The ongoing rewriting of the therapeutic contract in Metacognitive Interpersonal Therapy for narcissistic personality disorder: The case of Mark.

In order to effectively treat individuals suffering from Narcissistic Personality Disorder (NPD), it is crucial to establish therapeutic goals and identify tasks to achieve them. However, this is a challenging process with NPD patients because they often struggle to find meaningful goals beyond the pursuit of status. Moreover, in order to change Furthermore, to promote change, they must confront painful emotions such as shame, guilt, or fear, which they habitually try to avoid. Additionally, they face difficulties in forming a positive perception of their therapists and cooperating towards mutually agreed-upon goals and tasks. As a consequence, NPD patients ask for change but hardly engage themselves in the work necessary to achieve it. Therapists therefore need to pay the uttermost attention to drafting, negotiating and continuously updating a reasonable and realistic therapeutic contract. In this paper we describe the story of a man in his thirties with NPD who was ridden with depression, guilt, envy and anger and did not find ways to pursue the healthy and adaptive behaviors he would need to pursue in order to leave a richer social life. The therapist overcame ruptures in the therapeutic alliance and then involved the patient in a process where they set the steps to follow, making sure the patient was convinced they made sense. After a contract was reached progress became possible. Implications for the role of the therapeutic contract in NPD treatment are discussed.

Arts and psychomotor therapies in personality disorder treatment: An appropriate therapeutic entrance to personal development: A commentary.

Personality disorders (PD) are based not just on maladaptive ideas about self and others, they also are grounded on embodied patterns of behaviors and reactions to interpersonal stressors. There is growing interest in working with the body and through the body so to address automatisms that lead to suffering and dysfunctional social action. In this issue of the Journal of Clinical Psychology: In-Session the use of art and psychomotor therapies for these patients was explored by seven different clinical perspectives. Patients described presented with different PD and associated symptoms. The arts and psychomotor therapies deployed in personality disorder treatment are: (visual) art therapy, music therapy, drama therapy, dance (movement) therapy, and psychomotor therapy making psychotherapeutic use of the different modalities: art, music, play, role-play, performance, improvisation, dance, body awareness and movement. Interventions provide kinesthetic, sensory, perceptual, and symbolic opportunities to invite alternative modes of meaning-making, accessing own needs and wishes, and communicating them to others. In this commentary we summarize some of the different topics covered by the clinical-based papers, including working mechanisms of arts and psychomotor therapies, the importance of bottom-up emotion regulation processes, how to treat trauma in the presence of a PD, how to integrate art and psychomotor therapies in a fine-grained formulation and how to understand the process of change. Although there is a need for more empirical research, we hope this issue makes a solid case that clinicians can effectively include art and psychomotor therapies when treating the full range of PD.

What do we need in order to successfully treat persons with pathological narcissism? How does change happen? Treatment principles and mechanisms of change emerging from single cases treated by experts: A commentary.

Persons with pathological narcissism (PN) or narcissistic personality disorder present with a wide array of symptoms and social problems. They need effective psychotherapies but empirical evidence for what works with them is mostly lacking. In this issue of the Journal and Clinical Psychology: In Session four authors from different orientations described single cases of patients suffering from different manifestations of PN. In this commentary we reviewed in detail the four cases and tried to distill (a) the treatment principles adopted; (b) the actual mechanisms of therapeutic change. We hope that the list of principles and mechanisms and change we identified here can help both clinicians and researchers develop and test effective options for persons with PN who are difficult to treat but do have chances to change in a meaningful way in treatment.

Working through the body in metacognitive interpersonal therapy to change relational patterns in dependent personality disorder: The case of Lia.

Persons with dependent personality disorder (DPD) have difficulties describing their inner world, and in realizing their negative ideas about the self, such as being weak, unworthy or powerless are just ideas. As a consequence, they tend to over-rely on others and may lose control over their emotions. Treating these persons can gain benefits from including body-focused techniques as they can promote a) awareness of internal states, b) better emotion regulation, c) the capacity to consider their negative ideas about themselves as not necessarily true, and d) gain power of and agency. We will describe the therapist used body-focused techniques in the context of Metacognitive Interpersonal Therapy when treating Lia, a 40-year-old woman suffering from DPD who also suffered from generalized anxiety disorder and had difficulties in making autonomous choices. She had a romantic relationship with a man she described as distant and judgmental so she felt lonely and not entitled to express her discomfort or capable to break up. The therapist used body-focused techniques, together with behavioural exposure, mindfulness and guided imagery, to let Lia be more aware of her thoughts and feelings, and then to regulate affects and realize she had previously capacities. At therapy termination anxiety diminished and she could break up with the partner and start a new one where she felt free to express herself. We suggest how bodily-focused techniques can be used to enhance therapy effectiveness in DPD.

