GIANCARLO DIMAGGIO

CENTER FOR METACOGNITIVE INTERPERSONAL THERAPY

www.centrotmi.com gdimaje@libero.it

Thanxk to drs. Giovanna Attin Francesca Carabelli Luisa Buonocore

METACOGNITIVE INTERPERSONAL THERAPY

!

Early formulation late 90 Narrative therapy (Neimeyer, 2000) Self as dialogical (Hermans, 1996; Hermans & Dimaggio, 2004) Constructivism (Kelly, 1955) Interpersonal psychoanalysis(Mitchell, Aron)

METACOGNITIVE INTERPERSONAL THERAPY

!

Centrality to the concept of interpersonal schema CCRT-based case formulation (Luborsky & CritsChristoph) Ongoing focus on the therapy relatinship. Preventing, managing, negotiating, reparaing alliance ruptures (Safran & Segal, 1990: Safran & Muran, 2000)

METACOGNITIVE INTERPERSONAL THERAPY

!

Use of techniques for treating symptoms E.g.: CBT, Mindfulness Developed for treating personality disorders Currently applied to schizophrenia (Lysaker et al.; Salvatore et al.). RCT or non-controlled trials for schizophrenia underway (Netherlands, Australia) Individual, group and family modalities

METACOGNITIVE INTERPERSONAL THERAPY

Theory of human motivation based on evulotionary concepts. Humans driven by: ! Attachment ! Caregiving ! Social Rank/Antagonism ! Sexuality ! Peer Cooperation ! Group inclusion ! Self-esteem ! Agency ! Autonomy/Exploration (Gilbert, 1989, 2005; Lichtenberg, 1992)

METACOGNITIVE INTERPERSONAL THERAPY

!

Developed for PD To date outpatient therapy. Private clinics Some cases treated in institutions Whole range of PD but Exquisite focus on Over-constricted PD

GENERAL FOCUS PERSONALITY DISORDER WITH INHIBITED OR CONSTRICTED TRAIT ! ! ! ! ! ! ! ! low affiliation avoidance of attachment and intimacy restrained expression of emotion over-controlled, both in emotion and behavior perfectionist cognitively rigid risk adverse poor emotional awareness and more in general poor self-reflection (part of the metacognitive disorder)

PD INHIBITED 2
!

Poor metacognition Stereotyped, constricted and dysfunctional interpersonal schemas Emotional overregulation. Examples: avoidant, obsessive-compulsive, paranoid, narcissistic, passive-aggressive, dependent, depressive or schizoid PDs (full-blown, sub-threshold, co-occurent)

MANUALIZED STEP-BY STEPPROCEDURES 1

Dimaggio, G., Salvatore, G., Fiore, D., Carcione, A., Nicol, G. & Semerari, A. (2012). General principles for treating the overconstricted personality disorder. Toward operationalizing technique. Journal of Personality Disorders, 26, 63-83.

Eliciting the details of autobiographical episodes Fostering awareness of emotions and dominant beliefs; Mutual in-feeding between enriching autobiographical memory and improving metacognition

MANUALIZED STEP-BY STEPPROCEDURES 2

understanding psychological causality, such as how others actions evoke a belief that in turn triggers an emotion, and how that emotion leads to actions; ! evoking a series of associated episodes to promote awareness of stable patterns and subsequently reformulate schemas; ! achieving metacognitive differentiation or a critical distance from internalized meaning-making patterns.
!

creating new self-narratives - access to healthy self - exploration of new patterns of meaningmaking and behavior: overcoming fear and avoidance - integration of new experiences in a more nuanced identity - foster agency and experiences driven by innermost wishes - practice new skills and learn more adaptive communicative strategies

Dimaggio, G, et al. (in press). Accessing autobiographical memories and promoting metacognition in the inhibited-constricted personality disorder. In J. Livesley, G. Dimaggio & J. Clarkin (Eds). Integrated treatment for personality disorders. New York: Guilford. Dimaggio, G. et al. (in press). Enriching self-narratives in patients with personality disorders: Advanced phases of treatment. In J. Livesley, G. Dimaggio & J.F. Clarkin (Eds). Integrated treatment for personality disorders. New York: Guilford.

Mutual in-feeding between enriching autobiographical memory and improving metacognition

MIT KEY FEATURE:

Continuous elicitation of narrative episodes and then seek for mental states (until last therapy session)

Seek for basic states (core feelings) and then ask to retrieve associated elements until a narrative episode is recollected

Why the attention on metacognition inside autobiographical memories/narrative episodes?

Self-narratives are a way humans use to shape their construction of reality and communicate to others
Bruner, 1991

Autobiographical memory: a personal way of making meaning of events

Neimeyer, 2000

When asking to recall specific details of an episode a therapist is seeking

Nuances of affective-laden meaningmaking processes, including some that would not appear if the therapist stuck to the overgeneralized memories or intellectualizations patients often use to convey why they think they are suffering.

SELF-DEFINING MEMORIES Where core affective experiences and the basic processes of meaning-making nest
(Singer et al., 2012)

Autobiographical memories Life-story memories Self-defining memories Narrative-scripts

Patients suffering from many PDs have been described as being unable to recall detailed autobiographical memories and tell them to their therapist Patients resort to, intellectualizations or abstract statements when communicating their problems
Dimaggio, G. (2011). Impoverished self-narrative and impaired selfreflection as targets for the psychotherapy of personality disorders. Journal of Contemporary Psychotherapy, 41, 165-174. Dimaggio et al. (2012). General principles for treating the overconstricted personality disorder. Toward operationalizing technique. Journal of Personality Disorders, 26, 63-83. Dimaggio et al., (2007). Psychotherapy of Personality Disorders: Metacognition, States of Mind and Interpersonal Cycles. London: Routledge.

AUTOBIOGRAPHICAL MEMORIES IN SESSION

Specific life episodes involving the self ! Clearly set space -where - and time boundaries ! Descriptions of the actors in the scene and their interactions. ! The dialogue between actors ! Details of the environment (pictorial quality), the narrative landscape ! They can be recent and/or co-constructed in-session, not specifically remote ones ! Many patients will never be able to retrieve developmental memories therefore
!

Any moment of the therapy conversation can later be recalled and become a patients selfmemory.

If patients are unable to recall even recent events, the clinician may ask them to focus on future episodes in-between sessions, until specific narrative episodes are slowly recalled.

IMPOVERISHED NARRATIVES IN PD

!" GM

means !" Generalized Memories

IMPOVERISHED NARRATIVES IN PD
Overgeneralized memories/Intellectualizations. ! Lack of space and time markers (where? and when? left unaddressed) ! Poor description of mental states of the characters ! The narrative landscape lacks detail and pictorial quality. ! The articulation in the dialogue between characters is inadequate and a characters actions are not met by any reaction in others ! Repetitive themes/Redundant interpersonal schemas (always the same story)
!
Dimaggio & Semerari, 2001; Salvatore, Dimaggio & Semerari, 2004

INVESTIGATION OF THE DETAILS OF AUTOBIOGRAPHICAL MEMORIES UNIQUE SITUATION IN WHICH TO SEARCH FOR MENTAL STATES!

PATIENTS WITH IMPOVERISHED NARRATIVES/USE OF INTELLECTUALIZATIONS

Personality Disorders patients report more general e.g. I tend to - instead of specific memories - e.g. That day during the fight I was with Narcissistic PD, Obsessive-Compulsive and Avoidant PDs.
Dimaggio et al., 2007; 2010; 2012 a; b

Unlike persons with Borderline PD (Renneberg et al., 2005), patients with Avoidant, Dependent and ObsessiveCompulsive PD reported fewer specific and more categorical memories compared to non-clinical controls.
Spinhoven et al., 2009

TYPICAL INTELLECTUALIZATIONS (OVERGERENALIZED MEMORIES) OF PATIENTS WITH PD

Ive always kept my girlfriends at a distance because I want to preserve my freedom
!

