Metacognitive Interpersonal Therapy for Personality Disorders

A treatment manual

Giancarlo Dimaggio, Antonella Montano, Raffaele Popolo, Giampaolo Salvatore

• Publisher: Routledge
• Year: 2015
• Print ISBN: 9781138024182
• eBook ISBN: 9781317591177
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Patients with personality disorders need targeted treatments which are able to deal with the specific aspects of the core pathology and to tackle the challenges they present to the treatment clinicians. Such patients, however, are often difficult to engage, are prone to ruptures in the therapeutic alliance, and have difficulty adhering to a manualized treatment.

Giancarlo Dimaggio, Antonella Montano, Raffaele Popolo and Giampaolo Salvatore aim to change this, and have developed a practical and systematic manual for the clinician, using Metacognitive Interpersonal Therapy (MIT), and including detailed procedures for dealing with a range of personality disorders. The book is divided into two parts, Pathology, and Treatment, and provides precise instructions on how to move from the basic steps of forming an alliance, drafting a therapy contract and promoting self-reflections, to the more advanced steps of promoting change and helping the patient move toward health and adaptation.

With clinical examples, summaries of therapies, and excerpts of session transcripts, Metacognitive Interpersonal Therapy for Personality Disorders will be welcomed by psychotherapists, clinical psychologists and other mental health professionals involved in the treatment of personality disorders.

Chapter 1
Personality disorder psychopathology

Form and contents of subjective experience

Once the important aspects of personality pathology have been defined it is possible to develop reliable tools for conceptualising the case in a ready-to-use way and then for accurate treatment planning. Personality disorders (PDs) are complex pathologies, contributed to by various aspects, whether temperamental, learnt or developmental, and dysfunctions in relationships and in the capacity to understand mental states. They include difficulties in undertaking independent actions, regulating affects and consciously managing subjective suffering.

The areas delineating PD psychopathology and which are focused on by metacognitive interpersonal therapy (MIT) are the following:

• impoverished narratives/intellectualising narrative style;
• limited or fluctuating sense of agency;
• pathogenic interpersonal schemas;
• dysfunctional interpersonal cycles;
• recurring mental states;
• metacognitive dysfunctions;
• maladaptive forms of coping and cognitive biases;
• problems regulating affects.

Given that in this book we are proposing a treatment model that can be applied consistently to all the PDs treated, we are not going to systematically describe how each area is altered in each single disorder. The reason for this choice is that, on the one hand, there are numerous dysfunctions and elements of subjective experience appearing transversally in the various disorders and, on the other, the co-occurrence among the various PDs and the presence of dysfunctional personality disordered traits of one in another PD render the pathology boundaries fuzzy. As regards mental states, the forms of subjective experience reoccur in the various PDs and there is no mental state that is pathognomonic of one disorder. Certainly disdainful grandiosity characterises narcissism but also surfaces in avoidant PD as a result of positive reinforcements of self-esteem. Diffidence towards others seen as humiliating, mocking and threatening is the most evident feature of paranoid PD but avoidant PD displays it in the same way and many vulnerable narcissists experience this same state. Harsh criticism, driven by morally perfectionist standards, is characteristic of obsessive-compulsive PD and is also found in passive-aggressive, depressive and narcissistic PD and, directed mainly towards the self, in avoidant PD.

The same applies to metacognitive dysfunctions. No single dysfunction in the system for comprehending mental states is specific to one PD and many have been found to varying degrees in several disorders. There is a lack of convincing research evidence to show that each PD has its own characteristic metacognitive malfunctioning profile (Carcione, Semerari, Nicolò et al., 2011; Dimaggio, Semerari, Carcione et al., 2007; Dimaggio, Carcione, Conti et al., 2009; Semerari, Dimaggio, Nicolò et al., 2005).

The rationale for our description of psychopathology is, therefore, to provide clinicians with an insight into the alterations in cognitive/affective processes, interpersonal and metacognitive functioning and what patients typically think and feel, to give them the ability to construct patient-specific case formulations. We shall, however, point out what aspects are most closely linked to specific disorders. The reader will therefore be able to recognise that shame, avoidance of relationships in which one feels judged and difficulties in naming one’s own emotions are elements that frequently point to avoidant PD. Shifts between icy and contemptuous rage and emptiness, the idea that others are hampering the pursuit of one’s goals and a proneness to get paralysed when the other does not provide admiration, together with a tendency towards an intellectualising narrative style, probably point to narcissism.

