dance is appropriate, harmonious; we don’t stay for more than necessary on either side, nor do we get paralysed in confusion and uncertainty. A fine balance between ‘of’ and ‘at’ the border. The relational nature as a constitutive figure of the human condition, «is also learning – the result of a process concerning the individual, the community and the whole of mankind»4. While many voices in the philosophical and anthropological field outline the ‘way’ and ‘possibility’ of living together through the paradigm of giving5, the «wish to bond with the other as constitutive dimension of the I»6, just as many voices, from a psychological point of view, by now share the awareness that the development of the individual goes through different ways of being-with-the-other as both origin and goal of such growth7. The way to fully conquer such feeling of oneself and of the other, and of history, which connects the minacious progress of the relationship in a significant weave, constantly entails a dilemma. How can I fully be myself with the other? How can I combine my (corporeal, historical) individuality with the inappropriable difference of the other, without giving up neither my integrity nor the meeting? Self-confidence and confidence in the environment are two competences emerging circularly. Before being able to entrust myself to the other, I have to be able to say: «I feel». In order to be able to say «I feel», I need the other significant (parental person) to acknowledge and support my experiences, by giving them a ‘proper’ name (in the sense of ‘my own experience’ that ‘belongs to me’, and in the sense of ‘it’s actually the feeling I’m experiencing now’).

4 Id. (2013), Disagio psichico e risorse relazionali, cit. 5 E. Pulcini (2008), L’individuo senza passioni, Bollati Boringhieri, Turin. 6 Ibid., 212. 7 Cf. G. Salonia (2013), Disagio psichico e risorse relazionali, cit.

The development of the individual goes through different ways of being-withthe-other as both origin and goal of such growth

How can I fully be myself with the other? How can I combine my (corporeal, historical) individuality with the inappropriable difference of the other, without giving up neither my integrity nor the meeting? Self-confidence and confidence in the environment are two competences emerging circularly

The vicinity to the other becomes torment between wish of contact and fear of experiencing an intolerable confusion

It is as if the old and human fear of being alone and at the same time losing one’s own integrity due to the relation with the other might crystallise without the possibility of a solution

All this is learnt first of all in the intercorporeity8 between child and parental figures. The emergence of feelings and emotions in the child’s body (visible in the breathing rhythm, facial expressions, muscle tension) need the adults’ ability to distinguish to whom these experiences belong to and what their name is, starting from a proper awareness of their own corporeity. Such name should indeed come out from the felt and thought body. In fact, the bodily-relational experiences take shape and clarity at the crossroads of these two ways, perceiving and deciphering corporeal signals and assigning them a meaning through words. If the child is not able to learn the capacity of recognising his own experiences and the one of others in the relationships, because his parent is confused and therefore anticipates or twists his child’s experience by replacing it with his own, the dilemma between personal integrity, which establishes roots in the faith that such experiences belong to him and have such name, and the possibility to meet the other through it, becomes unsolvable. The vicinity to the other becomes torment between wish of contact and fear of experiencing an intolerable confusion. The reiterated and distressing question people with Borderline Language (BL) ask, could be described as a tiring and fluctuating short circuit: «Is what I feel right? To whom does it belong? Do I give up myself (I’m insane) or the other (he’s mean)?». It is as if the old and human fear of being alone and at the same time losing one’s own integrity due to the relation with the other might crystallise without the possibility of a solution. Hence, being able to say ‘I feel this in front of the other’ becomes a windy path. And even if the other is somehow reachable, he still remains incomprehensible9.

8 Cf. Id., Accade tra i corpi. Intercorporeità e gesto mancato nella Gestalt Therapy, Il Pozzo di Giacobbe, Trapani, soon to be published. 9 As G. Salonia states «The Ego is not given a primary experience, but as arrival point of a needed path to ‘reach’ oneself […]. The presence of someone that takes care of and helps the child to reach himself is crucial for this path», in Id. (2013), L’esser-ci-tra. Aida e confine di contatto in Bin Kimura e in Gestalt Therapy, in B. Kimura, Tra. Per una fenomenologia dell’incontro, Il Pozzo di

Since the experience of such failure takes place in the relationship with significant figures, in a trusted context, each relationship will be assailed with deep ambivalence: the wish to approach and the terror of being sucked down, absorbed, mislead. Thinking of this unstable ridge between separation and connection to the world, I see S. intensely looking at me, sitting on the chair, during the first few meetings. She scrutinises me, with static eyes that incessantly try to decipher me. However, only her head sticks out towards me, towards the world; the rest of her body doesn’t support her in this difficult, impossible effort of collecting signs about «Who is he?», «Is he going to fool me?». For that reason, I try to ‘feel as a whole’, from top to toe, in order to avoid following her in all her micro-movements. Meanwhile, she tells a series of events of her university life where the others she talks about are not ‘coloured’. Her connection to them is given by a series of actions («I went, we came back, and then we moved») that are related neither by an emotional plot nor by precise intentions. At some point, she bursts out: «The point is that I didn’t go with them to the beach in the end… I didn’t want to, I don’t know… and while they were asking me – are you sure? – I saw they were in a rush, they didn’t really care whether I was going or nor. So I held my ground. Then, when I was home alone… my bad mood rocketed… a voiceless thing… I turned around in my room for what seemed like a century… I cried… I don’t know… they were light-years away… I was paralysed… it was a terrible afternoon». If I don’t clearly perceive what I feel and what I want in a relationship, I can be ‘attacked’ by the other, but I cannot stay together with the other. If I allow the definition of myself to differentiate from the experience and needs of the other, a chasm, a sense of alarming disconnection opens.

Giacobbe, Trapani, 5-20, 14.

If I don’t clearly perceive what I feel and what I want in a relationship, I can be ‘attacked’ by the other, but I cannot stay together with the other

2. The background-figure dynamics

What is striking in the encounter with borderline experience modes, what literally comes over the therapist’s borders like a wave, is that everything is shaped

I feel confusion, a petrified chaos because there’s no direction

There’s a lack of logic and emotional connecting tissue, an articulation of inter-subjectivity in time. Even space seems to shrink, since there are many, too many events

What is striking in the encounter with borderline experience modes, what literally comes over the therapist’s borders like a wave, is that everything is shaped10! While M. is talking, I notice the speed he uses in telling episodes of his week, (I almost see him ‘skipping’), but rather than given by the stream of words, this speed is given by the impossibility to build a consequential time frame, which connects intentions to actions and actions to time. His words are strong, extreme as of quality, categorical. The volume of his voice is very high, regular. I feel my breath speeding up when in front of him, I speed up my thoughts to memorise facts, names, places, moments. I feel confusion, a petrified chaos because there’s no direction: you would need a bigger room to hold this whole turmoil. I guess I need to find a piece of wood acting as a raft in order to cut through the waves unharmed. Such type of experience could be defined as a temporal mode, according to Bin Kimura’s words, pointing to moment by moment in the present, being absorbed in the immediacy11. It is about a way of building experience, in which the formal functions of its structure – space and time – are distorted. If these are also emerging features ‘of’ and ‘at’ the contact border, we may think that a prematurely hyper-defined, anticipated and interrupted bodily-relational experience is also an experience of ‘too fast’ figures that emerge without being able to be completed first. The fluent and recursive background-figure, that is the co-construction of an emerging figure, stands out and then pulls back, assimilated, on a background that turned richer, and therefore is compressed, accelerated. It produces as many figures as the existing feelings, events, current details12. There’s a lack of logic and emotional connecting tissue, an articulation of inter-subjectivity in time. Even space seems to shrink, since there are many, too many events.

10 Cf. G. Salonia, supra. 11 Cf. B. Kimura (2013), Tra. Per una fenomenologia dell’incontro, cit. 12 Cf. G. Salonia, supra.

I feel crowded, suffocated in front of M., as if I’m unable to distinguish the basic features of what he’s recounting. While listening to him, I am struck by the ‘denseness’ of his stories, as if they were flat, without any substance, since the conferment of intentions, emotions, cause-and-effect connections, his own and the one of others, is missing. The deficit of mentalisation identified by various authors13 seems to be a global emotional shade that dominates and, at the same time, colours and addresses the whole narration. It always springs either from failure in differentiation or from the feeling to be inevitably and definitively abandoned. «My mother is a bastard, I tell her: – I go out – easy, and she puts on the face of a grieved Madonna, and her school teacher voice… makes me crazy… I meet A. in the square, she keeps to herself, says hi to me in a cold way… she’s also an asshole… everybody is an asshole…». Trying to put order in M.’s emotional confusion or supposing explanations for his reactions to events is impossible. The feeling and picture I have is again the one of a needed raft, one to find and grab on to in the middle of a storm. For now, making sense of things doesn’t matter. What matters is recovering an atmosphere, a point on which to stand. I try to ‘piece together’ the details; tiny interventions about where and when, about ‘placing things in a row’, about recalling similar, already told episodes, about ‘while you were feeling like this… then the other’. M.’s breath is less heavy. He stops at some point and says to me: «So this… is a complete mess, uh? It seems like The Bold and the Beautiful… but now it’s less messy». He heaves a sigh, then stands up and approaches the French door of my studio: «It’s really nice here, such view in front, roses on the terrace… it’s peaceful…». I get up and stand next to him, watching the fields stretching out in front of us. He looks at me: «You see, when I’m here it

13 Cf. A. Bateman, P. Fonagy (2006), Il trattamento basato sulla mentalizzazione. Psicoterapia con il paziente borderline, Raffaello Cortina, Milan.

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M. seems to feel the need to weave a plot for himself, before being able to make contact with me

We could summarise the core of borderline experience in a constant seesawing between independence and dependency, between the wish for such closeness that does not become confusion and wish for separation to avoid emptiness and isolation

The ambivalence and instability of relations therefore reflect the fear of being abandoned, and at the same time of being absorbed

is like tidying up… the problem is, when I leave there’s chaos again. Are we meeting next week?». M. seems to feel the need to weave a plot for himself, before being able to make contact with me. At the same time, I would say that such plot emerges at the contact borders between his wound and my ‘patches’. By plot I mean the patient’s possibility to tell himself the sense of events and current relations. While on one hand, from a ‘genetic’ viewpoint, the hypertrophy of the present is a way of building experience, which has to be reconnected to the sense of continuity of one’s own story, on the other hand, you must take into account that confusion on experiences and the terror of scam in the vicinity are actually unbearable in the presence, in real and current relations.

3. Intentionality and bodily-relational experiences We could summarise the core of borderline experience in a constant seesawing between independence and dependency, between the wish for such closeness that does not become confusion and wish for separation to avoid emptiness and isolation. The experienced relational fields distinguished by unpredictability, chaos and trauma with significant emotional figures have been contributory causes of the borderline patient’s impossibility to extricate himself between his own experiences and the one of others, making him opt for the ‘all or nothing’, ‘black or white’ logic. «I’m either enthusiastic or desperate towards that situation, that person; the other is either wonderful or revolting». The ambivalence and instability of relations therefore reflect the fear of being abandoned, and at the same time of being absorbed: I can’t trust anybody (closeness will confuse me), but I also desperately need the other, who allows me to anchor my experiences14. Indeed, the experience of warmth is like reliving the swindle, the fear of being sucked down again. The person

14 Cf. V. Conte (2011), The borderline patient, cit.

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is forced to destroy the relationship, in order to protect himself, but he also considers it most important, and thus gets stuck in a terrible dilemma. When the BLP feels some warmth, he distances himself, because he doesn’t reason anymore, he no longer knows what emotion he feels, and distancing himself represents the only way to clarify what he’s feeling15. Scission, an ancient defence mechanism16, is rather a constant alternation of intense approaches and estrangements that are as drastic, due to unacceptability, complexity and ambiguity that all current relations are (constitutively) burdened with. Feeling two conflicting emotions, such as being mad at a beloved one, or perceiving two conflicting emotions in the other («he’s my friend but got back to me in a rude way»), is unbearable. Here’s when confusion and the feeling of being ‘duped’17 emerges again. The sense of emptiness, recurring in BLP words, can be defined as living experiences acutely in the absence of a steady background able to offer experiences, compactness, containment and persistence18. If the emotional state, from a GT perspective, and the state of mind are not individual variables, but the result of a relational co-creation process, the sense of emptiness achieves the specific feature of an emerging feeling in the field, when I am not able to define what I feel, in front of the other; in other words, whether what I feel belongs to me or to the other, and at the same time, I am not able to decipher what the other feels about me. So, how can an emotional presence become something that can be assimilated? A relation can become background if I don’t have to pay attention to any sign, gesture, word, detail, in a state of hyper-apprehension, for fear that incongruity may throw me back into confusion. Then, the sense of emptiness consists in not reaching the other through one’s own clarity and, vice versa, not being able to

15 Cf. 16 Cf. 17 Cf. 18 Cf.

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G. Salonia, supra. O.F. Kernberg (1984), Severe Personality Disorders, cit. G. Salonia, supra. A. Correale et alii (2009), Borderline, cit..