My relationships always head south because men are unreliable

! !

which is blatantly false!!!

Example: OVERGENERALIZED MEMORIES IN AVOIDANT PD

If talking about problems at work, therapists prompts simply generate answers such as: Theres competition. People are edgy. Theres no mutual respect If therapy is successful specific autobiographical episodes appear: Last Tuesday I felt drained of energy by working too hard. I needed a vacation, but, when I asked for it, one colleague told me I was being unfair because she deserved the vacation first. I froze and was unable to retort.

THE INTERPLAY BETWEEN NARRATIVE MODE AND METACOGNITION/MENTALIZING ! Narrative mode and mentalizing should interact with each other
Dimaggio et al., 2009 Consc & Cognition Dimaggio et al. (in press) Frontiers in Cognition Saxe, Moran, Scholz & Gabrieli, 2006.

Neuroscientific evidence supports the narrative and self-reflective systems being distinct, although interacting with each other; each has its unique neural circuitry, while other brain areas are shared Pretend play, Theory of Mind and narrative processes share some brain areas.
Spreng & Grady, 2010 Spreng & Mar, 2012 Whitehead, Marchant, Craik & Frith, 2009.

OVERLAP BETWEEN AUTOBIOGRAPHICAL MEMORY AND MENTALIZING:

Superior temporal sulcus Anterior temporal lobe Aateral inferior parietal cortex (angular gyrus) Posterior cingulate cortex Dorsomedial and ventral prefrontal cortex Inferior frontal gyrus Amygdala.
The functional overlap facilitates the integration of personal and interpersonal information and provides a means for personal experiences to become social conceptual knowledge. This knowledge, in turn, informs strategic social behavior in support of personal goals. In closing, we argue for a new perspective within social cognitive neuroscience, emphasizing the importance of memory in social cognition.
Spreng & Mar, 2012

OVERGENERALIZED MEMORIES, ALEXITHYMIA AND THEORY OF MIND

62 students ! Autobiographical Memory Test-Minimal Instructions ! Difficulties in Emotionalizing (Bermond Vorst Alexithymia Questionnaire) ! Poor ToM Understanding of irony in mentalistic jokes
!

Results Alexithymia and poor ToM both related to Overgeneralized Memories

!

Palmieri, Dimaggio & Gasparre, 2012.

IMPOVERISHED NARRATIVE and EMOTIONAL UNAWARENESS

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Impoverished Narrative: paucity of every detail of a specific memory: scenario, descriptions of characters, definition of space and time boundaries Emotional unawareness (alexithymia): difficulties putting emotions in words and communicating ot others An alexithymic story is often deprived of other pictorial details and is thus an impoverished narrative.

Evoking Autobiographical Memories

Activation of metacognition/Increased access to emotional experience

Activation of metacognitive mode/Access to emotional experience

Evoking Autobiographical Memories

MIT FOR AVOIDANT PD

AVOIDANT PD: PATHOLOGY Alexythymia Poor awareness of emotional triggers Dominant states of mind: Alienation; Shame; Fear of criticism; Resort to pleasant activity when alone; Constriction in intimacy; Compensatory narcissistic fantasies. Maladaptive Schemas: Avoiding intimacy/Fear of being controlled Social rank: Self as inept/Others judging and spiteful

! ! !

TYPICAL INTERPERSONAL SCHEMA 1

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Wish: To be accepted (social rank motive) If then procedure: If I will show my abilities then Response of Other: Criticize/Reject Response of the Self: Shame, Withdrawal, Depression. Self-image as unworthy and inept confirmed

TYPICAL INTERPERSONAL SCHEMA 2

Wish: To be accepted and loved (attachment) ! If then procedure: If I display my feelings ! Response of the Other 1: Rejects ! Response of the Other 2: Controls. Limit freedom (shift to autonomy/exploration motive) ! Response of the Self 1: Unworthy, depressed, shame, withdrawal ! Response of the Self 2: Anger if unable to avoid. Withdraw if possible
!

Stable sense of nonbelonging to groups Lack of social skills and communicative abilities Poor understanding of others minds Avoidance as preferred coping strategy
! !

Emotional avoidance Avoidance of social exposure

AVOIDANT PD
Nicolas, 37 yrs. old
!

History of hallucinations. Severe OCD, social phobia. Lifetime diagnosis of psychosis. WRONG! Re-assessed: Avoidante PD, schizoid, passive-aggressive and paranoid traits Never worked. Never had interpersonal relationships State of mind: feels inadequate, judged. Avoid contacts for fear of being considered inferiorr or awkward. Feels weak, poor self-efficacy. Lack of plans for the future Inside the family: angry at her mother. Protest about food bot being good enough.

! ! !

AVOIDANT PD IN SESSION During a session - after 3 months individual therapy, 5 months of combined family-individual - therapist makes an observation He lowers his eyes, face is tense, as keeping any expression in control. T: Nicolas, while I was asking you if you had felt shame and embarassment in other moments, your face changed, became more rigid and you lowered your eyes. did something painful came to mind now you have difficulties manging? Therapist tries to make the observation consistent with her analysis of non-verbal behavior

N: Hem yes (he raises his eyes up and looks at the therapist). When I was 16 I went by my father to tell him about the music in my head I couldnt get rid of. I wanted to share and be reassured, I was hoping he gave me some help and solve the problem.

T: How did your father react. What did he say? N: He didnt even look at me. He punched the door telling me it wasnt possible and then went by my mother T: What did you feel in face of such as a reaction from your father? N: Anger, because he didnt understand I felt bad. Then disappointment and sadness, because I couldnt image it went that way T: Nicolas, can we say that when you try to disclose yourself in front of someone important to you - be your father or the therapist in order to share or be helped, the other tends to react by not understanding, joking or going away? N: But maybe I should have better shut myself up

! ! ! ! ! ! ! ! !

Shame Lack of eye contact (avoidant behavior) Self as fragile/ill (overall he had a self-image of self as flawed) Seeks help (attachment) Other as rejecting/spiteful (father yelled at him) Self as alone Anger Shame at the others joke (shift to social rank motive) Withdrawal/Avoidance as a coping strategy in face of criticism and rejection But

Appropriate managing of therapy communication reduces withdrawal and foster autobioghraphical memory and metacognition

LEAVE AVOIDANT PD ALONE IS PROTECTIVE NOW BACK TO MIT CORE IDEAS ! Therapists and patients need to progressively build shared representations of patients mental states
Bateman & Fonagy, 2004; Stiles, 2006; Dimaggio et al., 2007

Where to seek evidence of mental states? Self-narratives Session-markers: voice, prosody, gestures Use this shared evidence for joint treatment planning

! !

Therapy must be adjusted to patients metacognitive or mentalistic abilities. Example: Absence of emotional awareness goal promote emotional awareness. Proscribed delivery of: Relational Symptomatic interpretations or interventions

assuming psychological awareness the patient does not possess

PROCEDURE OUTLINE
PART 1: STAGE-SETTING Operations aimed at reconstructing patients inner world, inferring it from elicited or spontaneously related episodes from their autobiographies.
A step must be accomplished to pass to next step

Dimaggio, Salvatore, Fiore, Carcione, Nicol & Semerari (2012). General principles for treating personality disorder with a prominent inhibitedness trait. Towards an operationalizing integrated technique. Journal of Personality Disorders.