Homework assignments in relational psychoanalytic treatment of personality disorders: A case study of a patient with narcissistic personality disorder.

Homework assignments, or specific tasks patients are asked to engage in or complete between sessions, are a controversial topic among psychoanalysts. While many argue these interventions contradict psychoanalytic principles, others believe they can help address problems and promote coping skills. We propose that homework can be a legitimate aspect of relational psychoanalysis when used in a way that is attuned to the patient's experience and that homework may be an important component of treating personality disorders (PD). We present the case of a man diagnosed with narcissistic PD. He often felt superior to and reported that he despised others, though the core self-image was of fragile. He embraced the role of the omnipotent caregiver, which came with boredom and anger and lack of satisfaction in his social life. The patient tried to control therapy, asserting that he could psychoanalyze himself. As a result, therapy was stalled and progress was limited. At this point, the therapist asked him to complete homework assignments that encouraged him to refrain from his compulsive caregiving to better understand what motivated this behavior. Through this process, the patient came to realize he acted out of avoidance, as he did not want to disclose his own vulnerabilities and flaws. At that point he was able to experience relationships while adopting different stances and finding new meanings. We argue that homework can be fully integrated into the relational psychoanalytic repertoire to improve self-reflection and foster change in patients with PD.

A pilot randomized controlled trial comparing a novel compassion and metacognition approach for schizotypal personality disorder with a combination of cognitive therapy and psychopharmacological treatment.

BACKGROUND: Schizotypal personality disorder is characterized by a pervasive pattern of maladaptive behavior that has been associated with the liability for schizophrenia. Little is known about effective psychosocial interventions. This pilot non-inferiority randomized controlled trial aimed to compare a novel form of psychotherapy tailored for this disorder and a combination of cognitive therapy and psychopharmacological treatment. The former treatment - namely, Evolutionary Systems Therapy for Schizotypy-integrated evolutionary, metacognitively oriented, and compassion focused approaches. METHODS: Thirty-three participants were assessed for eligibility, twenty-four randomized on a 1:1 ratio, nineteen included in the final analysis. The treatments lasted 6 months (24 sessions). The primary outcome was change across nine measurements in personality pathology, the secondary outcomes were remission from diagnosis and pre-post changes in general symptomatology and metacognition. RESULTS: Primary outcome suggested a non-inferiority of the experimental treatment in respect to control condition. Secondary outcomes reported mixed results. There was no significant difference in terms of remission, but experimental treatment showed a larger reduction of general symptomatology (η2 = 0.558) and a larger increase in metacognition (η2 = 0.734). CONCLUSIONS: This pilot study reported promising results about the effectiveness of the proposed novel approach. A confirmatory trial on large sample size is needed to provide evidence about relative effectiveness of the two treatment conditions. TRIAL REGISTRATION: ClinicalTrials.gov; NCT04764708; Registration day 21/02/2021.

The interplay between therapeutic relationship and therapeutic technique: "It takes two to tango".

The idea that the therapeutic relationship is at the core of psychotherapy is shared by most therapeutic approaches. Also, an increasing variety of therapeutic approaches, consider experiential techniques as central tools to promote effective therapeutic change. Commonly, it is argued that the creation of a positive, empathic, safe, and solid therapeutic alliance should be a prerequisite for administering these techniques. However, recent evidence is beginning to challenge this cautious stance showing that the introduction of experiential work early in therapy can be safe and effective. So, the quality of the therapeutic relationship may either facilitate or hinder the use of experiential techniques, but the use of these techniques may also strengthen or cause ruptures in the therapeutic alliance. So how do we balance the attention to the therapeutic relationship and the use of active, emotionally arousing techniques? In this paper, we present an issue of the Journal of Clinical Psychology: In Session exploring the complex interplay between therapeutic relationship and experiential practices in light of different psychotherapeutic approaches. We do so by first providing an initial overview of the topic. Next, we introduce the five papers of the issue along with some thoughts on how authors from diverse psychotherapeutic orientations contributed to illustrate and reflect on this multifaceted "dance" between therapeutic relationship and techniques.