Scission, an ancient defence mechanism, is rather a constant alternation of intense approaches and estrangements that are as drastic

The sense of emptiness, recurring in BLP words, can be defined as living experiences acutely in the absence of a steady background able to offer experiences, compactness, containment and persistence

Anxiety, fear of being close and distance at the same time, anger, confusion. More or less so acute that they become unbearable

It’s useless. I’ve always been thinking that I’m not made properly. It’s not about character flaws. The others don’t understand. It’s something different, as if I was born ‘uneven’

achieve one’s own clarity through the feeling of a deep and sincere ‘reliability’ of the other. While, from a clinical point of view, such dimension seems to be a constant the patient’s entire life experience lies on, he accomplishes it as a sudden, ‘other’ dimension into which the person sometimes seems to slide, without managing to control it and knowing the reason for it; and the fight to get out of it is exhausting. «It’s that issue I already mentioned to you. An emptiness, a deaf, bad mood, I don’t know if I can make myself understood. It’s a mix of things… I’d like to pounce on somebody but also on myself; I’d like to cry but I can’t. Sometimes it’s so unbearable that I just would like to feel nothing. I move around in the house like a caged animal… I don’t know what I want. I think of a thousand ways to feel better, a thousand concrete things I could do, but nothing suits. I’d like someone to get closer, but then I’ll avoid him anyway, I even mistreat him if he tries. And while I step aside, I feel even worse… but I don’t know whether it’s towards myself or towards him». Anxiety, fear of being close and distance at the same time, anger, confusion. More or less so acute that they become unbearable. Sudden uncertainties of mood and such depressing experiences are always followed by the feeling of failure in reaching the other19; they always involve either the perception of an abandonment or failure in separation, in a real and actual situation. Thoughts about death often are the only way out against the exhausting fight to reach one’s own subjectivity. A sense of unworthiness, which is deeply marked in the corporeal experience, surfaces in the most difficult moments, but also in those marking an evolutionary passage in therapy, a growth where the patient, however, also becomes more aware of his own difficulties. «It’s useless. I’ve always been thinking that I’m not made properly. It’s not about character flaws. The others don’t understand. It’s something different, as if I was born ‘uneven’. The more I

19 Cf. V. Conte (2011), The borderline patient, cit.

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realise how difficult relationships are for me, the more I feel tired sometimes. As if I was to build a road that is obvious for the others, while it’s a constant fight for me». Even a seemingly insignificant event, such as feeling excluded by friends, can trigger a feeling of confusion and madness, because the person is not able to free himself from his own twist of experiences, and the one of others, concerning significant figures, with whom the distance control is, by definition, a continuous seesaw. A well-recognisable feeling, even if intense and unpleasant, is more tolerable than not knowing what you are feeling. The acting out therefore is a way to soothe such feeling. The search for excessive sensory experiences (drug abuse, search of risks, chaotic sexual behaviour) or self-harming behaviour aim to make the emotional wave more acceptable. Taking an action to tolerate a feeling, or better, the distress of confusion of feelings. Physical pain is ‘better’ than mental pain20. M. describes one of those moments like this. He tells how he was going nuts during an exchange with his girlfriend: «I just couldn’t understand it; she accepts the flowers and the gift, she tells me I’m the sweetest person in the world… then she says she feels uncomfortable, it’s better if we don’t meet anymore, then she comes closer and kisses my lips and worries about me… – Don’t mess things up! –. Look, I am currently fond of you… but why can’t we stay together? Then I became really distressed… so I went for a ride on my motorbike at full speed… there was a guy standing outside the bar where I stopped for cigarettes, a misfit. I said… now I stare at him, preparing myself in front of someone else, who probably is bigger than me, searching for trouble…I feel like energy from my feet reaches my head and hands. Adrenaline rises and I don’t understand anything… but I feel alive and I don’t suffer any blows». In the borderline experience, self-harm, not ritual but impulsive, comes immediately after a relational mess. If the mess is not too officious, the person will take the blame to keep a ‘univo-

20 Cf. G. Salonia, supra.

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The acting out therefore is a way to soothe such feeling

In the borderline experience, selfharm, not ritual but impulsive, comes immediately after a relational mess

G. doesn’t want to die by cutting herself, but tries to tolerate distress

cal’ image of the other significant person, who would become incomprehensible otherwise, because he would be a carrier of ambivalence. At that moment, it’s the only way to go back to one single, clear emotion. A female patient reports an episode where her doctor, known for years and to whom she puts total trust, smiles and says to her at the end of the appointment: «Look how beautiful you are, you lost weight, you are wonderful… if only I was younger!!!». Words are accompanied by a gesture, a kiss and a hug she feels more affectionate than usual. Only after does G. feel distressed. «I was going back home, I felt dazed…then I started to feel bad. He had never behaved like this. He’s always been very kind, but very formal, polite. Every time he examines me, he makes me undress in pieces, so that I’m always as dressed as possible… I felt like a piece of junk. I wasn’t able to think of anything else at home, I couldn’t understand. I cut myself under the shower». In G.’s logic, such language and such an informal gesture on behalf of a man who is much older than she is, who has a treatment role, are alarming. She comes from a family of musicians, highly educated parents that pay attention to language and distances dictated by roles. However, at the same time, she’s been trusting this person for years. So, such words and gestures are unintelligible to her. G. doesn’t want to die by cutting herself, but tries to tolerate distress. Different to suicide, acting out, has a logic that always needs to be found in relationships, even therapeutic ones. D. tells me about a difficult evening she spent crying and telling herself that she would never be able to finish her project for a university exam. She doesn’t stop repeating that she’s incapable; she’s sitting on a chair with a pained, discouraged, irritated expression. She talks about the difficulties of getting her head together, about her tiredness due to tight schedules, about how bad things work at University. I ask her what happened during the day, or the day before. She manages to focus on one episode in which the same teacher of the course is involved. «I sent her an email because I realised there was no online booking for my exam. I was worried:

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all my efforts for the project and then I cannot take the exam for some bureaucratic problem. I write to her asking if she can help me to understand how I wasn’t down for the exam, despite having a written receipt. I know that, as a rule, the teacher has to carry out the online process. I thought it would be offensive to be direct and tell her:… Did you forget? She replies that it’s not her, but my problem, maybe I’ve been inaccurate in the process and I should talk to the secretary. Like this, abrupt». In our mutual dialogue, we clarify a couple of concrete things. D. realises she knows how those things should work, she could be sure of that. But she also reckons that she went ‘haywire’ when she was denied the evidence, getting an ‘abrupt’ response and being pinpointed as inaccurate, as she actually doesn’t feel like that. «I felt ‘palmed off’ and also a pain in the neck, while she was actually in the wrong. At first, maybe I felt anger, but then I’m always like this, discouragement catches me… and then I’m the one feeling bad». The denial of evidence or the imposition of a significance that doesn’t belong to her are ‘fields’ a BLP does not manage to get out of. Even furious anger caused by «small offenses and insults»21, according to DSM-5, actually subtend an iron logic: it comes from a feeling of being duped and not knowing why. The person needs fury, in order to avoid getting mad in a relationship, where the other does something intrusive, aggressive, denying, or underestimates his perception. Anger expresses the need for clarity and assumes an implacable quality bound by the need of being told: «You’re right». It is not about a reason bound by facts, about how things go in practice, but rather about a substantial validation of one’s own perception: «What you felt about yourself and the other has true roots». If such background is established, it will also be possible to negotiate significances, accept the difference of reciprocal experiences and intentionality, and in the end, the relational outcomes they lead to. If this does not happen, there can be no space for anything else if not for this very painful feeling of ‘short circuit’ and madness. Indeed, a BLP is not able to dis-

21 American Psychiatric Association (2013), DSM-5, cit., 767.

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The denial of evidence or the imposition of a significance that doesn’t belong to her are ‘fields’ a BLP does not manage to get out of. Even furious anger actually subtend an iron logic: it comes from a feeling of being duped and not knowing why

It is then necessary to distinguish reality and relations vertically: either black or white

tinguish denial of his own experience from an experience that is simply different from his’. The alternation of the extremes of hyper-idealisation and devaluation, referred to in the second criterion of DSM-IV22 – and missing among diagnostic indications of DSM-523 – actually complies with the impossibility of accepting the limits of the other, as generators of confusion and terror of being duped. It is then necessary to distinguish reality and relations vertically: either black or white. According to some authors24, the dissociative dimension is not a specific mode of transitory reaction towards intense emotional traumas (as indicated in DSM-IV criteria), but a wider and pervasive condition that characterises the patient’s entire psychic experience, even if coping with amplifications following on from particularly stressful events. The constriction of the area of awareness and the depersonalisation can lead to an unbearable increase of tension (that’s where the above-mentioned agitation comes from), as well as to a drastic decrease of sensitivity. Even in this case, the GT interpretation emphasises the emergence of those experiences at the contact borders in relation to the other25. A patient describes a recurring experience, where she perceives a feeling of distress, a contracting stomach and at the same time an empty ‘head’, when she has to choose whether or not to expose herself professionally in front of people she doesn’t know. «I feel relaxed, present in the situation and then suddenly have a black out – I feel unable to think. It seems as if my head is detached from my body, I feel dull, even my sight is reduced, also my hearing. The room gets bigger, the people further away… it looks like a slow-motion scene». At this point, I ask her what happens with the strong distressed feeling. «Actually, it calms down at this point. I don’t feel much, as if I have been anesthetised. I keep on telling myself that I am not

22 Cf. 23 Cf. 24 Cf. 25 Cf.

Id. (1994), DSM-IV, cit. G. Gionfriddo, supra. A. Correale et alii, Borderline, cit. G. Gionfriddo, supra.

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capable, that I will make a terrible impression, that everybody will see that I am not right. Thoughts go through my head, but my body doesn’t feel anything. It’s a bit like floating. And I have someone else speak for me». It seems as if depersonalisation and unawareness are a way of tolerating the situation’s intrinsic ambiguity. Since she cannot decipher what the others are thinking and feeling towards her, and cannot distinguish her own feelings of fear, excitement etc., the solution is softening an incomprehensible wave by ‘switching off her body’. That way, the complexity of the field is simplified. Self-harm bound to desensitisation including the distress of disappearing, of passing away desensitised (distress placed more towards the psychotic) is a different experience. It is not about an impulsive act that placates confusion in the here and now, but about an attempt to become resensitised: to achieve self-denial through the feeling of warm blood that he gets through self-harming. A severe disorder of the Id-function of the Self can be seen in such experiences, often emerging after traumatic experiences where the body has been deeply confused and invaded (such as, for example, in sexual abuse inside the family)26.

4. The GTBL model: the specificity of Gestalt Therapy work with the experiential borderline type The time is out of joint. O cursed spite, that ever I was born to set it right! Hamlet, Act I, Scene V27 How to be oneself without suffocating the other, and how to open oneself up to the other without asphyxiating oneself? It is absolutely necessary to address this question, if one wants to escape the deadly and bloody oppositions that currently animate and agitate the chaos of the world. Édouard Glissant28

26 Cf. G. Salonia, supra. 27 W. Shakespeare (2011), Hamlet, William Collins, London, v. 190. 28 É. Glissant (1998), Poetica del diverso, Meltemi, Rome, 19-20.

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It seems as if depersonalisation and unawareness are a way of tolerating the situation’s intrinsic ambiguity

Before we face the specific aspects of Gestalt Therapy work with the mentioned experiential mode, I would like to offer some food for thought starting from extracts of verbatim deriving from a therapeutic model developed by Kernberg29, to which we can add some possible answers with regard to a gestaltic viewpoint. Comments from a GT point of view are original contributions by Giovanni Salonia, director of the Institute of Gestalt Therapy H.C.C. Kairos, while I am going to add some considerations deriving from theoretical-clinical principles of GT and outline a peculiar working method with BLP: the GTBL model – ‘Translation of Borderline Language’ – developed by the same author30. The clinical extracts were taken from a verbatim of a session (the fifteenth) with a BLP, done by a therapist according to the Transference focused psychotherapy31. Aim and purpose is not commenting on a colleague’s work (risking considerations deriving from other points of view), but to share an ability to read, which I believe is rewarding, to reflect on this particular experiential method. Since an insertion into a relation, that already is at its fifteenth appointment, is not possible, the background given by the fourteen previous appointments, as well as information of the patient coming from other sources are missing; observations including positive and problematic implications are focused on the ‘here and now’. The session is anticipated by a non-said: before meeting the therapist, the patient tells the secretary that she intends to kill herself by swallowing some pills. The secretary tells the therapist, and the patient is aware of this, according to a previously agreed contract. Patient: Hello (she clears her throat) hmmm… I want to start by saying why I didn’t come yesterday… it was really pouring

29 Cf. J.F. Clarkin, F.E. Yeomans, O.F. Kernberg (2000) (or. ed. 1999), Psicoterapia delle personalità borderline, Cortina, Milan. 30 Cf. G. Salonia, supra. 31 Cf. J.F. Clarkin, F.E. Yeomans, O.F. Kernberg (2000) (or. ed. 1999), Psicoterapia delle personalità borderline, cit.

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down in the morning and my car is no good in the rain, but if I had really wanted to be here, I probably wouldn’t have even thought about it. It was just an excuse to avoid coming here [the patient starts to admit that she doesn’t want to come here]. Therapist: Well, I think we need to work on this straightaway, because my secretary accommodated you and changed the time of your appointment. But again, you should have been here at twelve fifteen and it’s twelve twenty-five now. Luckily, I could meet you today, and my secretary could accommodate you. It was lunch time and I thought, as you mentioned, it was easier for you to come in the mornings to avoid rush hour. But I’m not sure if this makes any sense to you, therefore I am discouraged in regard to… [the therapist agrees that this is an important topic and makes the patient interact with her, putting into practice the desire to escape from treatment by arriving late]. Salonia: It seems that the here has become a difficult or dangerous place. (Pause). I wonder whether the wish of killing oneself – and in quite a violent way – is connected to the ‘here’… Patient: (interrupts) I didn’t want to be here today [the patient confirms she didn’t want to be here today]. Therapist: Fine. At the moment, the point is not whether you wanted to be here today or not, because there will be other times when you will not want to be here and that you might hate coming here; but the point is that you have to be here, and this is part of the therapy. I don’t expect you to sign an agreement with me, as you behave as if you couldn’t wait to come here. I totally understand that sometimes you won’t feel like coming here, and this is one of the points we have to face. However, if you take action rather than working on it, it means that this kind of therapy may not be right for you. This therapy requires you to behave well [the therapist refers to the agreement, pointing out that the patient has to attend irrespective of how she feels; otherwise she won’t be able to undergo such treatment. The therapist reiterates the agreement rather than delving prematurely and more deeply into any dynamics]. Patient: Hmmm, hmmm.