STAGE-SETTING STEPS !
! Elicit specific autobiographical episodes instead of accepting generalized and abstract statements Focus on the details of these relational episodes to discover how a patient felt, thought and acted. If poor narratives then: first seek for details of inner states, i.e. session-markers. Use these to elicit associated memories

Identify cause-effect psychological links, e.g. how a thought elicited an emotion or vice-versa, or how an emotion triggered a behavior.

Elicit new related episodes until therapist and patient are have enough evidence to form hypotheses about the schemas underlying interpersonal exchanges (one swellow does not make a summer).

PART 2: CHANGE PROMOTING

Any technique or stategy suitable for promoting change

STEPS
! Fostering ability to question their ideas and distinguish between fantasy and reality

! Awareness of healthy self in session ! Focusing on adaptive self-aspects formerly overshadowed by dominant problematic experiences until they are integrated in self-narratives Promoting new behaviors in a tentative and exploratory manner

Forming an integrated view of the self capable of making sense of contradictions and lapses Decenter: form a nuanced understanding of the others minds as different from ones own. Treating symptoms using specific techniques assuming good mentalistic knowledge

! Later step: ackowledge responsibility for problematic interactions, own involvement in interpersonal cycles.

Not a phase-model of treatment. Need to continuously move back and forth between stage-setting and changepromoting Work through the same problems over and over again until they are solved.

Not a sequence with fixed starting and ending points.

Start from the level a patient achieved previously

As new aspects of the self arise, one can turn back and begin stage-setting again until a new narrative scenario has been scanned.

WHEN TO PASS FROM ONE STEP TO THE NEXT? MARKERS

! Changes - both positive and negative - in metacognition Changes in quality of affects Changes in quality of the therapeutic relationship: for example a reduction in confrontational or withdrawing attitudes

! !

Markers 2
!

Access to new autobiographical memories Symptom reduction

If interventions lead to improvement - or at least non deterioration - in some of these factors then

Switch to interventions requiring greater reflective abilities or capable of provoking increased negative affectivity without activating defensive reactions.

STEP-BY-STEP PROCEDURE
Dimaggio et al. (2012) Journal Pers Dis Dimaggio et al. (2010) Enhancing mental state understanding in overconstricted personality disorder using Metacognitive Interpersonal Therapy. In G. Dimaggio and P.H. Lysaker (Eds.). Metacognition and severe adult mental disorders: From basic research to treatment. London: Routledge.

Collect a detailed autobiographical memory (where, when, who, what, why)

Construct a reliable text which patient and therapist can easily consult. Specific memories Rich in narrative and psychological details Easier agree when forming hypotheses about existing schemas or negotiating strategies to change ineffective behaviors.

GOOD AUTOBIOGRAPHICAL EPISODE

WHEN: located in well-defined moments WHERE: specific places WHO: clearly portraying the actors on stage and the dialogue among them WHAT: defined plot, including a theme weaved around the protagonists wishes and their vicissitudes during interpersonal relationships WHY: the reason for which the story gets told, i.e. the question the person wants to be solved of the message that the story conveys to the addressee NO GOOD Generalized statements or theories

ELICITING NARRATIVES
! "Could you describe an episode from your life relevant to the topic you are talking to me about? ! "Where were you? Who was with you? ! "What did you answer then and what did you do?.

THEN

STEP BY STEP SESSION PROCEDURES

Collect a detailed autobiographical memory (where, when, who, what, why) Identifying emotions, thoughts and desires

Understanding the emotions and ideas within patients discourse.

Some patients: telling a story comes first and this is the avenue to detecting affects.

Other patients: emotional signs, e.g. prosody and face, are easier to access than a detailed episode and serve as cornerstones for collecting associations and forming a story

What did you feel while the episode was occurring?

What was your reaction when your boss yelled at you? If descriptions are vague (e.g. I felt tense), the therapist should prompt further details. Non-verbal signals are fundamental and one could watch for any nuances revealed by voice and posture: Did I see you grimace while you were telling that part of the story? Did you feel something?. Once the emotion has been defined then forming a story: So we know you were ashamed. Does that remind you of some moment in which someone made you feel this way?.

Attempts at clarification can fail if patients become defensive.

Avoid pressurizing

Concentrate less on inner states and more on topics on which dialogue is smoother, even if without apparent psychological importance, until signs indicate that emotions can be explored again.

Problem: Affectivity too flat TYPICAL FOR Avoidant PD Too low a level of emotional arousal. Then Work on re-enlivening the therapeutic relationship Using humor or encouraging patients to talk about matters that vitalize them and increase arousal

STEP BY STEP SESSION PROCEDURES

Collect a detailed autobiographical memory (where, when, who, what, why) Identifying emotions, thoughts and desires

Identify links among events, affects, ideas and actions

YES

PD patients often act with no awareness of their underlying motivations.

Need to link emotions, cognitions and behavior with each other and with social environment

Therapists asks what generated an emotion or triggered a reaction, explore the links between the details in the story what someone said or did - and the patients actions, and by understanding specific thoughts associated with actions or affects.

Nicolas describes himself as tense and distressed but is not able to elaborate on that nor to say why T: Nicolas so in this episode you described me you felt tense. This started when your mother was asking you what would you prefer for lunch. What do you mean with tense? What is that made of? N: An inner tension, it feels like irritation T: So whats your mother does that irritates you? N: It irritates me because first she asks me what I want and then she cooks something different, so I dont even answer and I leave

T: So here you feel something related to your mother behavior when shes in the kitchen. May you tell me more about how did you feel in that moment when you discovered she didnt cook what you expcted to? N: (he breathes, lowers his eyes) She hurts me. It hurts when she doesnt listen when I ask something.

Problem: Patients dont put emotions in a context. then Invite the patient to record significant episodes over the next few days and consider whether any of these events might cause the emotion. Repeated requests from her therapist to explore recent episodes has then helped Nicolas to recognize how an argument with his father caused his sadness and tendency to withdraw

Nicolas, unlike the first moments of the therapy conversation, realizes that his wishes and perspective are unworthy as the other disregard them. He then feels sad, alone and then angry at the sneaky parental constrictions.

STEP BY STEP SESSION PROCEDURES

Collect a detailed autobiographical memory (where, when, who, what, why) Identifying emotions, thoughts and desires

Identify links among events, affects, ideas and actions

YES

YES

Elicit associated life-narratives

IMPROVED ACCESS TO EMOTIONAL TRIGGERS THEN ELICIT ASSOCIATED AUTOGRAPHICAL MEMORIES T: What are you feeling now? N: Sadness, because my mother at times is not focused T: So can we say, Nicolas, that the idea the other doesnt give you attentions you think you deserve make you feel sad and then withdraw? Do other episodes come to mind about you feeling sad when the other disregards you? N: Well, once my parents brought me swimming without saying me anything and they knew I hated swimming!

Therapists need to help patients understand suffering comes from an inner source and not an external one in order to make them change PD patients are instead unable to acknowledge that problems are mostly caused by their representations of the self with others, and not by the actions of he real others.

PROVIDE EVIDENCE
Having but one example of a kind, that is one episode of a specific theme, is not enough proof for the existence of inner schemas driving behaviors one swellow does not make a summer.

Elicit the recollection of episodes that are FELT OR THOUGHT TO BE similar or psychologically associated with a progenitor.

General: Can you recall similar episodes to this occurring at any time in your life and in other contexts - work, friends or family?

