The intersubjective matrix as a clinic paradigm?
An interview with Professor M. Ammaniti
By Ferruccio Cartacci – Director of “Psicomotricità”
To accompany this issue of the magazine dedicated to childhood clinical experiences and how they intertwine with parenthood, we decided to examine developmental research done in the last decades. We found an effective summary of research in Massimo Ammaniti’s and Vittorio Gallese’s book, The Birth of Intersubjectivity (2014). Their book testifies to how fertile contamination can be when a psychodynamic approach comes out into the open on the body or bodyness, today called “interpersonal neurobiology” (and, from our point of view, interpersonal neurobiology has a good deal in common with the history of psychomotor theory and practice).
The intersubjectivity matrix, that has its formation during gestation and continuing until birth, arouses curiosity in infant health care professionals. Not only the theory is interesting, but, more practically, also the paradigm and its epistemological anchorage is useful in clinical action and diagnosis. It encourages paying more attention to epigenetic factors, that is, those factors that “assemble themselves” in the period from pregnancy to initial care of the newborn. Traditional classification, for example, often ignores these factors.
We interviewed Professor Massimo Ammaniti, Psychoanalyst and Professor of Developmental Child Psychiatry in the School of Medicine and Psychology at the Università della Sapienza in Rome. He has an important role in the mother-infant field of research. We warmly thank him for his willingness to answer our questions.
Ferruccio Cartacci: Intersubjectivity, the intrinsically relational nature of human beings, is explored throughout your book (Ammaniti and Gallese, 2014) where you chose to study its origin and development. In what way is there a novel approach to the intersubjectivity synthesized in your book? Can you help our readers better understand its newness?
Massimo Ammaniti: I would say that our approach considers recent developments in the field more than proposing something new. We use Jerome Bruner’s definition of intersubjectivity - the way in which human beings are able to understand what others think. The definition is sufficiently broad and emphasizes above all, and to be precise, the cognitive aspects. Our approach also keeps the affective aspects in mind, however, and some distinctions should probably be made.
There is a level more related to empathy, the emotional resonance regarding the affective state of another person, namely what is experienced in a relationship with another. There is also an affective resonance in which one is aware that the affective states are induced by someone else and aren’t one’s own, therefore allowing for differentiation between oneself and the other. This level is more immediate and has been confirmed at a neurobiological level by the recent discovery of mirror neurons.
Still another level exists, and it is probably the level Bruner referred to, and it is defined in different ways such as contemplation, mentalization, and assumption of another’s point of view. The process is more specifically cognitive and the neurobiological basis is different than that involved in the mirror neuron area. We are speaking mainly of those areas, namely the frontal and prefrontal lobes of the cerebral cortex, concerned in metacognition.
What we can basically say, returning to a more clinical or rehabilitative approach is that an immediate affective resonance with a patient or family, or whatever else, is something automatic and implicit. Resonance is activated every time we meet a person, look at him and observe his expression and behavior. We experience resonance with that person’s state of mind. The other level, instead, is more explicit and symbolic; it allows us to contemplate the other’s state of mind beyond the first affective resonance.
Cartacci: Your criticism of “solipsism”, that is, the individual ego’s primacy, leads us to directing criticism at most of our culture including, therefore, the prevailing philosophy observable in the educational system and also in rehabilitation and therapy. Do you agree with these cultural repercussions?
Ammaniti: Yes, basically, meaning that much of scientific literature follows that direction. Jean Piaget, for example, studied all of the stages of cognitive development independently of their relationship with another person. I would describe Lev Vygotsky’s school of thought, instead, as being completely different. Freud, too, defined development on individual terms in psychoanalysis. Only in the last few years has more attention been given to what we might call the relational aspects of development and the role interaction plays in it. I think it worth quoting Robert Emde who emphasizes that not only the ego exists, but also what he calls a wego. Whatever the therapeutic or rehabilitative relation, be it helping a child or an adult, we are creating a specific relation. I can use this definition in our discussion by remembering Adriano Milani Comparetti who spoke of a rehabilitative dialogue already in the sixties. He referred to the relation that is created between the person doing rehabilitation and the patient who participates in rehabilitation and called it an exchange, a dialogue between two persons. I think this is one of the central aspects of any kind of therapeutic and rehabilitative intervention.
Cartacci: Certainly. Milani Comparetti also encouraged a dialogue with the foetus, attributing to it a sort of intention, if I’m not wrong.
Ammaniti: Yes, he did without a doubt. Our book mentions a study in which Gallese participated. It was clearly shown that two twins not only touched the placenta walls, but also increased motor exchanges between themselves from a certain phase onwards. All of this contributes to our saying that intentionality exists from pregnancy onwards.
Cartacci: Your work often underlines how intersubjectivity begins with interbodyness , also called embodied simulation. This neurobiological and developmental acquisition of knowledge through research is an immense theoretical support for TNPEE and psychomotor therapists. Historically speaking, our paradigms were more operational than theoretical, and they now have scientific support. After all, a part of the Italian public health system still considers our activity as something vague, possibly feasible, but lacking in reliable basis, or else it advocates psychomotor treatment in a progressively as reduced, divided into segments and with a neutralized form of relation. We would appreciate your opinion on this.
Ammaniti: The term “interbodyness” or embodied simulation, first suggested by Gallese, stresses how the body is the first level of exchange. On one hand, it refers to Andrew Meltzoff’s research on the newborn’s imitation; on the other, it refers to successive research such as Myron Hofer’s work on hidden regulators. Hofer claims there are a series of body mechanisms that intervene to regulate basic rhythms during between mother and infant body contact. Last, but not least among references, I would add research on attachment. The first level of attachment begins precisely with the body and its reflexes to then arrive at procedural or practical knowledge and then a more explicit symbolic knowledge. I therefore firmly believe in the fundamental aspect that a good relationship is initially constructed at a body level and that it offers us important implications for therapeutic work. I often say that psychotherapy is somewhat under the insignia, noli me tangere, don’t touch me and don’t come close. It reminds me a little of the image of Christ in front of Maddalena. Rehabilitative work, instead, is strongly bound to exchange, to contact, to body closeness and is certainly dominated by body language.