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Therapist: As I mentioned to you, you have to be here and you need to bring all your problems and the things that cause you problems so that I can work on these with you. However, I can’t, even if I wanted to, and I don’t want to run after you when you say: «No, I don’t want to come, or I feel like this or that today». We can’t carry on therapy in this way. I acknowledge it and I hope you can acknowledge it, too [the therapist highlights the message: no treatment, unless the patient is happy to come irrespective of how she feels]. (Pause) But since you are here, what is happening, besides the fact that you are telling me you didn’t feel like coming here. You should have brought the drugs. Do you have them with you? [the therapist immediately proceeds to address the patient’s suicide threats (communicated by third parties before this session). She insists on taking away the drugs the patient was keeping for the purpose of her suicide]. Salonia: yes, i understand. ‘Here’ is not the best place for you. I wonder whether coming here increases or reduces your wish to kill yourself! The therapeutic relationship, in its disentangling here and there, is the frame that allows giving a meaning to the patient’s words and experiences

The therapeutic relationship, in its disentangling here and there, is the frame that allows giving a meaning to the patient’s words and experiences. Besides referring to rules and agreements to be followed, it is possible to connect the patient’s difficulty of being punctual and to comply with the commitment of what is happening in the therapeutic relationship, and to help her explore how much the ‘here’ of the therapy is something that, at the moment, is increasing (or reducing) her distress. Interruptions or delays are often significant in BLP, either regarding an accumulation of dissatisfaction in the therapy or a higher level of independence. (…) Patient: Hmmm, hmmm. (Pause) Actually, I also have a feeling that nobody can help me. Even if I ask for help, I feel that the help I need and the weight I am are too much for anybody to deal with; therefore, it’s better if I cope with it myself. And if I can’t cope with it myself, well, then that’s the way it is [the

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patient responds to the confrontation, almost an interpretation, through the viewpoint of an extreme internal representation of herself, of someone needy and asking in an impossible way. Such representation of herself feeds the patient’s egosyntonic self-destruction, as it bears a sense of helplessness]. Therapist: Fine, would you like to understand what happens while you are actually creating the situation you say you are afraid of? Salonia: it seems that, when you say you’re desperate – and you say it by professing the death-wish – you don’t feel understood in your desperation, but confused because it arouses anger. As for the people being close to you, maybe their fear for what you could do is so strong that they are not able to see your desperation. Do you think this happens also ‘here’? A further basic principle of the GTBL model is the relational interpretation of the patient’s symptoms-behaviours. Giving a name (confusion) to what happens to the patient in the meeting with the other allows for the relational weave of mutual experiences to be retraced, in which behaviour – even extreme modes – gain importance. Only after having validated the patient’s experience (not being understood in her desperation), can she be put together with the person in front of her, the therapist (the fear and anger of significant people being in front of so much desperation). Additionally, a characteristic of the GTBL model is the therapeutic work ‘at’ and ‘on’ the contact border of the experiential patient/therapist field. How does the therapist’s presence contribute in creating a certain intentionality? And how can she support the evolutionary step, the next included in this? Patient: Is this what happened? Therapist: Yes. Hence why you are behaving in such a way that not only poses a risk to your own life and has nearly killed you, but you are also starting to be a burden on others. You mentioned there were two people last week, for whom you were a burden. Peter has assumed this burden, but if you keep on like this, you may destroy your relationship with him, and you

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Giving a name (confusion) to what happens to the patient in the meeting with the other allows for the relational weave of mutual experiences to be retraced, in which behaviour – even extreme modes – gain importance

don’t know for how long he might want to stay with you. What’s more, you are lying to him by hiding things; any human being could be fed up with it eventually, and I believe you are leading him to this in a certain way. It’s kind of a paradox, what you wish is to have someone to help you, someone that can make you feel like he’s interested in you, and you won’t be alone and unprotected anymore; and then you do all you can to be in the position of being alone and not protected [the therapist extends her intervention, confronts the patient with the destructive consequences of her suicidal behaviour towards her husband and the internal division of the patient: she desperately wants to be helped and causes a fed up feeling in those who try. This also refers to countertransference of the therapist, which is here used in a subliminal way as one of the aspects of the intervention]. Patient: I am actually quite used to feeling like this [the patient admits such division, but provocatively states that this is the way things are]. Therapist: I believe that the fact you are used to feeling like this doesn’t lead you anywhere. The fact is that it’s useless, besides being very efficient in killing yourself. While dying, you might say: «Well, and what, if I die?»; I know you would give me such an answer, but this is actually something to take into consideration. And then, if you die: what happens is that I don’t agree with you, but it’s true you have this power. However, if you are here and I am here, it’s because we are on the side of those who try to find solutions to their lives, given that I’m not in the position to discuss any solution after you’ve died. But I believe this is the dimension of the enemy we are facing, the fact that you would say: «And then, what if I die?» [the therapist confronts the patient about her passiveness and the contact with her self-destructive side. He offers to help her, but highlights the reality that nobody would be able to stop the patient if she really decided to commit suicide, a real danger for the treatment. The therapist implicitly refuses to take on her responsibilities for the patient’s survival]. Salonia: you’re searching for a place where this does not happen. Because when you feel like this, you only think about dying and nothing else is of interest.

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This is the support to the next, to the evolutionary intentionality held in the patient’s apparently ‘unchangeable’ words and experiences. The woman’s statements in regards to the way she feels do not only represent a provocation or request of endless availability: first of all, they show a bodily-relational experience (a wish to meet the other, to be accepted and understood), where original intentionality was crystallised and blocked, and where she could be misunderstood again and hurt in the terror. Patient: But if this is how I sometimes feel, should I deny that I feel like this? Therapist: No, I understand you may feel like this. All I need from you and all you need from yourself now is to not act like this. So, I believe we may have clarified the confusion regarding why you want to be ‘triumphant’ in death. You are smiling while I’m saying this, but that’s the point. That you’d prove nobody can help you and that there’s never been someone you could have spoken to. Neither Peter, nor myself now, nor the hundreds of people you were in contact with before you met me. Punishment is much more important than life. And this would be a great triumph, you would be dead, but you would prove that nobody has ever been there for you. You would be the most powerful person in the world. Your childish part is acting here. A triumphal defeat, obtaining such defeat is worth your whole energy, all of your particles. A successful suicide [the therapist highlights the therapeutic agreement again: the patient is free to have suicidal ideas, as long as she doesn’t put them into practice. And she quickly goes on to confront the patient with her triumphant smile when she believes to have the power of triumphing over the therapist by killing herself. The quick interpretation of transference in the hereand-now bound to the challenge with the therapeutic agreement reflects the clinical experience of the therapist]. Salonia: good! That’s the point. How to behave when you feel something? You see? It can sometimes happen that we are overwhelmed by feelings or have destructive feelings… the important thing is not acting accordingly – or better, not hurting oneself and others – but asking for help, asking someone to explain what is happening.

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It is about connecting ‘feeling’ and ‘acting’, but first of all confirming and helping the person to define what she’s feeling, in order to put together her experience with the other’s then

I understand: you sometimes ask by threatening suicide, rather than asking in a clear way, and this causes answers of rage or fear in others. Who knows, maybe if you would tell of your own desperation, it would be easier for others to confront you without fear or annoyance. However, one thing is ‘feeling’, another is ‘acting’. It is about connecting ‘feeling’ and ‘acting’, but first of all confirming and helping the person to define what she’s feeling, in order to put together her experience with the other’s then. Patient: I understand I have to change my way of thinking. Therapist: I don’t know if you understand it. Patient: No, there’s a part of me that understands it. There really is. But there also is… […]. Therapist: (interrupts) I don’t know if you are currently just trying to be clever. You are smiling about this. Patient: Hmmm, hmmm. Therapist: I am really worried this may not work. And there will be small homicides of sessions because your time is very limited. You complained that two hours per week are not enough, but you don’t have two hours per week. You have 30 minutes per week, 45 minutes per week [the therapist widens the interpretation (…)]. Patient: You are absolutely right. Salonia: i understand it’s hard for you. Sometimes, when you say you understand, i have the feeling you might please me because you’re afraid of telling me you don’t agree. As if you are trying to be polite. Try to also speak to me about the things you are not convinced about… Therapist: Well, yes, we should have our two full sessions per week, not a minute less. Patient: So I’m ruining the whole thing. Therapist: Well, I believe we are fighting over it, since I am actually insisting that this is the problem, and the fact that you are here now is proof of the other part, and I count on this other part. […] But to tell you the truth, you give the impression that we cannot count on this, and I believe it might be true. We

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cannot count on the fact that you lean towards life, trying to make something exciting of your life, and you have the ability to create a very interesting life for yourself, but right now death is more exciting to you than life. And if this is true, there comes a point at which you have to object. It seems like I am preaching, trying to talk to a nonbeliever, but you are explaining that the best thing is death [the therapist frankly explores, together with the patient, the possibility that the therapist could be manipulated in the position of a powerless ‘preacher’ of survival and of the one featuring the healthy part of the patient’s internal conflicts]. Patient: I’m describing it like this because this is how I feel […]. Therapist: The attraction of death. Patient: I don’t like it, I don’t always like being like this. Yes, there are moments I like being like this, and I feel as if this was the way, it is and will always be like this. But there are other times where I really feel that I tried so hard, and nothing seems to change. It would be better for a while… […]. Therapist: (interrupts) You know what I think about this… you tried so hard, but from the results, I believe you tried in a way that has not been efficient. Rather than coming to grips with the conflict inside you, you manipulated people, you lied to people, you tried to solve your problems trying to kill yourself… In other words, this was your attempt. I am sorry to say it because I understand you might have exerted yourself a lot here, but I’m not too sure what you were trying to achieve or what you have actually achieved […]. Salonia: i see your anger and your mistrust. Negative feelings, the wish to die, don’t go away despite all your effort and strain. I know. It’s a long way. And the fact that you tell me your anger and mistrust is justifiable…these doctors… they talk and talk… but then i’m stuck with my desperation. I understand. Try to keep trusting in spite of everything. It’s a battle between life and death…in all senses… The part of you wishing death is tired of hoping. I’d say… this commits us to do better. I believe you are developing regarding the trust in our relationship and maybe, in view of the fight your are already constant-

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Giving the patient the opportunity to tell of her own mistrust and anger to and towards the therapist, even for the smallest aspects leading the patient to the terror of being confused and hurt, allows her to make the first step in being able to take on the viewpoint of the other, rather than hindering it

ly experiencing, you may manage to be faithful in attending therapy… (Now or later) tell me… what could-should i improve according to you? These last two interventions legitimise the patient’s diffidence and ‘resistance’, while not underestimating the need that the patient maintains a commitment to therapy: giving the patient the opportunity to tell of her own mistrust and anger to and towards the therapist, even for the smallest aspects leading the patient to the terror of being confused and hurt, allows her to make the first step in being able to take on the viewpoint of the other, rather than hindering it. (…) Therapist: Yes, well, this explains why you do it. The reason you have, which is fantasy, with fantasy I don’t mean not true, but it’s a perception you have of falling apart. But if it was like this, why would I ask you to do something that would make you feel worse and would make you fall apart? [the therapist interprets this statement as expression of a paranoid reaction towards the therapist, that she could hurt her]. This would mean you have a therapist that is here to destroy you and make you fall apart, because I would ask you to delve into things you would feel and experience right away, conflicts with specific people in specific moments of your life, and all this becomes beyond reach, since you are quite convinced that the best way to deal with me is saying as little as possible, or not being here at all, reducing our sessions, or if you talk, saying very little, even if it seems you are telling a lot, but you use general statements. And the aim, as you clarified, is for me to ask you to do something that will hurt you, destroy you. (…) I can understand it. (…) But is it true? Why don’t we analyse if you are justified in thinking that you have a mean therapist, who is here to make you feel worse and fall apart and makes you lose control, as if this was my intention? [(…) the therapist is trying to interpret the patient’s protective identification, why she is projecting her internal self-destructive enemy over the therapist]. Patient: (interrupts) No, it’s not that... Therapist: (continues) And you have to protect yourself from me

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Salonia: if you don’t feel understood… the need of defending yourself triggers… The lack of clarity seen as something for which also all the current relations of the patient are – constitutively – full of, is an aspect to which the PBL is hypersensitive even in the therapeutic relation, and this throws her immediately again into a feeling of danger! Patient: (continues) I don’t necessarily think it is your intention. I believe you might not understand that this is the way I feel. That’s why I don’t tell you. Therapist: This is interesting, because I’m a doctor, I’m a psychotherapist and I should know what I do; however, in your opinion, you are deeply convinced that the effects of what I’m trying to do with you will make you feel worse, and will actually make you fall apart. Salonia: i may also make mistakes… with you. And i wouldn’t be the first one, i imagine… you know what difference we can create? That you tell me… «here, doctor, you didn’t get it…». What do you think? Before being able to decentralise the patient’s perception, a BLP emphasises the need to reveal the relational meaning these ‘wrong certainties’ refer to: this doesn’t mean that the therapist shall abdicate his role or forcedly admit an intentionality that doesn’t belong to him, but legitimise the patient’s perception with an element that, even if minimal, risks throwing her again, within the therapeutic relation, into fear of being duped and redefined. (…) Patient: I’ll tell you what it looks like. It’s like the repetition of my relationship to my mother, when I was very young. Because I couldn’t go to her, I couldn’t trust she would be there for me, from both a physical and emotional point of view, only me… there was no trust at all, and therefore I dealt with everything myself and I didn’t talk about anything […]. Therapist: So, what happens between us is a repetition of that?