Specific cues:: You said you felt ashamed and angry, when your father did not help you. Has this happened with other people in other moments of your life?.

STEP BY STEP SESSION PROCEDURES

Collect a detailed autobiographical memory (where, when, who, what, why) Identifying emotions, thoughts and desires

Identify links among events, affects, ideas and actions

YES

YES

Elicit associated life-narratives Overt reformulation of schemas

THERAPISTS
!

Form hypotheses (covertly first) about the inner schemas underlying regularities in feelings, thoughts and reactions. Focus on the more significant psychological aspects Summarize a number of episodes and then pinpoints how the structure of the story is stable over time and space, and feelings or reactions are triggered by similar events

Therapeutic relationship provides information for reconstructing schemas. Did you ever had the same disturbing feelings during a session? If a patient has difficulty replying, whereas the therapist can clearly recall episodes in which the former acted in a similar way to the latters self-narratives then

Note the link

You told me that you feel ashamed because your friends consider you clumsy. Last time I thought you almost blushed as if you were afraid of being judged by me. Was your emotion in the two situations similar?.

STEP BY STEP SESSION PROCEDURES

Collect a detailed autobiographical memory (where, when, who, what, why) Identifying emotions, thoughts and desires

NO

Identify links among events, affects, ideas and actions

YES

YES

Elicit associated life-narratives Overt reformulation of schemas

STEP BY STEP SESSION PROCEDURES

Collect a detailed autobiographical memory (where, when, who, what, why) Identifying emotions, thoughts and desires

NO

Identify links among events, affects, ideas and actions

YES

YES

Elicit associated life-narratives Overt reformulation of schemas

Dominant negative selfrepresentations

E.g. Unlovable

self/Rejecting other

pass to

CHANGE-PROMOTING

STEP BY STEP SESSION PROCEDURES

Collect a detailed autobiographical memory (where, when, who, what, why) Identifying emotions, thoughts and desires

NO

Identify links among events, affects, ideas and actions

YES

YES

Elicit associated life-narratives Overt reformulation of schemas Dominant negative selfrepresentations

Distinguishing fantasyreality/ Differentiate

DIFFERENTIATE/DISTINGUISH FANTASYREALITY Problem: Imaginal world treated as true (Bateman &

Fonagy, 2004; Fonagy et al., 2002)

Being left alone forever because partner does not telephone one day Being fired because boss has an angry face. Being criticized by others when displaying feelings Promote the distinction Ex.: When youre out of contact with your dear ones, you always think youre going to be left alone forever, but this has never happened. Considering it now, dont you too think that catastrophe is not as imminent as you imagined?.

PROMOTING DIFFERENTIATION AFTER RECOLLECTION OF MULTIPLE EXAMPLES: Nicolas

T: Last session you told me about your shame and embarassemnt, and then anger when your father joked about your anxiety. Now you are saying that while you were telling me you liked a girl you saw in the bus, you noticed my smile. You felt ashamed because you fancied I tought you was awkward.

T: Then you got angry because I was not giving relevance enough to your sharing your feelings with me Do you still feel now my smile was about not taking it seriously N: Not really T: May we think there is a link between your wish for opening and the tendency to feel belittled and ridiculed and not understood?

Self-disclosure and therapeutic metacommunication in order to

!

Highlight the unrealistic nature of negative expectations You were convinced that Id have criticized you for arriving late to this appointment. Its what you always think when you do something you consider to be against the rules. Do you feel criticized by me now?.

STEP BY STEP SESSION PROCEDURES

Collect a detailed autobiographical memory (where, when, who, what, why) Identifying emotions, thoughts and desires

NO

Identify links among events, affects, ideas and actions

YES

YES

Elicit associated life-narratives Overt reformulation of schemas Dominant negative selfrepresentations Dominant positive selfrepresentations

Distinguishing fantasyreality/ Differentiate

Distinction between fantasy and reality only as regards negative or egodystonic self-representations. Not prematurely challenging representations that are either positively biased or egosyntonic such as My partner shouldnt ask help for help from me because my work is much more important than her needs or negative but still egosyntonic Everyones ill-intentioned and tries to trick me, and for this reason Im entitled to overtly express my anger risks eliciting negative reactions that would be counterproductive and alliance-threatening.

Narcissistic features: everyone admires him for his exceptional qualities and his partner loves him and is ready to forgive his unfaithfulness. Little sense in stressing this assumption is quite unrealistic. If therapists confronts these assumptions Typical impact on the therapy relationship

Almost useless to try to convince a paranoid patient that threatening others or retaliating is not the right way to soothe her anxiety or restore justice

Such convictions should not be challenged until therapy is advanced and alternative views of others should not be proffered at this stage.

Turn back to stage-setting and focus on other details of their self-narratives until pain or suffering emerges

STEP BY STEP SESSION PROCEDURES

Collect a detailed autobiographical memory (where, when, who, what, why) Identifying emotions, thoughts and desires

NO

Identify links among events, affects, ideas and actions

YES

YES

Elicit associated life-narratives Overt reformulation of schemas Dominant negative selfrepresentations

Dominant positive selfrepresentations

Distinguishing fantasyreality/ Differentiate

Abstain from criticising/ Dont consider as a target

STEP BY STEP SESSION PROCE4DURES

Collect a detailed autobiographical memory (where, when, who, what, why) Identifying emotions, thoughts and desires

NO

Identify links among events, affects, ideas and actions

YES

YES

Elicit associated life-narratives Overt reformulation of schemas Dominant negative selfrepresentations Back to stage setting until negative thoughts or affects are identified as sources of problems

Dominant positive selfrepresentations

Distinguishing fantasyreality/ Differentiate

Abstain from criticising/ Dont consider as a target

STEP BY STEP SESSION PROCE4DURES

Collect a detailed autobiographical memory (where, when, who, what, why) Identifying emotions, thoughts and desires

NO

Identify links among events, affects, ideas and actions

YES

YES

Elicit associated life-narratives Overt reformulation of schemas Dominant negative selfrepresentations Back to stage setting until negative thoughts or affects are identified as sources of problems

Dominant positive selfrepresentations

Distinguishing fantasyreality/ Differentiate

Abstain from criticising/ Dont consider as a target

STEP BY STEP SESSION PROCEDURES

Collect a detailed autobiographical memory (where, when, who, what, why) Identifying emotions, thoughts and desires

NO

Identify links among events, affects, ideas and actions

YES

YES

Elicit associated life-narratives Overt reformulation of schemas Dominant negative selfrepresentations

Distinguishing fantasyreality/ Differentiate

YES

Access to healthy self/ Explore new ways of relating

STEP BY STEP SESSION PROCEDURES

Collect a detailed autobiographical memory (where, when, who, what, why) Identify links among events, affects, ideas and actions Identifying emotions, thoughts and desires
YES

NO

YES

Elicit associated autobiographical memories Overt reformulation of schemas Dominant Egosyntonic self-representations Access to healthy self/ Explore new ways of relating
YES

Back to stage setting until negative thoughts or affects are identified as sources of problems

Dominant negative selfrepresentations Distinguishing fantasy-reality/ Differentiate

Integrate different or formerly inconsistent self-other representations

Decenter/Acknowledge own contribution to interpersonal problems

Abstain from criticising/ Dont consider as a target

MIT FOR AVOIDANT PD: THE CASE OF LEONARDO

From Dimaggio, G., Attin, G., Popolo, R. & Salvatore, G. (2012). Personality disorders with over-regulation of emotions and poor self-reflectivity: the case of a man with avoidant and not-otherwise specified PD, social phobia and disthymia treated with Metacognitive Interpersonal Therapy. Personality and Mental Health, 6, 156-162.