The interplay between therapeutic relationship and therapeutic technique: The whole is more than the sum of its parts.

The interplay between the therapeutic relationship and experiential techniques is powerful. The whole is more than the sum of its parts. Therapeutic relationship predicts therapy outcomes, especially when this involves shared goals, agreed methods, and a strong interpersonal bond. When patients feel safely held in a therapeutic relationship, they feel more confident and willing to participate in experiential techniques. Conversely, the therapist's careful, purposeful implementation of techniques can help strengthen the therapeutic relationship. While the interplay between relationship and technique can be complicated, resulting in rupture, carefully repairing ruptures can both strengthen the relationship and increase willingness to engage with techniques. We comment on five case studies from this issue of the Journal of Clinical Psychology: In Session. We review the literature regarding this interplay between relationship and technique, summarize the case studies and lessons learned, consolidate the findings into a framework, and propose avenues for future therapy consideration and research.

Experiential techniques and therapeutic relationship in the treatment of narcissistic personality disorder: The case of Laura.

Experiential techniques can be used to address maladaptive interpersonal patterns in patients with personality disorders (PDs) as long as they are delivered minding about the therapeutic relationship. We present the case study of Laura, a 38-year-old woman presenting with covert narcissism, generalized anxiety disorder, depression, and complicated grief treated with metacognitive interpersonal therapy. Laura initially refused to engage in any experiential work out of fear of being judged and abandoned by her therapist. To navigate this therapeutic obstacle, the therapist focused on exploring and eventually repairing early alliance ruptures. Thereafter, Laura engaged in experiential work, which helped her address her narcissistic interpersonal patterns. After 2 years, Laura's symptoms and narcissistic problematic behaviors decreased. This case study can help us understand how experiential techniques can be successfully used in PD psychotherapy as long as attention to the therapy relationship is paid.

Treating Avoidant Personality Disorder With Combined Individual Metacognitive Interpersonal Therapy and Group Mentalization-Based Treatment: A Pilot Study.

ABSTRACT: Avoidant personality disorder (AvPD) is a severe but understudied condition. The current pilot project reports data on acceptability and outcomes of a novel treatment combining biweekly individual metacognitive interpersonal therapy (MIT) and weekly mentalization-based therapy (MBT) group therapy. A total of 30 patients with AvPD were consecutively included in the program. The primary outcome was AvPD-specific personality functioning measured by self-report after treatment. Secondary outcomes were symptom distress, interpersonal problems, quality of life, and psychosocial functioning. Twenty-two patients completed treatment, with a mean duration of 13 months. On the primary outcome, effect sizes were generally moderate to large (effect size range: 0.59-1.10). On secondary outcomes, effect sizes were large (effect size range: 0.77-2.3). Both in terms of acceptability and outcomes, results are promising for the combination of MIT and MBT for AvPD. The approach is a strong candidate for further investigation in future large-scale randomized controlled trial.

Treating intimate partner violence with metacognitive interpersonal therapy: The case of Aaron.

Intimate partner violence (IPV) is responsible for loss of lives and significant psychological, financial, and social costs. Research into therapeutic effectiveness show inconsistent results irrespective of therapeutic orientation. The capacity to understand one's own mental states as subjective and distinct from others is an important factor in the regulation of mental states and physiological arousal associated with the perpetration of IPV. Metacognitive Interpersonal Therapy (MIT) offers an innovative approach in working with male perpetrators of IPV. The current paper outlines 14 sessions of MIT with a 45-year-old male perpetrator. A core aspect was helping the client resolve how his view of self and others were subjective experiences that were distinct from relational objectivity. The emergence of healthy self-narratives was fostered through experiential processes, involving guided imagery, rescripting and body focused interventions. Qualitative outcomes are summarized and implications for the use of MIT in treatment of perpetrators of IPV is discussed.

Metacognitive interpersonal group therapy for adolescents with avoidant personality disorder: The case of Sofia.