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Patient: I believe it has a lot to do with it, yes. And the relationship to my father was such that all I did was try to finish things and try to show him that I was able to do things […]. Therapist: Then, let me tell you, if it’s like this, up to you evaluating if it is, the repetition of aspects of the relationship to your mother and father means you are confusing me with them? [the therapist keeps the focus on the here-and-now]. Patient: Well, it has to do with my level of confidence in people. Therapist: Well, you know, I may understand what you are saying; since you had this type of relationship with your mother and your father, you tend to see everybody as if they were your mother and father, and therefore there’s no chance me and you will have a relationship that is different, that is not a repetition, this is impossible… [and she confronts the patient with her theory that all relationships have to follow the model of relationship to her parents. The therapist again refuses to be dragged into the patient’s exploration of the past and is probably suspicious regarding an intellectualised ‘psychoanalysis’]. Salonia: is there any word or attitude of mine that recalls such relationship you could not trust? (…) Therapist: However… you are dealing with me, you know, with such a clear idea, coming from both your mother and father, that, hmmm, you are, I believe, saying that relationships to other people have to be formed like they used to be with your father and mother, who were your only father and only mother; and therefore, if it was like this with them, you decided that it will have to be, or you expect it to be, or you’ll make sure it will become as it used to be with your mother and father. Is this what you are saying? Patient: It seems this is what I’m doing, but I don’t want to, but it’s what I did, yes. Therapist: Is this what you did? Patient: Yes. Therapist: Yes, because, it’s, hmmm… you know, it’s, I’m trying to say that it is like I was your father and your mother here, and not another person. You know, I’m doomed to be like your father and mother.

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Patient: I know, but there’s still a lack of confidence, inside me, towards other people. Salonia: i believe that, if you tell me exactly when and why you don’t trust (but in the precise moment it happens, that is which sentence, which attitude annoys you) we can change the type of relationship… From a GT viewpoint, the relationship with the therapist is not a reboot of the relationship to the parental figure. The patient doesn’t confuse the therapist with the past, but seizes the here and now, which throws her again into confusion. Supporting the next, the following step, means opening the actual relationship to a different possibility to be co-built at the contact border. The patient can tell the therapist, concretely, which elements (even the slightest) confuse and hurt her, and the therapist, just as effectively, is there to take them into consideration. This allows the patient to walk away from the presumption of the therapist’s ‘infallibility’, to which she holds on to in order to tolerate the fear of being duped and abandoned again, and to open herself up to a relationship in which the difference of perception and experiences finally is not necessarily a scam, distress and source of pain. (…) Therapist: You have control over your life and your death. Patient: But I feel like I have more control over my death. Salonia: it seems to be a last resort when you don’t manage to make yourself understood. At least one thing will be clear: i want to die and i die… to escape confusion and desperation. For BLP, the acting out is a way to escape distress of confusion. Therapist: Well, I think you have this kind of transition and it scares you, once again because it’s the part that you add with your thought, the triumphing one, you know, you are a child with such a power; hence, you are a child in the sense that you are reasoning like this, which is reasoning by analogy, generalising from one thing to another, which is like the reasoning of a young child. And even the way you deal with this, how you

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Supporting the next, the following step, means opening the actual relationship to a different possibility to be co-built at the contact border

adapt, is childish because what does a child do when he has no control over his life, like you did? What can he do, except say “I can control my own destructiveness”? I can do this, no need for others to do it. This is a way of facing things in a way a child would understand […] Patient: But I’m not a child. Therapist: But the child’s still in there, and this is the explanation as to why you sometimes feel like a girl. You have definitely kept these two things, these two solutions since you were a child. They are very clear. Patient: Yes. Therapist: This is the best you can do. Salonia: the child in us comes out again sometimes. In order to grow up, a child needs to be understood and accepted. Everytime you don’t feel understood and accepted, the girl explodes… and tries to get out by way of desperation, even if it involves hurting herself… Maybe the girl was able to talk more today. … We are approaching the end… what can you take with you from today? (Said with complicit tone) besides… obviously the decision to be punctual and to not commit suicide… How can you help the BLP to ‘find the words to tell herself’

How can you help the BLP to ‘find the words to tell herself’32? The beginnings of the therapeutic relationship with people which lead this experiential method are often «difficult, contradictory and requests are ambivalent»33. At our first meeting, L. mentions this is her second therapeutic attempt. She feels she was helped in reducing some of her impulsive and self-mutilating behaviour during the previous therapeutic path, but she keeps on feeling bad and doesn’t know why. At the same time, she highlights: «I tried seeing a male therapist because I don’t have any respect for women, in general. I think they are sneaky. Actually, I think nobody can do anything for me, I’m like this, and I’ve always been like this.

32 Cf. V. Conte (2011), The borderline patient, cit. 33 Ibid., 74.

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I’m even a bit tired of trying to change». «I want your help and refuse it at the same time» is often the ‘surface’ message that the therapist is confronted with. The expression of a scarred relational background, as we say, by two great fears: the fear of being abandoned and the fear of being swallowed up. Mistrust, worry and strain that these patients take from the therapist are signs of the fear being drawn into the fusion. And yet, a new intentionality emerges already in L.’s few words: getting closer to the female, choosing what frightens most, because she somewhere feels this to be, even if unconsciously, an important chance. Even if she is scared. The entire therapeutic relationship will be highlighted by such strong bivalence, even if it is in different forms and intensities along the way. The other aspect is the chaos the person bears immediately, both in varied symptomatology and life events. During the session, this is materialised in the verbal and emotional waves the patient seems to submerge the therapist with, and that she fills space and time with. The fact that these patients have always felt bad does not only emerge from their story, them not remembering a specific and precise beginning of their discomfort, but also from a deep sense of unworthiness and defectiveness that their experience and definition of themselves seems to centre on, beyond recognition of their skills in certain fields, or very critical attitudes towards others. It is staggering how tenaciously they can hold on to this definition, as if it provides integrity, even if at a very high price, alleviating them even in moments of anxiety. Like having a painful, but still clear and univocal landing point.

4.1. The climate A basic coordinate of therapeutic care with this experiential style is the idea of developing a relational climate seen as an ability to co-build a relationship, in which the patient can learn to ‘speak’ again34.

34 Cf. G. Salonia, supra.

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I want your help and refuse it at the same time» is often the ‘surface’ message that the therapist is confronted with

A basic coordinate of therapeutic care with this experiential style is the idea of developing a relational climate seen as an ability to cobuild a relationship, in which the patient can learn to ‘speak’ again

The path of the GTBL Gestalt model is characterised by concreteness, by putting the ‘right’ words to the experience in a long journey, which is never taken for granted with this relational style

The BLP requires no experience or bursts of awareness regarding his own story, but he does firstly need an atmosphere where he can express himself by feeling that the other, the therapist, is showing interest towards him and what he says in a polite, clear way that is not too passionate. It is a substratum of presence and continuity, woven through a relentless attention to the present. These patients, as Salonia says, are the ‘real advocates’35. This means staying with current experiences, with records that are sometimes draining, with everyday episodes to start weaving a common thread made of attitude by clarifying things bit by bit. Through the space-time dimension («What happened? When? Where?») as well as the exploration of the sense things had for the patient (« Together let’s look at the effect this thing, this other thing, had on us and the different degrees of intensity»). The path of the GTBL Gestalt model is characterised by concreteness, by putting the ‘right’ words to the experience in a long journey, which is never taken for granted with this relational style. M., a guy with strong features of impulsiveness, as well as destructive and self-harming behaviour towards drug abuse, refers to such concreteness with strength. When he recounts two episodes including his mother and a girl (recurring in the few weeks since the beginning of our relationship), I see a high common denominator of confusion and experience of abandonment. I try too early to provide an explanation too: «And so what? Even if I know why I behave like this, it doesn’t change anything!!! I felt bad when I left her outside her house… and I didn’t know when I’d see her again… I wanted to break everything… or go over to the other guy and smash his face up… I felt bad, and didn’t know what to do when I got out of there, I didn’t know what to do…». «Tell me precisely, I believe you urgently need to find your way with what to do with this girl, and I have gone too far». M. calms down a bit, he starts giving me details of what happened; I don’t ask questions, and only ask clarification about

35 «words and behaviours of BLP are real language to communicate their own experiences, corporeal and relational meanings (feelings, emotions, perceptions) which the subject lives in the being-in-the-present-of-the-relationship», in G. Salonia, supra, 40

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small things, I leave him putting sequences, dialogues into order. Only after do I ask him what annoyed him the most. I am stunned by a very specific aspect that emerges at this point, a detail that to him is more important than the general ambiguity of the situation: «I don’t care if we only have a half thing, if she also sees the other guy… I lost my temper over the fact that if we have a date, you can’t not be home. It just makes me drive like an idiot on my scooter to all the places I could find you, for you to tell me: I changed plans, I had something to do… at least tell me». Together, we hypothesise to clearly tell her that she should inform him if a date falls through, and M. says to me: «I can do it, this I can do. But well, you are all weird, you have a thousand things to do, and the minute after you change direction». «I’ve also been quick with you. I did what I said today». (Laughs) «Well, this time you managed to get by». I feel that it’s true, I didn’t grasp his need, but anticipated him, as he is too used to hearing. M. does not feel the need now, and has no chance, to look at his story and primary relations, in which he thrashes around with pain and rage. It has to become clear to him, bit by bit, what happens to him through a relation where emotional waves find space and containment, so that experiences start to be distinguished, almost unwind, in the sense that they have a pause, a breath between one and the other, rather than being blocked in a distressing vortex. The repetition of these stories that are chaotic, always different and yet similar, are a way of preparing the ground to identifiability and definability of feeling, a way to test the ground, in the relationship to the other-therapist. Approaching gradually, to see if the other can handle it, to see if he gets tired and distances himself in the end by providing even brisk explanations and interpretations.

4.2. Clarity: finding the words to tell yourself Currently, even the psychoanalytic model has a series of reservations about the use of interpretation with this relational style. Gabbard, for example, highlights how a purely interpretative

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In the GTBL model viewpoint, the crucial knot is to read the relational value the definition of experience takes on with these patients

An emphatic answer is risky, as it can be experienced like a definition

approach risks that some patients experience the therapeutic situation like a repetition of childhood trauma36. The fact that the therapist makes the client’s emotional status explicit, can be felt as an expropriation, almost as theft of thought. If the person does not even manage his own internal, changing and chaotic world, how can he tolerate somebody else mentioning it, explaining it, and depriving him from the little he feels to be his own37? In the GTBL model viewpoint, the crucial knot is to read the relational value the definition of experience takes on with these patients. The BLP feels immediately ‘trapped’, as if he was forced to feel an experience while he’s feeling more than one at the same time. «You feel neglected» is a language that risks being hyper-defined. At the same time, saying: «I appreciate your attention», already includes a deceit. In the ‘other’ logic of these patients, such a statement means: «You are either always careful, or I won’t appreciate you anymore». An emphatic answer is risky, as it can be experienced like a definition. An emphatic clarification is more useful, or better the clarification of the present action: «When you feel like this… then you act this way» etc. The suspiciousness these patients get in contact with in the relationship, takes on a sense that places itself in the original experience of mess and confusion, rather than being an intrapsychic feature or a structural aggressive trait. Entrapping the person in an experience that doesn’t belong to him, or doing it too quickly, means duping him and throwing him again into the older relational dilemma. Distrust toward the therapist therefore always includes, as in all relationships of their lives, a hook-up, a reason in the presence of the therapeutic relationship itself.

36 G.O. Gabbard, The therapeutic action in psychoanalytic psychotherapy of borderline personality disorders, in G. Leo, report of the relation presented by Glen O. Gabbard at the Study day Il cambiamento nel paziente borderline, organized by Psychoanalysis Centre Romano, Rome, 21 February 2004. web. tiscali.it/bibliopsi/gabbard.htm. 37 Cf. R. Meares (1993), The metaphor of play. Disruption and restoration in the borderline experience, Jason Aronson, Northvale, N.J.

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As soon as she sits down, L. immediately makes a list of a series of negative features that characterise her, providing me with a picture of her as a changing, impulsive, fussy and jerky person. Also her interests, her university achievements emerge, but she only quickly talks about these, giving them little or no importance. «I always feel like this, I’m up to no good». «And yet, you are telling me that you reach the goals you set yourself, that you feel like ‘marching like a train’ when it is about exams, etc.». I see she looks at me askance, with half-closed eyes, tightened lips, in silence. I have the feeling she would like to say something, but she doesn’t know if she can ‘risk’ it, if I will understand. What is happening between us? The steadfast attempt to convince myself of her inappropriateness meets my attempt to save the good things she talked about. The more the ‘negative’ list gets longer, the more my heartbeat speeds up, I feel like everything I say, even if I follow her words, is modified, rephrased by L… She needs a definition of herself, she can’t accept any other. And I? Am I able to just take it? I remain silent. I recover the rhythm of my breath; I straighten myself up on the chair. I look at her and only nod, as if to say: «Ok, I’ll stop, say what you want, I’ll just take it, I can do it». «I don’t know how to say it, maybe I’m not able to make myself understood… it’s that I feel like crap! At the very end, beyond the achievements… I feel like I’m not working… I’m not working as a person… every time I flare up, and it happens often, I am there and think I’m right; then I think I made a mess, that the other person was right, and that if the person leaves, he does the right thing… You don’t understand me, right? I’m absurd». «Let’s see if I understand. It’s like constantly fighting between ‘you feeling absurd’ or considering the ‘other absurd’. And in any case it’s great pain. At the end, you feel like you have a basic deficiency. Is it this? Tell me if I have understood or if I’m off track». She barely lets me finish my sentence, raises her chest with a wince: «That’s it, that’s it, that’s the point. Do you think I’m crazy?» «No, I don’t think you’re crazy. I think you want me to take this into consideration, that this is important».

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What is happening between us?