Cartacci: Your anthropological thesis regarding man’s intersubjective nature is fascinating. You claim his intersubjective nature originates in a “choice” made by hominids about a million years ago to cooperate in taking care of offspring, also because of the offspring’s immaturity. Human “cubs” therefore accumulated intrinsic abilities for communicating with more than one person and for constructing multiple bonds beyond the primary role reserved for the mother. On the basis of this premise, we would like some of your thoughts on the important debate about today’s children. What kind of problems do they present and what new resources do they possess?
Ammaniti: One of the main themes presented in the book is alloparenting as presented by Sarah Hrdy. One hypothesis is that the human cub had to get used to various presences in interaction while trying to understand diverse intentions, all of which contributed to the development of his/her intersubjective abilities. I would say that today there are certainly a variety of figures that interact with children, even if the family has become smaller. In other words, we no longer have a clan or extended family but a nuclear family. Today’s children, however, begin their social life outside of the family earlier. They go to day care and then kindergarten with their peers. There is a great openness towards the outside. Relationships are not all equal at this level. In fact, we first spoke of attachment, a relationship that guarantees security. The parents are in primis followed by other adult figures fundamental in security regulation. Alongside of these adults there are many other relationships, more for exchange than for security. In fact, we can speak of two systems - the attachment system having the function of regulating security and the intersubjective system having the function of helping us to understand the other. I believe this is the context in which children live today.
Cartacci: If we assume that the foetus-bambino has the ability to collaborate in its own birth and care, every interruption in this collaboration is a potential risk factor. We finally have an explicit referral in your book to C- section birth that can become a cultural option, when not imposed by necessity. Don’t you think that extended use of epidural anaesthesia during childbirth and the lack of breastfeeding (health professionals sometimes don’t promote it enough) represent interruptions or the attenuation of this natural mother-child collaboration? Can accumulating these experiences become an important risk factor?
Ammaniti: Without a doubt. I think in Italy, and elsewhere, but above all, in some specific areas, fifty percent or more of births are C- sections, especially in private clinics. In the meantime, we know that international scientific organizations recommend a fifteen percent limit for caesarean sections, obviously when referring to risk situations and not to routine.
One of the studies that we quote compares C- section birth to vaginal birth. Results indicate that children born in natural childbirth have a better relationship with their mothers because they tend to be more sensitive to the child’s signals. Those mothers who have given birth through the birth canal are. The child’s passage through the birth canal and the vagina stimulates nerve endings that activate l’oxytocin, a hormone that we know to be related to protection and maternity. I would like to add something that isn’t in the book, and that was probably already focused upon in the past, by Frédérick Leboyer, for example. He said that the baby is in some way more active in a vaginal birth; there is a more “participated” passage, not an extraction.
Cartacci: Certainly. There’s more collaboration and exchange. If face to face interaction and interbodyness are at the origin of intersubjective development, it seems to us that, for all practical purposes, they can also represent a clinical paradigm in which we aren’t constructing but restoring a dyadic communication through the body. An accurate and sensitive “mirroring”, at the basis of which we call a tonic dialogue, will be necessary.
We ask why tonic-emotional and tonic-postural modulations, that are an incarnation of mother-child regulation spoken about by many authors, are rarely taken into consideration by the same authors. We’re speaking about the muscle tone that so extensively supports communication modes in interaction such as eye contact, miming, body contact, gestures, play…we think that the function of muscle tone could be more widely explored.
Ammaniti: I agree with you. Daniel Stern spoke of it (not specifically of muscle tone, but he implicitly refers to it). He spoke of vitality, certainly a mental experience, but initially a body experience. Therefore, just as you said, it concerns personal muscle tone and its use in an exchange with another - how one offers his hand and shakes it, how one moves, one’s body posture, how one embraces and how another react. They are all important aspects that express inner tendencies and how the body represents mental states.
Cartacci: Precisely. After all, muscle tone reunites these two functions; it supports action and is the substance with which the relation is woven, reason for which we have to better evidence this synthesis. This issue of our journal addresses the therapist-parent alliance, the parent’s presence in therapy as a mediator and collaborator, and parent-infant therapy. Speaking of parent-infant therapy, there are many different clinical models in which interpretation prevails over interaction, however, and where little attention is given to the environment such as the therapy room, the materials used within that room and the play that occurs. We would like your opinion.
Ammaniti: I believe, and it is also the meaning of the book, that the interpretative aspect is undoubtedly at a more elevated level, as we already said before, and implies a certain degree of awareness. There are, however, different stages and beginning paths in which the relation is constructed through exchange, through closeness, through warmth, through face to face contact. I want to refer to Milani Comparetti again as an example of body dialogue with another. When we receive a child and his parents in our place of work, the first thing we realize is how and where they sit down, how they arrange themselves and interact, and how this expresses their personal tendencies. I think this is the first level and I would be sufficiently critical of excessive interpretation because it risks putting distance between the other and me. From my point of view, an interpretation is the final step when attempting to explain why a situation was created or developed as it did.
Cartacci: It seems to me that you are saying that an interpretation is an advanced tool in helping the other, but that it rests on and is rooted in the interbodyness, and it is for this reason these two things should be integrated.
Ammaniti: I agree.
Cartacci: Thank you once again, professor, for your availability and for your clarity.