With some follow up!

Leonardo is 38 yrs. old, has a degree and works as a collar in an embassy. He lives in a flat in the same building of his parents. He describes himself as a loner, mistrustful, not spontaneous and unable to build intimate relationships. He describes his mother as intrusive, anxious and controlling, representing others as a menace to the family.

The father was harsh, unpredictable, competitive and awesome. He frequently punished Leonardo for minor misbehaviours. The only coping strategy Leonardo adopted was shutting himself up. Both parents were judgemental of him and often sarcastic. He has four siblings but hardly talks with any of them. Feelings of social alienation were chronic.

Leonardo always believed he was unworthy, unskilled and inept; he fears criticism and is prone to feeling scorned. During SCID II interview he remembers episodes of humiliation during teenage, which highlights the roots for his paranoid features: L: Once, some friends stole my wallet because they knew I wouldnt react they peed on me once showering after gym I should have retaliate but I didnt

As regard psychological problems and former therapies, he suffered from panic attacks at 25, treated with medications only. Anxiety-related avoidant behaviours lead him to think he was unable to court any girl knocking his self-esteem down. In 2003 he started a weekly CBT for social phobia, which lasted for 5 years.

Symptoms of social phobia improved though never completely receded, but he decided to discontinue therapy as he felt therapist was unable to deal with issues of separation with his girlfriend.

He felt therapist was just offering common sense observations not helping him deciding whether to break the relationship or not.

Leonardo met 18 criteria at SCID II interview. Avoidant PD Sub threshold Dependent and Paranoid PD Prominent Depressive and Passive-Aggressive traits.

Axis I: dysthymia, social phobia and erectile dysfunction without medical explanation.

Assessment

1 year

SCID II Criteria

21

SCL-90-R GSI

1.2

0.9

Leonardo had separation issues with his girlfriend, Engaged in a relationship with Benedetta, a colleague of him.

He swinged from feeling constricted and overwhelmed - when she asked for reassurances about how much he loved her and anxiety outbursts as he felt he may break up and lose a safe haven, an alleviation to his sense of unworthiness.

He was unsure whether he still loved Benedetta or just needed her.

He thought when the story is over he should seek for another girlfriend, exposing himself to rejection.

Finally he wanted to become less inhibited and have a rewarding romantic and sexual life overcoming his erectile dysfunction.

Remarkable were his difficulties in describing inner states Barely able to name anxiety and anger, and lacked names for other emotions, thus making him hard to communicate to the therapist what he feels. Therapy started in September 2009 with weekly individual sessions led by a female therapist with 3 years of experience in MIT and was regularly supervised. No medication.

Leonardo typically started any session with hardly a story to tell. In order to overcome his impoverished narrative style, therapist turned the conversation towards topics which raised his interest, in particular his difficulties dating girls. As Leonardo presented with failures in describing bodily states in emotional terms, the next step was focusing on variations in arousal until affects could be recognized.

In many episodes similar to each other Leonardo only named bodily states such as sweating, feeling a lump in his throat and stomach pain, fearing he cannot swell and was afraid of choking.

After many such episodes in which the therapist struggled to understand what Leonardo felt, her repeated focus on bodily states and non-verbal insession markers in order to recognize emotions started being successful.

Leonardo was talking about a romantic rendezvous in a restaurant: Leonardo: when my friends told me they arranged a rendezvous with a girl I started sweating, had a stomach ache, I felt like making an excuse and stay home. Therapist: where were you? L: home, watching TV

T: you felt those sensations when you were still hanging on the phone or right after? L: phone T: did you remember thinking something specific? E: yes, that I would have looked foolish for sure in front of everyone. T: I understand. And, why did you think about looking foolish, how could you be so sure?

E: I thought that she would have start talking to me and I wouldnt have been able to utter anything so she would have be sure I couldnt even talk, I was stupid, kind of a nerd. T: so you were completely certain of receive a negative judgement even before knowing her? E: yes, I was sure. T: what did you feel when you had this scenario in mind right now? you look anxious, am I wrong?

E: yes, anxiety I started to sweat, felt stomach pain

This was the first of a series of narratives in which the therapist continued to focus on somatic experiences and tried to connect them with the nonverbal signals displayed during the storytelling, in order to put up hypotheses about what kind of emotion he was experiencing - and the related thoughts - eventually leading to recognizing he was often anxious.

Improved self-reflection: naming emotions and understanding their eliciting factors

Seek for associated autobiographical memories

After a few sessions a regularity started to come to the fore, a first hint at an existing interpersonal pattern:

Leonardo had a wish to be accepted, represented the self as stupid, goofy and inept when facing an other described as critical and rejecting and responded by avoiding contact

Beginning of the therapy: only able to describe vague disturbing somatic sensations leading to avoid social situations.

Six months: able to recognize he tended to lean on behavioral avoidance in order not to face social rejection and negative judgement which in turn made him feel anxious and ashamed

Nevertheless, at this moment Leonardo was unable to further elaborate this summary or swiftly shift to other topics, making the conversation flounder. He therefore did not attain a next step in selfreflection, that is recognizing he was guided by an inner schema; he was instead convinced his expectations mirrored the truth, a dysfunction in metacognitive differentiation
Semerari et al., 2007 Bateman & Fonagy, 2004

A crucial therapy step is helping patients become aware they are driven by inner expectations in particular internalized relational patterns and that thought does not mirror reality.

Daunting task. Patients stick to the truth-like quality of their narratives.

Leonardo was

sure girls would have rejected him.

In order to promote the fantasy-reality distinction, MIT moves by eliciting a set of narratives which the patient feels are associated to the one just told.

Therapist first asked Leonardo to not avoid meeting the girl.

Then they revised the actual date he had; his narrative after the event was completely consistent with the expectations: Leonardo could hardly talk.

He described the girl as too self-confident, reinforcing his idea she had judged him harshly because she was superior to him. During that session Leonardo was in a state of high negative arousal, but now with an awareness he was anxious because of perceived negative judgment. The therapist then asked him if similar episodes, happened in other moments of his life, came to his mind.

Leonardo acknowledged that was typical of him when facing new acquaintances or demanding social situations. He started recalling episodes at work and with peers.

The aim of eliciting associated episodes is collecting enough shared evidence for the existence of rigid patterns of thinking, feeling and behaving, independent enough from the characteristics of the actual other.

Leonardo reacted positively to this strategy. Awareness of underlying scheme !"Wish to be accepted !"Display skills and feelings !"Other reacts with criticism. Other-superior !"Self responds with shame !"Confirms self-image of self as inept Typical of Avoidant Personality Disorder (Dimaggio et al., 2007) Scheme is self-sustaining Discrepant information rejected: If I am appreciated this means the others are worse than me, or just they had not time enough to form a realistic picture of myself and my flaws.

Even his picture of Benedetta was schema-driven:

L: She accepts me because she is sick, weak and needs me, shes a dependent and immature person if she was a crackerjack she wouldnt spend her time with a fool like me.

Role-reversal: Leonardo switches to the spiteful role (though still inadequate) and the other is described as flawed and inferior.

Lead by this idea, he was leaning on breaking up, but soon feelings of impending isolation and desperation came up, preventing any move:

L: No one will ever wish to stay with me, Im too anxious, weak, Ill be forever alone.

Current therapy goal was sowing seeds of fantasyreality distinction and not trying and change a pattern the patient still does not know is a mentalistic construction. Therefore the therapist simply focused on how much Leonardo took this belief as true and was convinced of him.