The attempt to decentralise the patient’s perception, to make him understand a different point of view – defined as the ability of metalising – can only be there after having identified what happened to him in the relationship

Work can start now. It is essential for L. to feel like someone believes her as for her experience, but also making sure I see her ‘negative’ part. In her logic, if I’m polite, it’s like telling her: «I’ve only seen one part of you… as soon as I see your annoying sides, I’ll leave you». The attempt to decentralise the patient’s perception, to make him understand a different point of view – defined as the ability of metalising – can only be there after having identified what happened to him in the relationship. If he gets angry, he surely caught an element, even if only partially, of reality. Denying it makes him crazy. M. arrives clearly flared up at the session. The appointment is in a different studio, not where we usually meet. After several months of therapy, I felt the need to request a relocation, so I told him with plenty of time and explained my needs so that it was sufficiently protective for him. As soon as he arrived, he said: «Everything ok? You look tired…». I detect hostility: in the tone of his voice, in the fact that he doesn’t look at me and almost puts me aside to almost distance himself from me. He starts complaining about the traffic he faced to get here (even if the two places are very close to each other), about how unpleasant this place is. He harasses me with a loud voice, a stream of words: if I try to interrupt, his voice gets even louder. «Are you angry?» «Look, don’t tell me to come here again… I told you I don’t want to change. This place is ugly, cold… it really looks like a medical practice, with more rooms…». I remember I suggested some alternatives, different days, to be able to meet in the usual studio, but he refused them. His anger increases. His breath is blocked in the high part of his chest, his chest shakes slightly. It is as if we are beginning to have an arm wrestle. «You are the one that had other commitments. My preference was to skip this meeting, I told you, but you insisted. You harped on about the fact that I should come here, right? You managed it in the end, tell me the truth, you stamped your feet so that I would not skip this meeting and in the end you got me to come here». I recall something M. told me a couple of sessions ago: «I never manage to do what I like to do. When we have to organise

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something, it only ever matters what the other one wants to do. Do you want to go to the sea? On that day? Then it’s fine for me as well… even if I don’t feel like… but at that moment, I don’t even realise that I don’t feel like it… However, nobody asks me». So I reply: «It’s true, maybe I insisted too much, I stamped my feet. In order to avoid skipping the meeting, I decided to make you come here. A bit like when you told me nobody really asks if you feel like doing something. I can see it’s made you really mad». M. remains silent for a moment. Then he finally breathes. Then he smiles. «So you are human, too. Yes, I got really mad». There’s no space for excuses or my vision of things, nor the attempt to express my good intention to avoid skipping our meetings, having offered him several alternatives. The only thing that counts for now is the ‘piece’ of reality caught by M. I know I wanted to ‘maintain’ my role and my right to evaluate what would be good for him. And it annoyed me when he suggested skipping the appointment. I didn’t let him go, I didn’t trust the fact that he was finally choosing and not manipulating my availability. After all, I was the one that did not keep the faith with a commitment. And this is still a fact. For people with this kind of relational style, it is an effort to say: «I am mad at you», the result of a slow path. Being able to say: «This is my anger» is an arrival point. The risk of telling the other, despite the terror of losing affectivity, can only happen if they feel that the other is able to see their reasons, accepting them without getting scared, degraded or tense in their perception. Therefore, it is important to distinguish these two steps: «You are mad at me. Do you only want to tell me that you are mad or do you also want to know why I said or did this?». Apologising, indeed, means to ask the patient to give up his own feeling too early, as it is just in draft stage, and to have a different feeling compared to what he’s feeling. All in all, it means not catching the relational intentionality: «I need you to help me support my experience. If you excuse yourself, you ask me once again to connect with your experience». Only after is it possible to combine one’s own anger with the

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For people with this kind of relational style, it is an effort to say: «I am mad at you», the result of a slow path. Being able to say: «This is my anger» is an arrival point

Only after is it possible to combine one’s own anger with the reasons of the other and to stop at the bordering line where differentiation (there are two different point of views) divides, but doesn’t break the bond

Even the warmth that develops during the therapy should be measured with care

reasons of the other and to stop at the bordering line where differentiation (there are two different point of views) divides, but doesn’t break the bond, including the relief of feeling oneself, rather than the terror of feeling emptiness.

4.3. Cordiality Even the warmth that develops during the therapy should be measured with care: «The therapist needs to avoid any invitation of close proximity or any expression of warmth»38. In order to allow the patient to become aware of it, but also to avoid getting scared and to learn to control it, we often need to clearly explain our experiences towards him. After one year of work, A. notices my new clothes and haircut at the beginning of the session: «I like you. Your jacket, your skirt… I really like you». I just have time to show the first sign of a smile, and A. starts to quickly talk about how his week went. I feel that I was excited (it’s the first time warmth has emerged between us), but at the same time, I see A. being more and more overwrought. He keeps on talking about facts and giving himself a lot of philosophical and intellectual explanations, in which he seems to ‘get twisted up’ with difficulty. I catch his irritation, while I feel a huge distance: on one side, I preserve the warmth arisen between us, whilst on the other side, he raises a wall of thoughts. Therapist: What’s happening? Patient: I don’t know, I am screwed up with all these thoughts, it irritates me. Therapist: Maybe we should talk about what you just told me. Patient: I feel bad, I don’t want to be misunderstood, I don’t know what you were thinking, but I didn’t mean anything… I am confused. You are a woman, I’m a man. Therapist: Try to look at me. Can I tell you what I was thinking? Patient: Yes. Therapist: I’m a female therapist, I see you are a handsome young man, your intelligence; what you say, amazes me. I

38 Cf. G. Salonia, supra.

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appreciated your compliment. But I feel, above all, that our therapeutic relationship is changing. We are becoming closer. Maybe this is why you got worried. (A. leans his back against the chair, finally breathing. I ask him how he’s doing). Patient: You don’t know how much of a relief that is… when I look at you, you seem too calm, you don’t seem confused. I only wanted to tell you that I care about you, about our relationship. But I panicked. For one moment, I didn’t know what I was feeling. Once the boundaries are solid and clear, the patient will be able to combine clarity and affectivity, affinity and differentiation.

4.4. Specific interventions The above mentioned frame – climate, clarity, modulation of warmth – is supported by interventions aimed at defining the meaning of words: «What does it mean that you feel better? What can be the meaning of what your friend told your husband?». Building connections between behaviour and feelings is essential: from which element of the relational field does that experience come from? To whom does it belong? How can one put together contradictory (black and white) experiences to the same person or situation? You need to help the patient to understand the difference between the various experiences and the different intensities. Distress, anxiety, terror, fear, sadness and pain are different experiences and need different words to be defined and appeased. From concreteness to putting everything into words: this is the direction to take when teaching a person with such relational style not to replace his own experiences with a single experience, generally anger, and to replace one name with another, such as, for example, sadness instead of warmth or excitement39. The work on disturbed Id-function implicates a gradual intervention, including the consideration of the particular frailty these patients are affected with. Since they’ve undergone an

39 Cf. V. Conte (2011), The borderline patient, cit.

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You don’t know how much of a relief that is… when I look at you, you seem too calm, you don’t seem confused. I only wanted to tell you that I care about you, about our relationship. But I panicked. For one moment, I didn’t know what I was feeling

Building connections between behaviour and feelings is essential: from which element of the relational field does that experience come from? To whom does it belong?

You need to help the patient to understand the difference between the various experiences and the different intensities

invasion, it is important to initially maintain a present but passive attitude, rather than active one. Use of the ‘formal’ version of speech, rather than the ‘informal’ one40. Avoid touching them, since warmth confuses them. The deep corporeal desensitisation through which they have adapted and protected themselves against intrusiveness, pain and humiliation doesn’t allow them to have a clear sense of location in the world, of their own presence and their own boundaries in relation to the environment. The regulation of boundary layer (breathing and muscle/skin layer) and of boundary space (perception and sensitivity to interpersonal distance) is compromised and polarised in excessive permeability and/or rigidity. Even the perceptive functions – such as seeing – are desensitised and distorted in order to control intolerable experiences that emerge at the contact border with the other. Over a period of time in our therapeutic relations, I find that each time our work starts to explore his relationship with his mother and touches F.’s difficulty to regulate his distance with her, F. experiences a sense of dizziness and blurred vision. In our relationship, this means that we can approach each other, and he can confide in me more. Twisting perceptions is his way of regulating distance and his way of asking me if he will have as little control of the therapeutic environment as he used to have with the original environment. I have to understand and respect him, in order to have this corporeal experience together, which supports him and at the same time allows him to take risks. Many sessions start with us sitting on the floor. F. leans his back properly against the wall and rests his soles on the floor. Before telling me stories about his mother, he learns to regulate the distance between us, and also to regulate when and how to speak about specific events. Motor functions can appear distorted after such relational-corporeal experiences. Even though he technically excels in a sport, he feels and appears extremely stiff when moving. The upper part of his

40 Cf. G. Salonia, supra.

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body (head and chest) appears almost detached from his legs, forced to take on a round-shouldered position towards the exterior, and slightly bent to the back. This causes him continuous backache, which has forced him to stop training. When we meet, I imagine that his chest tries to come towards me, while the rest of his body ‘wants’ to walk away. When looking at his slender structure, I feel like I see a stiff power that could snap with one touch. As time goes by, whilst we gradually and carefully explore his corporeal feelings, A. starts to connect a series of experiences to these: «I stopped competing because time ago I felt that I could use my whole body… and I was scared… I felt so strong that I could hurt someone… I felt like I wouldn’t stop. I would have become a thug just to stop the rival from getting close to me. I remember, as a child, when my mother used to belittle me like this, without a reason, I was scared… I didn’t understand… then my whole body trembled… maybe I wanted to pounce on her… but I never said anything… every time I wanted to do this, I went into another room». Not knowing how to modulate the contact at the interpersonal border (leave the other the control or become destructive to avoid feeling invaded), the best solution now is to come into contact by ‘halving’ his body and withdrawing from experiences, in which there is a need to modulate ability and negotiate borders. The work on discrimination and definition of corporeal feelings allows us to restore border functions of the Id, and therefore to distinguish which experience belongs ‘to me’ and which one ‘to the other’, giving them proper names. Moreover, such work allows the patient to hold and assimilate his own feelings, experimenting with them like a wave with initial growth, intensity peak, decrease and an end. In fact, in the borderline experience, feeling and emotions are often overlying (in intensity and continuousness), since they are perceived as a state rather than a movement. This last observation leads to the importance of «not encouraging the expression of an experience without previously understanding its name and belonging»41. The risk is to expose

41 V. Conte (2011), The borderline patient, cit., 158.

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The work on discrimination and definition of corporeal feelings allows us to restore border functions of the Id, and therefore to distinguish which experience belongs ‘to me’ and which one ‘to the other’, giving them proper names

For the patient, working with borderline anger means that he finds out who and when someone has confused him

the person to an emotional amplification, rather than helping to modulate it. The BLP has to be ‘placated’, since his difficulty is not ‘feeling’ but ‘not knowing what he feels’. The corporeal resensitisation is an experience of repossession and growth, but also of openness towards new, often painful and restrained experiences, and the patient has to be in the position to savour them slowly. Especially the experience of anger which needs restraining and segregating, in order to be able to distinguish it from other feelings that are actually implied – for example pain – as well as to reconnect it to its relational meaning. For the patient, working with borderline anger means that he finds out who and when someone has confused him. Attacks, bivalent requests, the crossing of professional borders and interruptions all mark the entire therapeutic path with these patients. Without underrating the peculiarity of each situation, they always have to be put in the particular experiential background they come from. It means taking into consideration that the patient will try to regulate distances during the whole therapy process. Distancing himself is a way to restore it when warmth scares him. Being late to sessions can reveal his fight for independence. Attacking the relationship reveals a fear for accepting warmth, and at the same time an attempt to confide and trust. In such cases, one needs to avoid the rigid point of order and responsibility. This doesn’t mean that no clear frame should be set, above all when the gravity level implies a risk for the patient’s and the others’ safety. Rather, it means using the relational intentionality as a hermeneutical key, to regain an obscured direction and express a symptom. Another example is the patient’s attempts to make a phone call, although there is no moment of real discomfort, to test our solidity: «Are you allowing me to control your life, or are you able to hold onto me?». In such cases, not responding is therapeutic. When he accuses us of ‘not caring’, it’s different: he’s trying to show the negative part of himself. If we don’t respond to his provocation, it means to him that we are not able to see his ‘mean’ part, and so he will show it with ‘aggravating’ acting. He actually suffers when he attacks us… In his «You don’t care

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at all» there’s always a question: «Why should you love me?». The higher the gravity, or the psychotic quality of experience, the higher the therapists’ attention to the formulation of interventions aimed at restoring basic existential ground. The experience of the Self, not differentiated by what is ‘not Self’, is permeated by what happens in the environment and the relationship, and requires delicate work to build a non-threatening background, giving life again to contacts that are taken for granted; hence that can be assimilated (Id-function of the Self). The Ego-function can only re-emerge from corporeal, relational and emotional certainties, namely the ability to make choices thanks to an integrated and differentiated perception of the Self. Such self-assurance and stability also has to be built through a ‘wider’ therapeutic context. Hospital and community resources, differentiation of therapeutic roles (individual and group settings, pharmacological support), are all aspects of an intervention aimed precisely at giving back a solid and already curative background in and of itself. Furthermore, the constant dialogue between the different figures allows the single therapist to cope with experiences that inevitably emerge at the border contact with those patients. Not feeling tired, angry, powerless, invaded, is impossible. The ability to use one’s own feelings as a ‘border’ experience in order to guide the therapeutic intervention requires both avoiding being alone and thinking of being alone. This last aspect refers to the triadic dimension of the relationship. Just like the relationship of a child to his parent has to be seen on the basis of a co-parental relationship (experiences between father and mother)42, the therapist-patient relationship has to consider a third party, a co-therapist (whether he is really present or not), and the type of support and look he would have on our way of relating to the patient.