INTRODUCTION: Early intervention studies for adolescents and early adults are required to explore the acceptability and effectiveness of psychological therapies across the full range of personality disorders (PDs) beyond just borderline PD. The main aim of the current paper was to describe a Metacognitive Interpersonal Therapy group adaptation for adolescents (MIT-GA) presenting with PDs featuring overcontrol and social inhibition, and in particular Avoidant PD characteristics. METHODS: We report findings from a single case of a female adolescent diagnosed with Avoidant PD providing preliminary data on feasibility and the possible effectiveness of MIT-GA. RESULTS: Evidence of acceptability and meaningful clinical gains are described. CONCLUSIONS: Results suggest that MIT-GA could be a powerful treatment option in patients with generalized social avoidance who do not currently receive gold-standard psychotherapeutic treatments. This intervention also appears to be effective and cost-effective in initiating significant clinical changes in profiles of young patients with non-borderline PD symptoms.

A case study on a severe paranoid personality disorder client treated with metacognitive interpersonal therapy.

Paranoid personality disorder (PPD) is a severe condition, lacking specialized and empirically supported treatment. To provide the clinician with insights into how to treat this condition, we present a case study of a 61-year-old man with severe PPD who presented with ideas of persecution, emotionally charged hostility, and comorbid antisocial personality disorder. The client was treated with 6 months of Metacognitive Interpersonal Therapy, which included: creating a shared formulation of his paranoid attitudes; trying to change his inner self-image of self-as-inadequate and his interpersonal schemas where he saw the others as threatening. Guided imagery and rescripting techniques, coupled with behavioral experiments, were used to promote a change. At the end of the therapy the client reported a reliable change in general symptomatology and, specifically, in interpersonal sensitivity, hostility, and paranoid ideation; he could no longer be diagnosed as PPD and only some paranoid and antisocial characteristics remained.

Building the alliance and using experiential techniques in the early phases of psychotherapy for avoidant personality disorder.

Individuals experiencing avoidant personality disorder (AvPD) tend to make sense of social interactions via maladaptive self-and other attributions. They also experience difficulties in recognizing emotions. A further feature of AvPD psychopathology is the tendency to resort to maladaptive coping strategies, such as behavioral avoidance and perfectionism. Despite its impact, psychological treatments for AvPD remains poorly investigated. Herein, we describe the first five sessions of Metacognitive Interpersonal Therapy with a 28-year-old woman, whose treatment goal was to reduce social avoidance. We describe how this goal was achieved through a combination of working through the therapeutic relationship, alongside experiential techniques such as guided imagery, rescripting, and bodily work. Through this treatment configuration, the patient was able to increase self-awareness of her own emotions, enabling her to realize that she was guided by rigid schemas; specifically seeing herself as inadequate and others as judgmental. Finally, implications for the treatment of AvPD are discussed.

Metacognitive Capacity Is Related to Self-Reported Social Functioning and May Moderate the Effects of Symptoms on Interpersonal Behavior.

Impairments in metacognition or the ability to form integrated senses of self and others have been linked to deficits in laboratory-based measures of social functioning in schizophrenia. This study examined whether self-reported social functioning was related to metacognition in 88 adults in a nonacute phase of schizophrenia. Concurrent assessments were made of metacognition with the Metacognition Assessment Scale-Abbreviated, social functioning with the Social Functioning Scale, symptoms with the Positive and Negative Syndrome Scale, and neurocognition with the Wisconsin Card Sorting Task. Univariate correlations revealed that self-reported social functioning was related to metacognition. Symptom severity was linked to interpersonal relationships, and overall metacognition was found to significantly moderate that relationship such that the effects of symptoms on function grew less as metacognitive capacity was stronger, independent of the effects of neurocognition. This may suggest the potential of metacognitive interventions to titrate the negative effects of symptoms on social function.

Giving a Voice to Gambling Addiction: Analysis of Personal Narratives.

Gambling addiction (GA) is now considered a worldwide health issue. Although the topic of disorder awareness is a central issue in clinical practice, there are few studies examining this dimension in relation to GA. To bridge this gap, we conducted a qualitative study, administering interviews focused on awareness of GA and eliciting narratives of both the disorder and the whole life of participants. We adopted both qualitative and quantitative methods of research, using computer-aided content analysis. We administered to a sample of 15 treatment-seeking gamblers the Psychiatric Interview for Gambling Addiction and performed a qualitative analysis of the text using the T-Lab software. Five main thematic domains and four factors emerged, shedding light on specific aspects underlying the development of and recovery from GA. Specifically, the results suggested that dissociation processes, materialistic thinking and difficulties in social achievement underlie the subjective experience of GA. Moreover, closeness in interpersonal relationships and awareness of the disorder emerged as core features in the process of change. As a whole, the results highlight the specificities of disorder awareness in addicted gamblers. We discuss these results within the context of previous research and suggest clinical implications for the treatment of GA.