T: Leonardo, you look like youre always searching for reassurances from others, but those never arrive, or if you receive positive reactions those hardly cracks the negative opinion you hold of yourself. Why is this idea so hard to question? You just pay attention to signs confirming you dont worth a dime

CHANGE PROMOTING
In response to intervention like the former, Leonardo started to form a higher-order self-representation from which he acknowledged having a rigid belief he could not question. This awareness waxed and waned and for a couple of months only lasted in session.

During everyday life Leonardo sticked to the face value interpretation of others as critical and rejecting. According to MIT, beginning to acquire the ability to recognize that one is guided by an inner schema is the turning point between the stage-setting and change-promoting aspects of treatment.

Two operations in parallel allow change promotion:

!

patient is asked to expose himself to formerly avoided situation, thus creating a context for observing mental states elicited by the context

then, therapist and patient revise in-between sessions episodes in order to collect evidence that attributions to self and others are biased and fixed.

Thanks to this technique Leonardo became slowly aware being was unable to read signals other than rejection or criticism, and never considered discrepant, positive information.

He agreed trying dating some girl.

In session Leonardo progressively realized he actually received positive feedbacks and critically questioned how he was stuck to the idea that no valid girl could sincerely appreciate him.

This interweaving of behavioral exposure and insession reflection about states of mind elicited by the encounter allowed Leonardo recognizing he felt a sense of self-efficacy during romantic rendezvous.

He also broadened his theory of mind, which now embraced positive ideas of the others about the self.

This led him to form a slightly revised version of one prominent dysfunctional self-other pattern: he discovered that soon before the date, he envisioned the girl he had invited as too beautiful to reach, clever and superior to him.

He was sad about striving for a perfection he never could attain. During the dinner, as he detected signs of appreciations he started to question the girl beauty and intelligence as soon as she displayed positive attitudes toward him.

He arrived to the point of considering ugly and vulgar a girl he had described until the day before as a top-model. He recognized this was a stiff between-states shift and questioned whether what he thought about the girl soon before and during the meeting had to do with the real person in front of him or was but a rigid belief. In many moments he acknowledged the latter was the case and in fact he could perceive himself as worthy facing a pleasant, attractive and accepting other.

First becoming aware of emotions and their triggers

Then realizing affective reactions were stable

He was asked evoking related memories

Recognized the existence of a rigid interpersonal schema.

Self-efficacy grows. Time was ripe to break with Benedetta Still prone to shifts toward states of abandonment, isolation, nostalgia and low self-esteem, but eventually he sustained his decision. Increase in self-esteem promoted an unexpected change at work: he expressed dissatisfaction for aspects of his environment and was able to talk with his chief in order to ask for some change, with he obtained.

THE THERAPY RELATIONSHIP

Overcome the sense of boredom elicited by Leonardo emotional flatness.

Therapist and supervisor decided to search for areas in which Leonardo was more aroused and willing to talk

The only topic in which he reacted was his difficulties with girls, probably because the sexual motive was active.

T: Leonardo, Ive noted that when you talk about having a relationship with a girl other than Benedetta you are more active, I feel more your presence here, am I right?

Leonardo reacted positively and displayed nonverbal signs of feeling understood and that the therapist was truly focused on him. In parallel the therapist always kept a validating stance toward his difficulties:

T: It must be a source of anguish living day by day with the idea that you will never be able to conquer a normal woman and therefore you are deemed to remain alone or accept having relationship only when you rate yourself and the girl as just average at best

Moreover when Leonardo talked about his erectile dysfunction the therapist was particular careful to her own non-verbal behavior in order not to be felt as spiteful which was extremely possible given the patients expectations of being ridiculed , and to Leonardos one. She tactfully noted any sign of shame in order to talk about possible feelings of being judged by the therapist:

T: Ive noted that as you talked about your sexual difficulties with Benedetta you stopped gazing at me, lowered your eyes and turned your gaze on my desk. I feel you are embarrassed I understand you, you are telling me very intimate things and it is so common feeling ashamed when telling about sexual problems how do you feel now? Do you feel Im judging you, considering you inept or inferior?

Leonardo found talking about feelings of shame and inferiority relieving and continued discussing them with a relative ease, acknowledging the therapist was sincerely non-judgmental and empathic. In general during the first months he never displayed other signs or discomfort toward the therapist apart shame, nor he was overtly critical at the therapist, which could have been expected given his tendency to derogate women when a minimal degree of intimacy had been reached. These were likely markers of an overall good management of the therapy relationship

Improvements are evident in emotional awareness and metacognitive ability to distinguish between schema-driven interpretations and reality: Leonardo now possesses a more nuanced emotional language and is able to question ideas of failure, loneliness and rejection, at least during sessions.

Thanks to this technique Leonardo became slowly aware being was unable to read signals other than rejection or criticism, and never considered discrepant, positive information. Together with the therapist he agreed trying dating some girl. In session Leonardo progressively realized he actually received positive feedbacks and critically questioned how he was stuck to the idea that no valid girl could sincerely appreciate him.

This interweaving of behavioral exposure and in-session reflection about states of mind elicited by the encounter allowed Leonardo recognizing he felt a sense of selfefficacy during romantic rendezvous. He also broadened his theory of mind, which now embraced positive ideas of the others about the self.

This led him to form a slightly revised version of one prominent dysfunctional self-other pattern: he discovered that soon before the date, he envisioned the girl he had invited as too beautiful to reach, clever and superior to him. He was sad about striving for a perfection he never could attain. During the dinner, as he detected signs of appreciations he started to question the girl beauty and intelligence as soon as she displayed positive attitudes toward him.

He arrived to the point of considering ugly and vulgar a girl he had described until the day before as a topmodel. He recognized this was a stiff between-states shift and questioned whether what he thought about the girl soon before and during the meeting had to do with the real person in front of him or was but a rigid belief In many moments he acknowledged the latter was the case and in fact he could perceive himself as worthy facing a pleasant, attractive and accepting other.

Only thanks to the higher metacognitive awareness of his mental and interpersonal functioning he acquired critical distance from negative views about the self so letting his self-efficacy grow. This allowed him to decide time was ripe to break with Benedetta, and try walk his way alone. He was still prone to shifts toward states of abandonment, isolation, nostalgia and low self-esteem, but eventually he sustained his decision.

Currently, work is still focused on recognizing such those shifts and how passing from states of idealization of another seen as rejecting to states in which he reverses-roles once the other appreciates him does not depend on actual characteristic of the other, but on his schemas.

The increase in self-esteem promoted an unexpected change at work: he expressed dissatisfaction for aspects of his environment and was able to talk with his chief in order to ask for some change, with he obtained.

Emergence of the paranoid side, improvement of the erectile dysfunction, and management of countertransference. As almost always happens in patients with complex PD, improvement in one dysfunctional area leads to other personality disturbances come to the fore. For the first year of therapy his paranoid traits did not play a prominent role, something which happened once Leonardo started to have more contacts with women.

Self-esteem improved and he felt higher selfefficacy. Less avoidant and dependent so he could break up his relationship and tolerate feelings of loneliness and desperation.

In this moment the paranoid side of his personality appeared, in a somewhat unexpected way. Leonardo, during sexual intercourses with one girl he was dating with, started to have sexual fantasies with paranoid and sadistic features: L: I had to imagine that Monica wanted to steal my money and wedge me in with a pregnancy. I felt angry at her and so I wanted to have sex, as a way of punishing her for her malicious intentions.

Thank to this fantasies Leonardo felt more aroused and the erectile dysfunction waned, a mechanism that lasted at times with the same girl and with other women, mostly prostitutes, though in other moments he had again problems.