42 Cf. G. Salonia (2013), Oedipus after Freud, cit.

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In his «You don’t care at all» there’s always a question: «Why should you love me?». The higher the gravity, or the psychotic quality of experience, the higher the therapists’ attention to the formulation of interventions aimed at restoring basic existential ground

Not feeling tired, angry, powerless, invaded, is impossible. The ability to use one’s own feelings as a ‘border’ experience in order to guide the therapeutic intervention requires both avoiding being alone and thinking of being alone

4.5. BLP as a creative adaptation: integrating the clarity of one’s own feelings with the inflexible diversity of the other

The experiential style of borderline can be considered a way to avoid intrusiveness and hyper-definition on behalf of caregiving figures right in the evolutionary moment, in which recognition and definition of the other represent fundamental elements of subjectivity

For GT, the symptom represents a creative adaptation of the Organism in a difficult field, and the peculiarity that O. and E. meet with at the contact border. Such a statement does not seek to reject the severity of a psychological disorder, and the associated, individual and collective distress, but to take on a particular semantic perspective. Both human development and psychopathology emerge as relational co-creation that is supported and directed by intentionality. Enhancing such aspects means restoring their original significance, even with regards to pathological behaviour, as the best solution in a specific context. Such a primary adaptation becomes a ‘symptom’ when the intentionality expressed at the contact border with the environment (the anguish to avoid) is not seen and realised at all. Hence it becomes crystallised, repetitive, disengaged from time and the relational possibilities that are about to emerge. Creative adaptation in madness can be seen as «an attempt to solve a problem of the field that has never gone fine, and has never been interrupted»43. The experiential style of borderline can therefore be considered a way to avoid intrusiveness and hyper-definition on behalf of caregiving figures right in the evolutionary moment, in which recognition and definition of the other represent fundamental elements of subjectivity. The latter does not only imply the ‘awareness of being there’, but above all the awareness of a body that can be recognised by the body of the other, and separated from it. The person with this kind of relational style keeps on standing in an old dilemma: how can I distinguish myself from the other if I need the other to understand who I am?

43 M. Spagnuolo Lobb (2007), L’adattamento creativo nella follia: un modello terapeutico gestaltico per pazienti gravi, in M. Spagnuolo Lobb, N. Amendt-Lyon (eds.), Il permesso di creare, Franco Angeli, Milan, 336-356, 337.

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Confusion of experiences highlights the need to achieve subjectivity as the figure emerges at the contact border. Anger expresses an attempt to distinguish oneself, but you can’t feel separated in the relation if the anger does not allow you to find the names to ‘tell me what I feel’ first. As Salonia44 very well depicted, even we, as therapists, risk hyper-defining the patient: our obstinacy, our inability to admit mistakes, our fighting for a model, sometimes more than for a patient, are all ways to support a borderline experience, rather than relieve it. The fervent plea of a patient, who has reached a good stage in his journey, strikes me: «I understood one thing. I’ve been confused for a long time about what I was feeling, and I set up the relationship to this, to the fear of being abandoned. I have held the others with control and with severe pain. Now I do it much less, I manage to say what I feel, and I don’t get scared if it’s different from what the others feel. You know, I sense it when I see some hanky-panky… and I am able to protect myself… not always, but I’m more certain of what I feel. It’s an enormous relief. However, I have realised that not even this is enough, sometimes. I go to a friend and say to him: ‘I’m sorry I heard you saying this about me, a bad comment… for some time now, there has been a tense atmosphere between us. What is happening?’. And he replies that all is fine. I can tell you. The fact that I was sorry was of no importance. The point is not: ‘he has to think well of me’ or ‘I am right and want you to apologise’. Now I can also imagine his reasons, but I know there’s some nonsaid, I feel it clearly. Ultimately, the point is to meet somebody halfway. I felt irritation, of course, but I was actually sad about the fact that he wouldn’t ‘see’ things… Is it possible that some people don’t realise they can make others go crazy, when behaving like this?». I decide not to consider F.’s sadness, which gets to me, but to support the new and harmonious way I view his experience. «You can’t help it, F., you are a real specialist of inconsistencies in relationships!!»

44 Cf. G. Salonia, supra.

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I know I have witnessed an opportunity that borderline experience is not only a symptom and great suffering, but also the pride of a look which does not escape the truth

(Laughing) «It almost seems a good thing when said like this…» «It is, in a certain way. It is also sensitivity and special attention to the relationship. And this strikes me. You’ll probably always seize certain shades of meaning. The difference lies in how you can use them now: without having to give up your perception completely, without ‘damaging’ yourself». Through the therapeutic process, F. is accepting his wounds, his own story and the relational impossibilities his suffering arises from. Finally trusting himself is an attainment, even if this calls a relationship into question. The world is decipherable, as are all of his experiences. During our last meeting, we talk about the relief of having found a haven. His call for clarity moves me. I know I have witnessed an opportunity that borderline experience is not only a symptom and great suffering, but also the pride of a look which does not escape the truth.

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Valeria Conte

Borderline psychopathology, even if featuring characteristics that belong to neurotic and psychotic cases, it is situated in a different diagnostic and symptomatic picture

The term ‘borderline’ appeared for the first time in 1884 in a scientific text written by C. Hughes1, Borderline psychiatric records: prodromal symptoms of psychical impairment, where the writer says that people with this pathology spend their life in a situation next to madness. From the middle of XX century, the long and current process of systematization of mental disorders started; clinicians felt the necessity of organising the big range of symptoms for mental disorders observed in their patients in classes shared with everybody. The first classifications started to appear: in 1952, for example, the DSM-I2 was published. Analysts, also from most different positions, started to observe patients who featured personality disorders, but rarely showed hallucinations or deliriums, so they could not be considered psychotic, but at the same time, they were also lacking stability and predictability, which is typical of neurotic people, and they seemed to suffer in a more globally and less understandable way compared to neurotic patients. New hypotheses and diagnostic definitions were created, which defined an intermediate area on the border between neurosis and psychosis. Only recently − after a period of confusion and redefinition − such disorder received a good diagnostic and therapeutic observation, becoming more understandable from a theoretical point of view, and therefore more approachable from the clinical point of view: accordingly, borderline diagnosis ranks between neurosis and psychosis, but its area is independent. Borderline psychopathology, even if featuring characteristics that belong to neurotic and psychotic cases, it

1 C.H. Hughes (1884), Borderline psychiatric records: prodromal symptoms of psychical impairment, in «Alienist and neurologist», 5, 85-91. 2 American Psychiatric Association, DSM-I. Diagnostic and Statistical Manual of Mental Disorders, Mental Hospital Service 1785 Massachusetts Ave., N.W., Washington 1952.

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VALERIA CONTE

«IF I AM AFRAID TO DIE, COULD I DIE?» GESTALT THERAPY WITH A PATIENT WITH BORDERLINE LANGUAGE

is situated in a different diagnostic and symptomatic picture. Below, I will briefly refer some of the most important attempts of classification and systematisation of borderline disorder. In 1979 Spitzer, acting as supervisor of the DSM-III, analysed the two psychopathological conditions where the borderline term was used: the ‘borderline schizophrenia’ considered a light form of schizophrenia but with serious behaviour, affectivity, thinking and relationship disorders (Schizotypal borderline); and a second ‘borderline syndrome’ (unstable borderline) that manifests itself with personality, impulse and social relation disorders3. This classification was inserted in the DSMIII, where it was possible to distinguish between ‘schizotypal personality disorder’ and ‘borderline personality disorder’4. The DSM-IV and recently the DSM-5 indicate as characteristic of borderline personality disorder (BPD) – that Gestalt Therapy will refine and denote as “Patient with Borderline Language” (or PBL) – the trend to develop, in some particular emotional stressed moments, serious dissociative symptoms5. These symptoms included extreme suspicious, paranoid ideation and temporary distortions of perception, like illusions and short visual and auditory hallucinations. These symptoms distinguish such personality disorder from other disorders of the II axis. Even though some symptoms from a psychotic point of view can be present, including misperceptions or reference ideas, this is not enough to carry out a diagnosis in the psychotic area, since a real disorganization of thinking and its formal structures are missing.

3 Cf. R. Spitzer, J. Endicott, M. Gibbon (1979), Crossing the Border Into Borderline Personality and Borderline Schizophrenia. The Development of Criteria, in «Archives of General Psychiatric», 36, 17-24. From Spritzer’s work, a series of diagnostic principles emerged, which referred to two different meanings of the borderline term: he isolated two different types of diagnosis from these principles; he called the first one: ‘schizotypal borderline’, and he preferred ‘unstable borderline’ for the second one, that is to say, angry, impulsive and depressed patients described by Kernberg and Gunderson; cf. O.F. Kernberg (1987), Severe Personality Disorders, cit.; J.G. Gunderson (1984), Borderline personality disorders, cit. 4 Cf. American Psychiatric Association (1980), DSM-III, cit. 5 Cf. Id. (1994), DSM-IV, cit.; Id. (2013), DSM-5, cit.

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In some cases, the possible manifestation of delirium or hallucinations can recall the presence of current psychotic comorbidity. For this reason the studies of Rossi Monti, who described the function of the psychotic breaking in the patient with BPD depicting some characteristic of delirium6, are very important. Rossi Monti, who described the borderline delirium like a «safe harbour when there is rough sea»7 affirms that this kind of delirium heads for emergency, even dramatic, of collocating certain emotional states in organised thinking contents according to radical dichotomies that usually belong to the deliriums: for example, on one side victims, on the other side persecutors. The delirium permits to block in a fixed reality a relational event that usually is movable, changeable, dialectic. During the temporary delirium, things, situations, rules seem to be defined with great clarity, stability and predictability.

6 The author considers three areas to identify borderline delirium: the area of the Self, the one of relationship with reality and the one of relationship with time. Compared to the Self, the borderline delirium is ‘egodystonic’, ‘restricted’, ‘impulsive”, ‘minimal’ (like a micro-story). ‘Egodystonic’ in the sense that, as Meissner writes, the patient could identify the raving contents (or also hallucinations) as if they were produced internally (cf. W.W. Meissner (1984), The borderline spectrum: differential diagnosis and developmental issues, Jason Aronson, New York). ‘Restricted’ in the sense that it considers a daily event, even if it’s not central for the person. ‘Impulsive’ because it appears suddenly. ‘Minimal’ because the borderline delirium doesn’t deal with the big topics of human experience. With regards to reality, the borderline delirium is ‘reactive’, ‘atmospheric’, ‘relational’ because it starts from an important event that occurs in a significant relationship related to events and thatdepending on what happens in the person with particular feelings connected to the characteristic of a relationship. With regards to time, the borderline is ‘temporary’, ‘abortive’ ‘reversible’: time is restricted (minutes, hours, days) with subsequent fast retrieval of the reality exam. According to the author, nature of the borderline delirium is evident by looking at the immediate disintegration of the raving experience. Cf. M. Rossi Monti (2010), Trauma e deliri transitori borderline, in Il soggetto nei contesti traumatici. Scritti di B. Bonfiglio, S. Bordi, A. Correale, F. Gazzillo, G. Goretti,V. Lingiardi, G. Meterangelis, G. Moccia, A.M Nicolo, C. Pirrongelli, M. Rossi Monti, S. Selingman, I. Solano, Franco Angeli, Milan, 188-200. 7 Ivi, 195.

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In the borderline delirium, for instance, the main function is to allow things and situations to have a temporary and clearer configuration where it is possible to identify and differentiate oneself. The delirium experience in serious BPD, as Rossi Monti says, has the function of refuge and is always related to some mental state that concerned a relational condition belonging to the moment: a particular stressful situation that, according to the author, «comes from an interhuman relationship felt as particularly addictive for the emotional level»8. For the Gestalt therapy the reaction that the BLP has, sometimes incomprehensible and extreme, is the only possibility he has to be seen in the relationship with others: ‘going crazy’ in fact is experienced as a necessary relational way to get out from a confluent and seriously confused relational nature. Confluence is the condition in which a lack of contact occurs (lack of demarcation line of the Self). … However it’s obvious that wide areas of relatively permanent confluences are essential, as they make up the unconscious grounds that subtend the conscious grounds of experience. A child is in confluence with his family, an adult with his community, a man with the universe. If one is forced to become aware of these grounds of ultimate security, the ‘bottom drops out’ and the anxiety that one feels is metaphysical9.

1. The therapeutic relationship cures the borderline relationship During my clinical experience, I met patients that were very different from each other ‘within the borderline definition’; what they have in common is the confusion that distinguishes them in different levels: confusion in feelings, in words, in behaviours and even confusion in giving names to their own experience and the

8 Ivi, 193-194. 9 F. Perls, R. Hefferline, P. Goodman (1994) (or. ed. 1951), Gestalt Therapy, cit., 231-232.

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For the Gestalt therapy the reaction that the BLP has, sometimes incomprehensible and extreme, is the only possibility he has to be seen in the relationship with others: ‘going crazy’ in fact is experienced as a necessary relational way to get out from a confluent and seriously confused relational nature

During my clinical experience, I met patients that were very different from each other ‘within the borderline definition’; what they have in common is the confusion that distinguishes them in different levels: confusion in feelings, in words, in behaviours and even confusion in giving names to their own experience and the one of others

Confusion of a subject with BL (Borderline Language) is serious, because it ranks in the sense-motor register (Id-function), so it’s difficult for him to distinguish his own feelings and his own experiences from the feelings and experiences that belong to the environment

So, during the work therapy, it is necessary to build a relational setting that becomes for the patient a faithful and clear presence in the identification process

one of others. As Salonia10 says, traumatic confusion sets as severe pathology, occurring when a child «becomes aware of consciousness» but doesn’t have the instruments that allow him to be completely identified with himself yet. We are in front of a fleeting border and yet to be verified, so it’s not possible for the child to discern his own background from those that don’t belong to him. Confusion of a subject with BL (Borderline Language) is serious, because it ranks in the sense-motor register (Id-function), so it’s difficult for him to distinguish his own feelings and his own experiences from the feelings and experiences that belong to the environment: he lives in a dysfunctional, not temporary, rigid and invasive confluence. The relational confusion that belongs to the PBL doesn’t permit him to be identified with himself because a concrete differentiation and definition of his own experience is not possible. So, during the work therapy, it is necessary to build a relational setting that becomes for the patient a faithful and clear presence in the identification process. In this relational space, it will be possible to build a border where the patient will learn to differentiate and define what belongs to himself and what belongs to the others, and overcome the anxiety to feel something that he doesn’t understand. With such hermeneutic and clinical frame, it’s possible to read the therapeutic work started in 2008 with a patient called Giada. Through some extracts of verbatim and reports of some moments that we spent during the psychotherapy, we will show some important passages to understand Giada’s suffering, and to highlight the turning points of the therapeutic process.