In this chapter we will concentrate on the pathologies of both the narrative structure and the contents of experience, while in the next chapter we will describe metacognitive dysfunctions, reasoning biases, maladaptive coping, and difficulties in regulating affects and behaviour.

Impoverished narratives/intellectualising narrative style

We define impoverished narratives as a difficulty in recalling rich and detailed autobiographical memories describing the cognitive, emotional and somatic aspects of subjective experience, as well as a true and proper lack of conscious personal memories establishing one’s identity and guiding one’s actions. Patients with personality disorders or dysfunctional traits such as narcissistic, avoidant, obsessive-compulsive, paranoid, dependent and passive-aggressive, depressive and schizoid experience difficulty using episodes from their own autobiographies to explain their suffering and psychological problems to others (Dimaggio, Salvatore, Popolo et al., 2012; Spinhoven, Bamelis, Molendijk et al., 2009).

They often motivate their requests for psychotherapy in only vague terms or ascribe their problem to external causes, based on generic theories about human functioning. They offer abstract reasons and intellectualisations about others hampering their goals or undermining their possibilities of living a successful life (Dimaggio, Salvatore, Fiore et al., 2012). A clinician may see a static and scarcely outlined self-portrait. The narrative style is of the intellectualising type and the use of autobiographical memory to make meaning of events is marginal.

Giulia is a typical example of intellectualising narrative style. She suffers from generalised anxiety disorder and hypochondria, and has difficulties in her relationship with her partner. She is 33 years old, has a five-year-old son and works as the press officer for a political party. She suffers from passive-aggressive PD and below threshold obsessive-compulsive PD, and complies overall with 16 SCID-II criteria. We shall describe her history in more detail in the chapters about treatment. In her third session she talked about how she had reacted to an anonymous telephone call, whom she recognised was the partner of her lover. Because of the abstract way in which she narrated, it was not possible, however, for the therapist to grasp her inner world:

Patient: On my side there’s been a fall in my feelings for him because I’ve had so many experiences like that regarding relationships. It’s been a journey made up of little things. Perhaps not even the subject of a total, spoken, evident, explicit becoming aware and then, how can I say, a gesture counts and reveals everything, doesn’t it? What we hadn’t said to each other too … in this case this calling me on Sunday of his, he’d become desperate because he was alone, he’d been abandoned, hadn’t he? This searching for me, but not as a specific striving towards me, but as a stage in his desperation. This made me give him a wide berth because I however much it’s a little human to stretch out to another person to react to the suffering that they give you, however one should try a bit, how can I say?¹ … And then he’s a bit insistent in this, let’s say, that is he’s a very delicate person, isn’t he? Then one feels a bit overbearing too saying one hundred times ‘No, I don’t want to any more’, doesn’t one? … Last night I was trying to find an explanation for these things and he was. He could hear from the tone that it was a fight, an argument I mean. It was as if he was, let’s say, not up to conflict, that’s it!

As one can see, Giulia has a strong tendency to resort to generalisations and consequently provides very little information about her own inner world. Faced with comments like ‘It’s been a journey made up of little things. Perhaps not even the subject of a total, spoken, evident, explicit becoming aware and then, how can I say, a gesture counts and reveals everything, doesn’t it?’ can lead the therapist to feel disoriented. What does Giulia feel? What does she think? How did others affect her feelings or thoughts? Giulia describes other’s behaviours as ‘but as a stage in his desperation’, which does not allow the clinician to form an idea of his own. What does a person ‘not up to conflict’ think and feel? Moreover, Giulia often uses the third person (e.g. ‘one feels a bit overbearing too’), which forces the therapist to ask himself to whom she is referring.

To understand the patient, the clinician requires circumstantiated and contextual descriptions of suffering and the factors making it arise and persist, which is what we refer to as narrative episodes regarding interpersonal relationships. A good narrative episode is characterised by the following. It is communicating a specific autobiographical memory that took place within precise spatial (where) and time (when) boundaries. The actors on stage need to be identified (who) and there should be dialogue between the actors. Lastly, the topic covered (what) and the reason for which the story is being related (why) should be communicated (Neimeyer, 2000).

Narratives by patients suffering from PD often do not comply with these requirements. The stage where the action takes place is typically undefined and the time boundaries are often vague. The others are described in a generic fashion – ‘people’, ‘colleagues’, ‘men’, ‘women’, ‘relatives’ – and behaviours are explained on the basis of stereotypes or generalisations.