The emergence of this new pattern can be considered both a therapy success and another problematic personality trait to be treated.

According to the case formulation therapist and supervision noted this was possibly a reversal of the pattern in which Leonardo felt violently criticized by his father to whom he always submitted. In his sexual fantasies he now embodied the dominant role, facing an other despised and subjugated.

This fantasies and the associated improvement in sexual dysfunctions had a positive effect on his selfesteem which in turn lead to a decline of behavioral avoidance.

Having assessed early on problems with trust (paranoid) and hostility (passive-aggressive features) let patients and supervisor ready to shift topics and cope with the new emerging problems.

THERAPY RELATIONSHIP
The appearance of such those fantasies created strains in the therapy relationship. The therapist felt angry while listening to Leonardo sadistic wishes, as she took the girls side: He is so loathsome, who gives him the right to treat women like this and vent his impotence and frustration hurting them?. The therapist recognized these feelings did not have to be treated at face value and was able to keep them covert, but supervision needed to be focused on helping her tolerate them.

The supervisor validated her and acknowledged it was discomforting also to him listening to these fantasies which both felt as coarse, and totally lacked of the playful atmosphere and sense of sharedness with the partner which could have made them part of a richer sexual imagination.

Understanding these fantasies were likely an unavoidable step toward recovery helped therapist to regulate her emotion: role-reversal is often the first move toward personality change and in fact Leonardo felt now less subjugated and unworthy.

After one year, Leonardo no longer suffers from any PD. Social phobia is much less an issue and sexual problems are starting improving.

Therapist and supervisor agree sexual aggressive fantasies have to be dealt with great care, with validation for symptom improvement be made first Avoid Leonardo feel criticized when he enters a mental state which helps him overcome his sexual problems.

THE THERAPY RELATIONSHIP

MIT continuously pay attention to the therapy relationship (Dimaggio et al., 2010 b) in order to prevent or repair alliance ruptures (Safran & Muran, 2000). During the first months, the therapist had to work covertly to overcome the sense of boredom elicited by Leonardo emotional flatness.

This is a typical reaction induced in therapist by patients featuring alexithymia

Alerted to this risk, therapist and supervisor decided to search for areas in which Leonardo was more aroused and willing to talk; the only topic in which he reacted was his difficulties with girls, probably because the sexual motive was active.

T: Leonardo, Ive noted that when you talk about having a relationship with a girl other than Benedetta you are more active, I feel more your presence here, am I right? Leonardo reacted positively and displayed non-verbal signs of feeling understood and that the therapist was truly focused on him. In parallel the therapist always kept a validating stance toward his difficulties:

T: It must be a source of anguish living day by day with the idea that you will never be able to conquer a normal woman and therefore you are deemed to remain alone or accept having relationship only when you rate yourself and the girl as just average at best

Moreover when Leonardo talked about his erectile dysfunction the therapist was particular careful to her own non-verbal behavior in order not to be felt as spiteful which was extremely possible given the patients expectations of being ridiculed , and to Leonardos one. She tactfully noted any sign of shame in order to talk about possible feelings of being judged by the therapist:

T: Ive noted that as you talked about your sexual difficulties with Tiziana you stopped gazing at me, lowered your eyes and turned your gaze on my desk. I feel you are embarrassed I understand you, you are telling me very intimate things and it is so common feeling ashamed when telling about sexual problems how do you feel now? Do you feel Im judging you, considering you inept or inferior?

Leonardo found talking about feelings of shame and inferiority relieving and continued discussing them with a relative ease, acknowledging the therapist was sincerely non-judgmental and empathic.

Good markers: During the first months he never displayed other signs or discomfort toward the therapist apart shame, nor he was overtly critical at the therapist, which could have been expected given his tendency to derogate women when a minimal degree of intimacy had been reached.

Currently Leonardo has a stable romantic affair. He lives with Giulia since 1 yr and 6 months

His belief no one could like him and hes not able to court a lady with success because he is not bright, is goofy and inept is held with much less convintion.

Indeed thnaks to shared plamming he exposed himself to court the most dangerous girl, that is the cutest! He avoiced ones he considers shy or inept or ones that were interested in him first. Planning such exposure courting a gorgeuous girl!!! helped him changing his maldaptive interpersonal pattern

Though Leonardo acknowledges the existence of some recurrent themes rooted in his developmental history: the others doesnt accept for who I am; they want to change me, they criticize me harshly and theyll never absolve me. They dont take me seriously, dont respect me. No one longs for me

He still struggles for distinguishing between these fantasies and reality (lack of metacognitive differentiation).

He realizes at times that his fantasies the others purposefully criticize and disagree with him are his biased tendencies to interpret events.

Most often he reacts to impending humiliation and domineering attitudes of the others as they were true, as it was in his family

Tends to worry when engaged in such thougths

Does not recognize the impact his actions have on others. Therapy goal: experimenting gradual exposure to intimacy with his girlfriend!!! Im serious! That was the actual goal!

Leonardo and his therapist decide to ask Giulia to share one activity he tends to share only with friends

A sacred one

Really sacred

L. The experiment failed with this girl I just cant share anything! T (asks for AM): Do you wanna tell me how the night went? E. Saturday night we stayed really fine she was sweet, not aggressive at all. We had made low and it was good. I thought I could try and check what we talked about last session. I was happy to invite her... I asked her if she wanted to see the football match with me and my friends.

T. How did Giulia react to your invitation? E. She was delighted T. And then? E. I told her what we thought last session: I todl her in advance that when I watch football on TV Im quite catathonic, I just communicate via text messages, and just with friends. So if I wont talk with her she shouldnt get hurt. T. Well, excellent! And how did Giulia react to your specifications?

L. She was calm, she said Ok. Then she sat on the sofa with me and stayed in silence OF NOTE THIS WHAT ITALIAN MEN WANT THEIR WOMEN DO

! !

T. And how did you feel with Giulia near you? L. Well, it was strange at times I worried she could get bored, sometimes she could think Im a stupid in getting so excited for a football match, and gave my best swearings when my team was in trouble

T. .well, its hard for a supporter avoiding this, its a part of the game, dont you believe? Your friend were doing the same why thinking you could be judged for this?

L. .yes yes, its my usual fear returning you are right, the way I was watching the game was normal but its always that idea that if someone looks into my personal life will sure see something wrong

T. correct!

L. and then things started going bad! at the end of the match we went into the kitchen because Sara had brought a cake while I was keeping sending text messages with my friends about the match to tell you the truth I wasnt paying attention to her.

At a certain amont she got crossed telling I was not paying any attention to her. She brought the cake and the flowers and I couldnt care less she resigned because it was too painful staying with some so detached whos not interested in her

T. How did you feel then? What did you think about this reaction from Giulia?

L. That she is nut! A foul! A foul! But what does she want? She wants to deprive me of my freedom?!? You see Im not good to her for what I am I invite you home and then you make all that mess! Shes mad!!! I dont want a woman like her earlier I though I couldnt have her, but now I dont want her they want to subjugate you change you in what they want.

Its been very difficult for the therapist not to take Giulias side!!!
!

But this would have put strains on the alliance. The therapist felt compelled to try and promote Leonardos understanding of Giulias mind but very likely this would have led Leonardo representing her as the usual hostile woman who criticizes him and wants to change him.