1.1. Giada’s Story I saw something bad and I didn’t tell anybody. ...I saw the girl putting something in her mouth… I didn’t tell anybody… my head was saying ‘tell it, tell it, tell it’… … I thought ‘now the girl is going to die’. I’m bad… I’m worried… Giada

10 Cf. G. Salonia, supra.

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Giada came to me five years ago; she is eighteen years old and attends the last year of Linguistic High School. She is with her parents, who tell me that they are worried about her because during the last 5 months she didn’t want to go to school, she’s showing anxiety, fears, she can’t sleep and she is really worried about loneliness. The parents − or better, the mother who talks for everybody – says that at the beginning they wanted Giada to attend a psychologist, but Giada refused. Now they are supporting her desire to be followed by a psychologist but away from hometown. Later, I get to know that Giada met the same psychologist who was taking care of her mother, but the mother didn’t mention it to her daughter. When she went there with her daughter, she only said: «Talking with her can make you feel better; actually, I have also always felt the need to seek help for my depression, evidently we are the same...» The mother’s message of confusion/confluence is very clear. Giada’s rejection («I don’t want to talk with your psychologist. I want to meet another one, maybe outside our town») shows, clearly, her attempt of coming out from a fusional confluence that, at that time, was already implicit. If we contextualise Giada’s request of help in her life cycle, it’s clear that she is going through a significant (period of) transition (the last year of high school) that shows important evolutional tasks to deal with: life pushes her to go into the world. But, going into the world means, for Giada, to be able to differentiate herself, to know what she feels and what she wants: but she hasn’t achieved these skills yet and, unfortunately, she is not permitted to achieve them from and in the confluent-fusional relationship with her parents. At the first appointment, Giada comes with her parents and her boyfriend. The place where I meet them – Department of Mental Health – evokes, even though the welcoming atmosphere, fear and confusion, not so much in Giada, quiet desensitized at that time (‘the disorder protects her’), but especially in her parents and boyfriend. When I see them arrive, I realise that, even though the message that those who accompany her want to convey (she has a disorder and all of us are here for her) Giada is actually alone: nobody, in fact, is really ‘with her’. Giada is a tiny, skinny, faint girl with blonde hair and big blue eyes. When she introduces herself, she immediately communicates a sense of vulnerability: her breath is slow, as if she

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going into the world means, for Giada, to be able to differentiate herself, to know what she feels and what she wants: but she hasn’t achieved these skills yet and, unfortunately, she is not permitted to achieve them from and in the confluent-fusional relationship with her parents

The seriousness of the clinical situation and the need of an intervention at different levels, that is a differentiated taking charge for Giada and her parents, becomes immediately evident

One of the first things Giada refers to me is the fear of being «drained like her mother»

breathed very cautiously. I don’t hear her breathing. At the same time – I realise this later – I don’t even hear her coming in. From the beginning to the end of the session, her shoulders are slightly bent forward. She always sits in the middle of the chair, her body is not recumbent, it is not forward, it is not behind: it is half suspended. She always has a small bag on her knees, she often touches her hands, and actually, she caresses them rather than just touching them. She is second-born, her brother is three years older than her; she describes him like a marginal person: he spends little time at home and he doesn’t take part in family life. Giada would say about him: «Maybe my brother is right, earlier I thought that he was impolite with my mum, I thought that he didn’t care about her, but maybe he was right, my mother is oppressive, there is no other way to be with her…». Right from the beginning, the mother is very intrusive and anxious: she enters first, she talks on behalf of Giada, she refers she’s been depressed since ever! The father looks rigid, dignified, he doesn’t talk a lot but he seems to be careful and worried about his daughter. In the few words he says, he shows his feelings of anger and disqualification towards his wife. The seriousness of the clinical situation and the need of an intervention at different levels, that is a differentiated taking charge for Giada and her parents, becomes immediately evident. The parents accept to attend some sessions with another colleague, in order to understand how to behave with Giada at home. With such reasoning, the parents start to set borders between themselves and Giada. Difficulties emerge already in the first sessions: their relationships are very conflictual, ambivalent and embroiled. The mother says she’s not been well for a long time. The father, besides disqualifying his wife and appearing excessively restrained, shows an obsessive and ‘paranoiac’ jealousy towards her during the subsequent interviews. As for Giada, keeping in mind her symptoms and her high levels of suffering (social retirement, insomnia, anxiety, thoughts about death…), I think that a psychiatric visit and an individual psychotherapeutic path are necessary, acting as external anchor in comparison to the family. One of the first things Giada refers to me is the fear of being «drained like her mother». Bit by bit, the fear of vomiting

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comes out, which first turns into fear of becoming anorexic or bulimic, and then into fear of dying, and finally into the worry of hurting herself. Afterwards, compulsive behaviours are added to this, like washing her hands, accompanied by obsessive thoughts about hurting others, expressed like this: «I have bad thoughts… I’m scared…I see bad things and I’m scared they will happen». The path evolves and symptoms change accordingly: from anxiety to depression, from behaviour pertaining to food to obsessions, in order to reach the more difficult stages of suffering in the end, like hallucinations and temporary deliriums that disappear after short time without taking the shape of a proper delirium. The growing path is long and tormented for Giada, and it requires that she learns, in a relationship of confidence, the complex sides of the sentimental relationships, and that she overcomes ambivalences and confusions that terrify and sometimes defeate her. In a less serious PBL, what is experienced since childhood is confusion about words and about the way of understanding the meanings of experience; in a serious pathology, the patient was ‘invaded’ and confused in the period where his intimate experience was going to be created, by compromising the authenticity of his feeling (actually not ‘his’ feeling, but the result of an intrusion), so he feels scared about his feelings when he starts feeling something different, although intimately personal. Therefore, he has to learn how to keep back, overcome and go beyond invasion, confusion, and ambivalence.

The growing path is long and tormented for Giada, and it requires that she learns, in a relationship of confidence, the complex sides of the sentimental relationships, and that she overcomes ambivalences and confusions that terrify and sometimes defeate her

1.2 The way to be in a new relationship … My parents say that Dreams don’t mean anything… That it’s my subconscious

First year of therapy At the beginning of the first appointment, I feel that I would like to reach her without frightening her. During the first minutes, I try to ask how old she is and how she feels with regards to starting this new path together. She answers in pieces, look-

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At the beginning of the first appointment, I feel that I would like to reach her without frightening her

ing downwards, her head slightly bowed, as if she bore a grudge; she says she has no ambitions, no goals, and that she often cries for any reason. I am stuck and I feel I can’t reach her. Before leaving, I ask her if she has any request. Finally, she answers and everything starts with the question about dreams. Patient: Actually, there is something but maybe it’s not appropriate, I don’t know if you can answer me; it’s a question about dreams. Do dreams actually have a meaning? My parents say they don’t mean anything, that it’s just my subconscious.

I feel that with this question Giada tells me, on one side, her attempt of distinguishing herself from her parents, especially from the mother and on the other side, her readiness to run the risk towards something new, to another answer

I try to understand what this question means for her – for us – I search the intentionality of the contact: how Giada feels my presence and how she wants to reach me. I am at a loss with the answer of her parents (about the subconscious), I have the feeling that it increases confusion, because it may mean that dreams are not important and also that they are inexplicable. I feel that with this question Giada tells me, on one side, her attempt of distinguishing herself from her parents, especially from the mother, since she is not satisfied with her answer, and on the other side, her readiness to run the risk towards something new, to another answer. Therapist: What did you dream?... Tell me! – I say with quiet and interested tone. Giada tells me that she dreamt of a friend who committed suicide when he was 17, just before she started to feel bad. She dreamt about him being angry. She tells me that before the suicide they argued, and she didn’t invite him to her birthday party. Patient: I was angry at him, we argued and we didn’t reconcile. I feel the emotional intensity of this dream. I think that this complex experience (sorrow, sense of guilt, bewilderment) made her confused. She felt and, indeed, she still feels opposite and ambivalent feelings. She cared about him but she was mad at him. Certainly, she asks herself if there is a relationship between the quarrel and the suicide. Maybe she is scared be-

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cause she thinks that when she expresses herself something bad happens. Moreover, during the others sessions, it emerges more and more clearly how her mother invades her. When I listen to her, it is often difficult to understand to whom the fears belong. The mother even enters Giada’s dreams: she interprets them, she tells other people, she suggests meanings about death or life, according to her own mood. Sometimes I thrill more for the mother’s confusion rather than to the confusion of the daughter. One day Giada tells me: «When my friend died I didn’t go visit him. I didn’t want to go and see him; later my mother, who visited him instead, told me that not going was a good decision, because he was swollen and black, she told me it was bad to look at him, his neck were full of signs of the rope he used to hang himself with…». Her mother forces her to have a ‘contact’ with the friend’s dead body, although Giada wanted to avoid it by all means. It seems like the mother doesn’t have any attention, gentleness and respect for her daughter’s experiences, needs, choices: she defines what her daughter needs, what’s good for her, but actually without really ‘seeing her’. It becomes clearer and clearer for me how the mother ‘gets into’ Giada: as if nothing belonged to Giada, as if she didn’t exist – and couldn’t – by herself. From her side, Giada refers her mother everything she thinks, feels, and turns her mother’s answers, in an unaware and indiscriminate way, into her own ones. The mother ‘gets into’ Giada’s’ entire life, even into friendship: she tells Giada who she has to hang out with, she invites Giada’s friends over, although Giada doesn’t agree. When the daughter argues with a friend, her mother forces her to call the friend and solve the problem. One time, for example, Giada argued with one friend and it was difficult for her to forget about it, because the friend was in the wrong. Her mother didn’t like the situation, she criticised Giada, but only because the friend could have perceived her not as a tender and welcoming mother anymore, and she wouldn’t go and visit her anymore. It’s very clear how frail Giada’s borders are, how difficult it is for her to understand whom the discomfort and feelings belong

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Moreover, during the others sessions, it emerges more and more clearly how her mother invades her. When I listen to her, it is often difficult to understand to whom the fears belong It seems like the mother doesn’t have any attention, gentleness and respect for her daughter’s experiences, needs, choices: she defines what her daughter needs, what’s good for her, but actually without really ‘seeing her’

From a therapeutic point of view, supporting her in her intimate need to distance herself from her mother is not easy, because accepting that her mother, who is so good and sympathetic, actually doesn’t see her and doesn’t make her live her own life, is confusing and distressing. At a certain moment of the therapy, predictably, her mother even tries to get into the relationship with me Only with a lot of attention and gentleness, I managed to help Giada to split and distinguish herself from her mother, through a session full of fears and big confusion

to, and how she devalues her push to distinguish herself from her mother (and from her friend). From a therapeutic point of view, supporting her in her intimate need to distance herself from her mother is not easy, because accepting that her mother, who is so good and sympathetic, actually doesn’t see her and doesn’t make her live her own life, is confusing and distressing. At a certain moment of the therapy, predictably, her mother even tries to get into the relationship with me, trying to call me or even talking with me behind the daughter’s back at the end of a session. She takes it for granted that she decides what is important for me to know and what her daughter tells me during therapy. I back out of these scams with clarity a firmness. Only with a lot of attention and gentleness, I managed to help Giada to split and distinguish herself from her mother, through a session full of fears and big confusion. The therapeutic relationship kept the risk of splitting and braking up back. During the first year of therapy, I decided to be present in the relationship because I wanted to permit Giada to be with her anguish. Working immediately on the awareness of fears, indeed, would have not been advisable: fears would have intensified and it would have been impossible to hold them. Having remained in a constant and clear therapeutic relationship helped Giada with her contact with reality and allowed her ambivalent and confused language to be appropriately ‘translated’. Every Thursday I was in front of her, careful in finding her way, not mine. During the time, big fears came out: the anxiety of being with the others, shame, fear of vomiting. She doesn’t like her body, she says: «It makes me sick, I’m too thin». When she starts to feel her body, she is scared. Her borders are still fleeting, she absorbs everything like a sponge, she is very easily led. Feeling herself obviously is full of trembling and fears, which is therapeutically useless to discern at the moment. The questions about ‘what’ or ‘who’ frightens her would stress and confuse her even more. However, at this stage, working on the borders of the Self is important, offering precise, resolute and clear answers, building a reassuring relational climate. Being besides much frailty

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on tiptoe and – at the same time – firmly, is important to release levels of internal tension. Like the petrified child when he doesn’t find an adult able to contain his fears (and searching for ‘another’ caregiver to express his own distress), it is essential for the PBL to be in front of someone he can tell the worst things he thinks and fear about, and feeling a sense of containment in the other. Patient: You tell me if it’s true: I think I did something terrible to somebody, I hurt somebody… is it possible I don’t remember it? And that it is really true? Therapist: It can’t be that you don’t remember it, you didn’t hurt anybody. It’s important to be clear and straight, don’t investigate and don’t search obsessively for details; stay at a proper distance, neither too close, nor too far. Patient: I don’t want to have these feelings, I want to remove these fears, I fear that I’ll always feel bad, I fear that I’ll become anorexic or bulimic…I’m afraid of vomiting and afraid of dying … Giada swallows her mother’s ‘premonitions’ («You will always be like this»; «If you don’t feel well and you vomit, sooner or later you will die»), which lead the maternal fears and stress into her. I try to clarify what is inside and outside, what is hers and what belongs to the others. Giada learns to give a name to her feeling but she needs a translation11 to avoid the risk that she gets confused, to ‘turn mad’ in the relationship with the other. Therapist: Anger, fear, anxiety and shame... bad thoughts… Giada, which feeling do you feel stronger? Patient: Anxiety. Therapist: When you feel bad, anxiety starts … do you feel something else?