Struggling with perfectionism: When good enough is not good enough.

Perfectionism includes a tendency for high standards for self and others with a clear goal of successful performance in a variety of areas. A perfectionist often reacts with critical evaluations whenever performance falls below these standards. Moreover, perfectionists emphasize personal goals to gauge their worth, neglecting intimate bonds or openness to new experience. At the core of perfectionism lies a view of self as weak, flawed, and easily rejected. Perfectionism can result in chronic tendencies for emotional distress and interpersonal conflict. Treatment aims to explore personal views of self and others, viewing perfectionism as a form of maladaptive coping. When clients understand the role of perfectionism, they can discontinue striving to meet their extreme goals and unrealistic standards. The authors of the papers in the issue present their views on how to treat these maladaptive tendencies according to their preferred therapeutic orientation.

The intertwined path of perfectionism and self-criticism in a client with obsessive-compulsive personality disorder.

Psychotherapy for obsessive-compulsive personality disorder (OCPD), where perfectionism is a defining criterion, is understudied. Despite a high prevalence few evidence-based treatments are available for the presentation. Here we describe the course of a 6-month program of metacognitive interpersonal therapy with an OCPD patient with prominent perfectionism and self-criticism, which were considered primary outcomes of the case study. Therapy aimed initially at increasing awareness of maladaptive interpersonal schemas and promoting a healthy self. First, behavioral experiments were used to try and counteract perfectionism. Second, experiential techniques, such as guided imagery and rescripting, were used to help the client in connect with different, healthier aspects of the self, thus increasing personal and interpersonal wellbeing. Qualitative and quantitative outcomes at the intervention end and at 1-month follow-up are summarized. Finally, we reflect on how this case study can inform treatment of perfectionism in OCPD.

Metacognitive Interpersonal Mindfulness-Based Training for Worry About Interpersonal Events: A Pilot Feasibility and Acceptability Study.

Individuals with personality disorders experience worry and repetitive thoughts regarding interpersonal scenarios. Mainstream mindfulness-based approaches may be insufficient to soothe these individual's distress due to difficulties in letting thoughts go and refocusing attention to the present moment. For this reason, we devised an adapted form of mindfulness-based program called Metacognitive Interpersonal Mindfulness-Based Training (MIMBT) for personality disorders. In this pilot study, 28 individuals attended nine weekly sessions to evaluate the feasibility and acceptability, and to establish preliminary outcomes. All individuals completed the program. Attendance was very high (96%). Significant changes were observed on the primary outcome of reduction in repetitive thinking, measured using the Metacognition Questionnaire-30. We also observed a decrease in depression severity. Despite important limitations, this pilot study suggests that MIMBT has the potential to be a viable and well-accepted option for increasing positive outcomes in the treatment of personality disorders. Clinical considerations and directions for future research are discussed.

Disturbances in Self-Experience in Schizophrenia: Metacognition and the Development of an Integrative Recovery-Oriented Individual Psychotherapy.

BACKGROUND/AIMS: Disturbances in first person experience is a broadly noted feature of schizophrenia, which cannot be reduced to the expression of psychopathology. Yet, though categorically linked with profound suffering, these disturbances are often ignored by most contemporary treatment models. METHODS: In this paper, we present a model, which suggests that deficits in metacognition and their later resolution parsimoniously explain the development of self-disturbance and clarify how persons can later recover. We define "metacognition" as processes integral to the availability of a sense of self and others within the flow of life and report research suggesting its contribution to schizophrenia and link to self-disturbance. RESULTS: We describe a newly emerging integrative form of psychotherapy, Metacognitive Reflection and Insight Therapy (MERIT), designed to target metacognition and enhance the recovery of healthy self-experience. We describe eight measurable core elements that allow MERIT to be operationalized and discuss about how to address disturbances in self-experience. CONCLUSIONS: We detail research that provides evidence of the feasibility, acceptability, and effectiveness of MERIT across a broad range of patients, including those who might not otherwise be offered psychotherapy. MERIT represents one form of psychotherapy that may address self-disorders among adults with schizophrenia.