So

The therapist focuses instead on how much the patient was overwhelmed by the idea the other wants to dominate him, criticize him, subjugate him and limit his freedom. So she understands her tendency to fly away as acceptable, consistent with his fears

With this intervention the therapist underscored how much Leonardo once again was fighting with the typical critical and rejecting other who tells him what he does is wrong (mother, father, brothers) Leonardo realizes that the past is still hoovering on him So he considers his reaction to Giulia not anymore as righteous and appropriate but an automatism typical of him.

This awareness waxes and wanes

Outside the session its very difficult to him realize that Giulia is just suffering for being neglected and not criticizing harshly and then rejecting

As regard sexual life, things have changed very much Leonardo is able to relax with Giulia and have sex without sadistic fantasies, as long as he feels she is sweet, warm and nonjudgmental . Yes he is able sometimes to see her this way. So he wishes shes near. Sometimes

Sexual desire is not long subordinate to giving punishment though if the girl is not felt as warm he tends to walk away.

Patient and therapist share now the idea of how the capacity to have plesant sexual intercourses is related to anticipations of menace.

When Giulia is perceived as critical and judging Luciano tendency is to put her at distance and he losese sexual desire.

When he perceives as sweet and caring he feels safe and is attracted

STEP BY STEP SESSION PROCEDURES

Collect a detailed autobiographical memory (where, when, who, what, why) Identify links among events, affects, ideas and actions Identifying emotions, thoughts and desires
YES

NO

YES

Elicit associated autobiographical memories Overt reformulation of schemas Dominant Egosyntonic self-representations Access to healthy self/ Explore new ways of relating
YES

Back to stage setting until negative thoughts or affects are identified as sources of problems

Dominant negative selfrepresentations Distinguishing fantasy-reality/ Differentiate

Integrate different or formerly inconsistent self-other representations

Decenter/Acknowledge own contribution to interpersonal problems

Abstain from criticising/ Dont consider as a target

GIANCARLO DIMAGGIO
CENTER FOR METACOGNITIVE INTERPERSONAL THERAPY
www.centrotmi.com

gdimaje@libero.it

A 25 yrs. old patient Severe avoidant PD with passive-aggressive, schizoid and covert narcissism traits T: You feel disinterested in pursuing anything in your life. You say you are detached and life has no meaning for you. But when you describe the way you guide the team during your internet simulation games, you are full of energy. You describe how you want to lead the team, are able to motivate others and devise a strategy, and feel like sharing in something with others.

After repeated observations like these the therapist of this patient was able to motivate him to ask his fellow team members out for a pizza, which was the first real peer contact he had had in years.

The therapist should now create a context in which new actions and reflections can be used to enrich the patients life narrative with new scripts based on feelings of agency, autonomy, and fostering a sense of self-efficacy and self-esteem.

Accessing the healthy self-aspects and later giving them room in patients lives goes side by side with the re-emerging of dysfunctional narratives, which need to be seen from a different angle and not taken as true. In parallel: 1) promoting healthy self-narratives 2) taking a critical distance from dysfunctional life scripts

!" One

typical condition in which old patterns surface during behavioral experience/exploration is facing fear of social rejection. Patients with fear of social rejection and criticism, for example with a mixture of avoidant and obsessive-compulsive features, realize how they sense impending criticism deep within their bodies. They come to realize how this is an internalized attributional style, even in the absence of external cues. !" One patient, Geneva, 26 yrs. old, with a very severe PD with borderline, avoidant and passive-aggressive features, perfectionism, co-occurrent eating disorders and depersonalization, repeatedly stated that she felt unable to study in her university library because people would criticize her.

!"

After a difficult negotiation she tried to expose herself to this environment and she still reported being criticized, even if she acknowledged no one displayed any sign of rejection. It took more than one year of repeated exposure and reflection both in individual and group sessions for Geneva to understand that this pattern was automatic and not in line with signals coming from outside. Only recently has Geneva been able to date with a man and sleep with him, bearing in mind both what she thought beforehand: Im fat, ugly and stupid and hell laugh at me, and the actual sensations she felt It was hard to face the situation, but eventually I felt fine. He was kind to me. Now its up to me to do something different, that is not disappearing as usual through fear of being rejected.

!"

!" When,

for example, Geneva decided to go to study in university library and in the next group session reported this had not happened, the therapists validated the positivity of her focusing on the task and discovering that she held a selfimage so negative that she could not even face social contact. This helped foster self-reflection and let her realize further how that was mostly an internalized image.

!" In

the case of Lucien, a patient with a perfect match with the Narcissistic PD DSM 5 prototypes, traits of antagonism and perfectionism and prominent avoidant social behavior (see Dimaggio & Attin, 2012 for a thorough description of the therapy), planning involved first and foremost the awareness that his wishes for autonomy and exploration had always been met with parental criticism and rejection. He had, therefore, put together a life script in which any attempt at autonomy led to loneliness and the idea of being despicable. The result was that his innermost wishes were suppressed and unrecognized.

!" As

a consequence, planning involved becoming aware that his work as an assistant in his brother-in-laws law firm was unrewarding and not interesting to him; he kept him for principally for the sake of avoiding criticism in case he made his own choices; he also had to overcome his moralistic tendencies, which prevented him from leaving the job because he did not want to offend a relative. therapist and patient then discovered that a potential vocational area, consistent with his wish for autonomy, was nested in the patients passion for studying ancient history.

!" The

!" Lucien

then had to confront his parents perceived and actual negative reaction to the idea of studying archaeology. Finally the therapist and patient foresaw how going to the campus, talking with the staff in the university offices and conversing with other students would be extremely demanding tasks for him ,so that each of them had to be handled with great care. Thanks to this assessment, a new plan was formed which enabled Lucien to successfully get enrolled in a new university program.

!" We

would recall that planning contributes to the ultimate goal of obtaining a revised and enriched life script, which in the case of Lucien became something like: I am a person capable of working and having friends. I find pleasure in sustaining bonds. I am still concerned with the recognition issue and somewhat fear criticism, but I am able to carry on with my actions even when others are not praising me. We underscore that such a narrative must be grounded on actual autobiographical episodes discussed during sessions, avoiding the risk that it becomes an intellectualization not mirroring raw experience.

!" Arriving

at such a narrative involved Lucien first realizing how his wishes for autonomy were matched with expectations of being criticized and rejected by his parents, both actual and internalized. He then decided to face the pain of the expected rejection, supported by the therapists faith that he could tolerate such distress. Finally, he spent time exploring the university grounds and the library, overcame his parents skepticism about his ability to do so and faced up to all the related difficulties, both internal and external. !" We now provide details about the aims of what can actually be the most important aspect in promoting change and enriching the selfnarrative: Exploration/Behavioral change.

Before truly enriching the life-narrative, during behavioral exposure, old patterns surface again, trying to take control. At the same time as making room for new aspects of experience these patterns need to be revised repeatedly.
!"

This is usually the moment at which patients become aware not so much of the cognitive-semantic aspects of their meaning-making constructions, but of the affectiveprocedural ones, which are usually the hardest to change. !
!"

This is the moment at which not just ego-dystonic schemas are encouraged to surface and become an object of reflection, but ego-syntonic ones too. Patients with narcissism need to try and tackle their tendencies to be spiteful, resort to an ivory tower and enter into fights filled with frozen anger with partners and colleagues
!"

Patients with paranoid features need to become aware how much their attributions of malevolence to others come mostly from an inner perception of feeling vulnerable, inadequate and possibly subjugated, and slowly recognize that vulnerability is not a given truth, but a mental image they hold of themselves (Salvatore et al., 2012). !
!"

GIANCARLO DIMAGGIO
CENTER FOR METACOGNITIVE INTERPERSONAL THERAPY
www.centrotmi.com gdimaje@libero.it