11 Cf. G. Salonia, supra.

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It’s important to be clear and straight, don’t investigate and don’t search obsessively for details; stay at a proper distance, neither too close, nor too far

Patient: I’m afraid to die and to do something that helps me die. Actually, one day, while I was looking at a tree, I saw/ imagined myself hanged. I was scared of this image… Therapist: What do you want to know from me? Patient: If I’m afraid to die, could I die? Therapist: One doesn’t die with the fear of dying … How does it make you feel what I am telling you? Patient: Better… it relieves me… I’m impressed that the imagine of her hung friend comes back. I know that her mother’s fears swallow her up, so I proposed her to explore what her mother tells her and which ideas of death she continues insinuating in her.

1.3. Time to feel a border ….I’m scared about my thoughts, now the child is going to die, I had such a ‘bad’ thought

Second year of therapy At a later stage, the fear of touching items and the coaction of washing her hands emerge in Giada. She isn’t only afraid of touching items, but also that the others touch items she touched. During a session, she says to me: Patient: I felt guilty, I saw something. I saw a child who did something bad and I didn’t tell anybody. I ask myself what bad thing she could have seen. With huge difficulty, I help her telling me what happened to her. Patient: I saw that the girl child put an item into her mouth. Therapist: Children of that age put everything in their mouth! Were you worried about it? Patient: I haven’t told anybody what I saw. Therapist: Who did you have to tell it to? She doesn’t answer.

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Patient: I’m afraid of myself, I’m afraid of my thoughts, now the girl is going to die…I had such a ‘bad’ thought... I thought she would suffocate and die … Therapist: You were worried about the girl … this is a good thing. The fear for the girl turned into «I had… bad thoughts» and therefore «I’m afraid I’ve been mean». Building logic connections between what happens and what Giada feels, giving meaning also to the sliver of reality that belongs to the field, allows to organise, contain and build. The way that she uses the concept of contamination, with strength and decision, surprises me. Often she says to me: Patient: I wash my hand because I don’t want to muck others up… Therapist: This can’t happen. If I answer her with determination, she calms down. During the following sessions, the fear of not being able to control bad thoughts, for example, avoid hurting others, comes out. For example, if she meets somebody on the street, she imagines she could hurt him (probably kill him, but she doesn’t manage to say this clearly) and then she turns around to see if she really did it. She has to make sure it’s not true. And she remains very scared. Such thoughts overwhelm her when she’s outside. For this reason, she prefers staying home, in order to keep calm. Patient: I have bad thoughts, I preferred anxiety, I’m afraid it’s hallucinations Therapist: Giada, do you know what hallucinations are? Patient: Seeing things that are not there, if it ends up like the crazy ones that do it? I feel she is worried about going crazy. Then she continues: Patient: But why do I have them?

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Building logic connections between what happens and what Giada feels, giving meaning also to the sliver of reality that belongs to the field, allows to organise, contain and build If I answer her with determination, she calms down

Well, why does she have them? What is true in delirium? Asking herself is the only way for her to get out of the confluence with her mother, to distinguish herself. I try to answer to her question. Therapist: You know… sometimes we think about good things and sometimes not so good things…but it doesn’t mean that we always do what we think. At the end of the session, Giada tells me: Patient: I don’t hurt anybody, and anyway, those who love animals, those who don’t hurt animals, don’t hurt people.

This is one of the first times I see Giada different, she uses the pronoun “I” with pride, as if she discovered it for the first time

This is one of the first times I see Giada different, she uses the pronoun “I” with pride, as if she discovered it for the first time. She tells she’s been having a rabbit for some month that she is taking care of. This is her thought, her mother didn’t instil it. The way she tells me touches me. My deep feeling is related to the sweetness I feel it when she says: «I don’t hurt anybody». I would like to share this deep feeling with her, but I know she wouldn’t need it now. It wouldn’t be clear to her, she wouldn’t understand, she could think that her things make me sad. Therapist: Good… these are the kind of things that help you, you don’t hurt anybody, even if you sometimes have bad thoughts. One day, referring to a quarrel with her mother, she says: Patient: Maybe I know why I have bad thoughts. Maybe sometimes my anger doesn’t manage to get out. She tells me about a quarrel with her friend; after this quarrel, she goes into the kitchen to cry. Her mother gets in and tells her she should join her friend, as it’s not fair to leave her alone… She starts to cry. Patient: My mother told me a bad thing…

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That’s what I feared. Therapist: Is it something one can say? Patient: She said to me: you are nuts! You are crazy… but dad was present. Therapist: What did your dad say? Patient: He said to mum she made a mistake. The father supports Giada for the first time. This makes her feel less alone and less ‘crazy’ and, hence, she manages to give voice to her pain. A new period starts, in which Giada recovers the relationship with her father. They go out together, they go for long walks, and sometimes her father lets Giada try to drive, since she just recently got her driving license. It is a new closeness, never felt or experienced. At the same time, the parents also start to deal with their problems as a couple in their therapeutic pathway, and they don’t participate in sessions only to know how to deal with Giada. One time, Giada tells me she heard her parents arguing few days earlier. She would like to know the reason of the quarrel, because she thinks it’s because of her. Patient: My parents were talking to each other in the kitchen, I didn’t understand what was wrong… Therapist: Maybe they argued. Patient: They were a bit angry. Therapist: And what did you do? Patient: I got up twice to go and see. Therapist: To see what? Patient: ….Maybe it’s my fault. Therapist: Sometimes parents argue for issues concerning them. Your parents can argue too, as a couple, and not because of you. The episode happens, actually, some days before when, after the psychiatric examination, Giada is asked to wait outside, so that her parents could take an appointment for their interview as a couple. Giving the them space to face their problems as a couple and keep them separate from the parental problems, it also helps Giada to distinguish herself.

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Gradually, some small but important changes start to become evident in Giada. For example, she starts to tell something about her childhood, about games, about memories, and not only about fears. Sometimes even her excitement comes out.

1.4. The time of identification …I didn’t tell anybody…

Third year of therapy Patient: There’s one thing that I didn’t tell anybody… Such statement on behalf of Giada means she didn’t talk about it with her mother (choice of differentiation) and she is telling me (proof of confidence).

Growing up out of her mother’s confluence means feeling new, also unknown things, which need a name

Therapist: Tell me, I listen to you. Patient: The other day, I was talking with my friends about going to the cinema. When I do something new, different, I’m scared. Therapist: Yes, it’s true, Giada when you do something new or different, you are scared. Almost everybody is scared of doing new things. Patient: It used to be different. Therapist: Yes, because now you do it by yourself, you are growing up and this can scare sometimes. Patient: I’m scared of feeling bad, of having strong anxiety. Therapist: If it comes, it will also go. Did you have it? Patient: No, only at the beginning, not at the cinema… Growing up out of her mother’s confluence means feeling new, also unknown things, which need a name. One day, she clears her throat12 and tells me:

12 The action seems to be taken for granted, but it is actually not for her and not for me! We went from ‘not knowing what to say’ to clearing ones throat to be listened to.

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Patient: The other day I got anxious… I don’t understand why… Therapist: Tell me… You know, the fact that you cleared your voice before starting to talk amazed me, you did it also the time before. She smiles: she knows she did it. She tells me she felt her heart beating faster while she was watching TV, but she didn’t call her mother. During the session, she clears her voice again, she wants to talk with me about the fact that some friends, not the usual ones, organised an evening to go and eat a pizza with the catechist. Patient: I’m scared. And what if I get anxious then? Therapist: You won’t get anxious – I tell her firmly – if your heart beats fast, you can take a seat, you can ask for a glass of water… It is as if there’s not only strong anxiety now: we can also talk about what she would like to do, and not only about things that she can’t do because she is scared. She will go and eat a pizza, and she won’t get strong anxiety. During the last sessions, Giada feels a little better, her voice reaches me, she doesn’t have strong anxiety anymore, but she is still scared that it may come back. Intensity is different, it doesn’t invade her. Sometimes, she tells me some thoughts or events, for example, a quarrel with her boyfriend, and she commences: «This, I didn’t tell anybody». I’m impressed: I feel that we are building a relationship. ‘This, I didn’t tell anybody’: maybe it’s the first ‘stone’ of a border between her and her mother, and the beginning of a relationship with me. It’s her way to mark the new ‘between us’, her way ‘to reach me’. It seems that Giada found the right direction in meeting the other while being and expressing herself, her feelings, and her needs. And at the end… another dream. Patient: I had a dream. Some time ago, a young boy died in an accident, I dreamt about him, even if I didn’t know him. I don’t know why I dream about people I don’t know. Therapist: Sometimes we dream about people we don’t know, even if we just heard about them. Tell me…

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It is as if there’s not only strong anxiety now: we can also talk about what she would like to do, and not only about things that she can’t do because she is scared

‘This, I didn’t tell anybody’: maybe it’s the first ‘stone’ of a border between her and her mother, and the beginning of a relationship with me. It’s her way to mark the new ‘between us’, her way ‘to reach me’

Patient: The other day, at the cemetery, we met the mother of this boy because his grave is next to my grandma’s grave. My mother stopped to talk to the woman, and then she turned her head and said to me: «May we tell her?» I felt ashamed; I didn’t want to, I didn’t want my mum telling her that I dreamt about the woman’s son, because I didn’t know him. But she told her my dream… The same relational scheme: the mother ‘doesn’t see’ her daughter, she doesn’t see her embarrassment and asks the question in front of the boy’s mother. Actually, she is not asking for the daughter’s permission to tell the dream, she already did it! Therapist: In your opinion, why did she do it? Patient: Because in her opinion it could have been good for that woman. Therapist: You didn’t want to? Patient: No, I got angry when I arrived home. she has to fight every day to avoid being swallowed up

I see there’s no energy. It’s clear that she gets tired, oppressed, exhausted by her mother’s persisting style of not seeing her: she has to fight every day to avoid being swallowed up. Therapist: Sometimes your mother says and does things that confuse you.

Giada starts to see her mother’s initiatives as belonging to her mother, to distinguish what she wants from what her mother wants

Giada starts to see her mother’s initiatives as belonging to her mother, to distinguish what she wants from what her mother wants. This is a big change: not feeling confused among ambivalent messages, distinguishing whom experiences belong to and – even more decisive – feeling the anger with less fear of losing her mother.

1.5. The time of contact …Help me not to lose the things that I achieved…

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Fourth year of therapy Giada feels better. She interrupts the therapy for one year. She says she feels better; she starts doing things alone, with her friends, with her boyfriend. I believe it’s correct to support her desire to feel herself normal and to experience herself alone. One morning, her mother calls me and asks for «a therapy for Giada… just in case of need». After having talked to Giada alone, I realise that calling me was not her idea, even if she would like to tell me a lot of things. I finish my conversation with the mother, saying that Giada could call me, if she wishes. Indeed, few months later, Giada calls me, instead of her mother. My certain and respectful presence for her feelings starts to become an assumed ground for her, where she can identify and express herself. Giada asks me to start therapy again, when her mother – after Giada went for a holiday with her boyfriend and some friends – asked her to go back and sleep together, in the same bed «like in the nice old days». I’m struck by the words: ‘nice old days’. The ‘nice old days’ her mother remembers with such warmth, used to be times when Giada felt like going insane. The appeal of Giada is very clear and one day she puts it into words. Patient: Help me not to lose the things that I achieved. At the moment, therapy is going on. Sessions are full of daily things, no more long silent. Giada needs me to help her gradually clarifying some of the confusion that is still present, and to let her be in the world with less confusion and invasions. It’s a new phase of the therapeutic relationship, an atmosphere of confidence was established. With me she feels safe in respect of our differences. Surely, there are moments Giada is afraid of «feeling bad like before», she feels like a sponge that absorbs everything, she feels influenced, especially by the topic of death. Actually, her fear comes often back when she is in touch with the depressive background of her mother, who always insists that Giada should go seeing corpses with her. The ‘death body’ is something that really scares Giada, and I know we have to work with this image later.

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My certain and respectful presence for her feelings starts to become an assumed ground for her, where she can identify and express herself

Help me not to lose the things that I achieved

It’s a new phase of the therapeutic relationship, an atmosphere of confidence was established

During one of the last sessions, Giada leans her back and tries to cross her leg but she pulls back immediately, as if she got scared, and sat again at the border of the chair. Therapist: You can listen to your leg… She does, and she immediately says: Patient: But I don’t feel comfortable.

Giada’s body regained its integrity and now quavers by opening itself to the endless possibilities of her life. I feel this is a turning point: what started in her body now gets back to her body

From that moment on, the topic of womanliness comes out in every session. Short steps through which she tells me – between fear and bravery – the path towards her most intimate womanliness that she used to ignore, because it was ‘repugnant’ for her. Such path makes her ready to face her first gynaecological visit. I’ve been following Giada for several years now. An intense path that started with few words, her long silent, her frailty, cadenced with her «I don’t know what I have to say…». In these years, I have understood that she was probably searching for something related to her capability of feeling herself, but she didn’t find anything that really belonged to her. Her invisible and quiet body emitted the sensation of a body without borders. Everything could get in: words, images, experiences, people. So when something went out she didn’t recognised it. It could have been something bad, aggressive, for sure ‘bad thoughts’. The action was only a risk of hurting. For her, growing was like anxiety to be different. We are still here, in the place and time of our weekly appointment, both on time. I still don’t hear her arriving, she walks silently, but now – it’s strange – I don’t hear her arriving… but I know when she arrives! During one of the last sessions, after the silence, different by now, during which she prepares the words to ask me something, she says: Patient: I have to tell you something… since our the last meeting, I don’t know what happened but I felt the need to sort myself out, to dress a bit nicer, to take care more of myself. I felt a deep, intense emotion: Giada’s body regained its integrity and now quavers by opening itself to the endless possibilities of her life.

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I feel this is a turning point: what started in her body now gets back to her body. What started as disorientation and disintegration, gets back as desire of unity, beauty, light. Where fear and confusion were, the therapy tried to bring distinction and respect, continuously ready to give space and sense, like a translation, to Giadaâ&#x20AC;&#x2122;s real but buried, germinal but hidden world, to her intense but interrupted desire of saying to herself and being. It seems like the bodyâ&#x20AC;&#x2122;s voice wants to scream now, softly, that all this is possible and actually already started.

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