For example, when asking a narcissistic patient with paranoid traits reasons for his difficulties with relationships he may restrict himself to generic statements like: ‘I have to keep women at a distance because they try to trap me and restrict my freedom.’ A patient with avoidant PD and dependent traits declares: ‘If I lose my girlfriend, no woman will want me anymore because I’m useless.’ Statements like these provide very little information about what is actually eliciting thoughts and emotions that cause suffering, and they leave clinicians without the necessary data to understand the patient’s functioning.

An example of impoverished narrative comes from Riccardo, a 30-year-old biologist with a severe avoidant personality disorder, with passive-aggressive and schizoid traits and covert narcissism features. He attempted suicide by cutting his veins in a park the year before starting therapy. A few months after starting treatment he began an affair with a woman but he denied he was romantically involved and it was not possible to pick up any verbal indicators of a real interest in this person. When his therapist tried to ask him why he had started the relationship, Riccardo was unable to provide clear reasons, except for sexual ones. He resorted, rather, to abstract explanations to convince himself and the therapist that there was no relation whatsoever by stating, ‘We’re different in every respect. Our families have different backgrounds and her friends are all far left, while I’m right of centre.’ Riccardo expatiated in his theorisations. He was affectively flattened and described himself as ‘one able to surf between situations. I’ve got my way of navigating with a certain stylishness so as to manage any possible problems, which then in fact do not necessarily crop up.’ The therapist as a result had trouble grasping how Riccardo felt and why he acted in a certain way. Requests for autobiographical details led only to a minimal enrichment of an action scenario. Riccardo’s ability to access autobiographical memory was seriously hampered.

To make a joint case-formulation with the patient, the clinician needs details of the latter’s subjective experience in order to determine what impacted his behaviours during stressful interpersonal circumstances. In MIT, therapists do not look for abstract causes to ascribe to events but instead look at the ways in which patients, in specific situations of their episodes and interaction with others, think and feel and how thinking and feeling are at the root of their suffering and how it influences behaviour that hampers their well-being and stability of their relationships.

One reason for persisting in the search for specific autobiographical episodes is that these facilitate access to emotions (Gonçalves, Mendes, Cruz et al., 2012). People somewhat unconsciously evaluate significant and important events on the basis of their goals and these evaluations elicit emotions which then assume control of all behavioural systems. Emotions are the force driving actions. Emotionally driven behaviour is, therefore, at the top of the list of things a therapist should investigate. Abstract theories, on the other hand, provide little or no knowledge of the processes associated with emotions.

The narratives of the PD patients described here are lacking emotions and the patients have difficulty identifying both positive and negative emotions. This is a core aspect of the metacognitive dysfunction we will be discussing in Chapter 2. PD patients also underrate emotions, have difficulty labelling emotions, repress emotions and do not use them as a guide to social action, replacing them with general theories about the functioning of the human mind.

A good autobiographical memory, therefore, will include information from which one can deduce the wish pushing the person to act, what he did or thought to achieve it or what the conditions were as a result of which he thought it would be achieved, how the others responded and how the patient reacted to the others’ response. Typically in the impoverished narratives of patients suffering from PD, one or many of these elements are difficult to pinpoint.

PD patients display varying degrees of impoverished narratives but there are important individual differences. Some manage to describe recurring scenes but have trouble focusing on a specific episode. Others, on the other hand, are almost totally unable to transform the reasons for their problem into a narrative.

It is possible for autobiographical memories to have been simply not stored in long-term memo...

Table of contents

• Cover
• Title
• Copyright
• Contents
• List of abbreviations
• Introduction
• 1 Personality disorder psychopathology: form and contents of subjective experience
• 2 Personality disorder psychopathology: functions
• 3 Assessment and case formulation in metacognitive interpersonal therapy
• 4 Step-by-step formalised procedures
• 5 Therapeutic relationship
• 6 Shared formulation of functioning: enriching autobiographical memory, improving access to inner states and reconstructing schemas
• 7 Promoting differentiation
• 8 Construction of new self-aspects: access to self-parts, exploration, increase in agency, overcoming avoidances
• 9 Promoting the understanding of the other’s mind and integration
• 10 Treating symptoms and promoting mastery of relational problems
• 11 Comparison of metacognitive interpersonal therapy and cognitive behavioural therapies
• Appendix: Diagnostic instruments usually adopted in MIT
• References
• Index