Management of the therapeutic relationship in a patient with Complex PTSD and Personality Disorder.

Individuals diagnosed with Complex PTSD (C-PTSD) have experienced repeated and often prolonged traumatic events. From a therapeutic perspective this can lead to difficulties in emotion regulation within-session, challenges with patient-therapist attunement, and impaired coregulation of emotions during therapeutic interactions. As a result, frequent therapeutic alliance ruptures can emerge, which in turn pose challenges for symptom-focused work. We describe a case study involving a 38-year-old woman presenting with C-PTSD, dissociation, anxiety and borderline and dependent personality disorder traits. We explore how difficulties in attunement and emotion regulation during therapy were mostly attributable to (i) maladaptive ideas regarding the self and others; and (ii) difficulties in recognizing both her own mental states and those of her therapist. For instance, the patient believed that the therapist was distant and critical; which she held to be fact rather than reflective of a mental state. We show how the therapist addressed these difficulties, incorporating repair of the therapeutic alliance, which enabled a return to symptom focused work. The case description offers guidance on how to maintain a dual focus on therapeutic alliance alongside symptoms when treating C-PTSD (with or without comorbidity).

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.

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.

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.

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.

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.

The problem of overcontrol: Perfectionism, emotional inhibition, and personality disorders.

BACKGROUND AND AIMS: Some individuals with Personality Disorders (PD), particularly of a non-Borderline type, present with difficulties relating to over-control of cognitions, emotion and behavior, perfectionistic traits, and impaired social interactions. The current study sought to evaluate the strength of association, and interactions of both emotional inhibition and perfectionism in PD's, after controlling for symptoms and interpersonal problems. METHOD: We recruited a sample of 578 treatment seeking outpatients. Diagnosis of PD was made with the SCID-II. Individual's completed measures of perfectionism (Frost-MPS), Emotional Inhibition (EIS), Depression (BDI-II), Anxiety (STAI-Y), Global symptoms (SCL-90-R), and interpersonal problems (IIP-32). RESULTS: Perfectionism was related to interpersonal problems, to the majority of PD symptomatology and to PD severity via number of SCID-II criteria met. Emotional inhibition was linked to symptoms and interpersonal problems as well as with avoidant, dependent, depressive and paranoid PDs; and with overall PD Severity. Inhibition and perfectionism were correlated with each other. Both variables predicted PD above and beyond other variables assessed. Mediation modeling demonstrated that the effect of emotional inhibition on PD severity was fully mediated by perfectionism and interpersonal problems. CONCLUSIONS: Psychological mechanisms of overcontrol are a maintaining factor in many PDs. Both perfectionism and emotional inhibition impact on a broad range of PDs and there is an urgent need for research into these processes, and to adapt psychological interventions to consider these factors.

Metacognitive Interpersonal Therapy for Treating Persecutory Delusions in Schizophrenia.

MIT aims at progressively fostering metacognition until patients are able to understand what kind of interpersonal events or ideas about self and interpersonal interactions trigger their persecutory delusions and to question the delusional meaning they attribute to events.

Metacognition Is Necessary for the Emergence of Motivation in People With Schizophrenia Spectrum Disorders: A Necessary Condition Analysis.

Metacognition deficits are a putative cause of reduced motivation in people with schizophrenia spectrum disorders. However, it is unclear whether certain levels of metacognition are necessary for motivation to emerge. This study used a Necessary Condition Analysis to test whether metacognition was necessary for the presence of motivation and to identify the minimum level of metacognition necessary for high motivation to be possible in people with schizophrenia spectrum disorders (N = 175). Participants completed clinician-rated measures of metacognition and motivation. Necessary Condition Analysis revealed that metacognition is a necessary condition for motivation and that high levels of motivation were only possible, although not guaranteed, when at least a basic level of metacognition was present. The findings suggest that metacognition is a necessary building block for the development of motivation. Results suggest that targeting metacognition may be essential for improving motivation among people with schizophrenia spectrum disorders who do not meet this metacognition threshold.

Mindfulness moderates the relationship between aggression and Antisocial Personality Disorder traits: Preliminary investigation with an offender sample.

INTRODUCTION: Poor mentalizing has been described as a characteristic of Antisocial Personality Disorder (ASPD), along with the well-established role of aggressiveness. In the current study, we tested this hypothesis focusing on a specific aspect of mentalization (i.e., mindfulness). METHOD: We explored the unique and joint contribution of aggression dimensions and mindfulness facets to ASPD traits in an offender sample (N=83). RESULTS: Mindfulness deficits were associated with ASPD traits, and a significant unique association emerged between difficulties in acting with awareness and ASPD traits. Likewise, physical aggression confirmed its association with ASPD traits. Moderation analyses revealed that mindfulness interacted with aggression in predicting ASPD. Specifically, at low levels of mindfulness, the association between aggression and ASPD dropped to nonsignificance. CONCLUSIONS: Results suggest that fostering self-mentalizing is a relevant treatment target when treating offenders with ASPD.

Metacognition moderates the relationship of disturbances in attachment with severity of borderline personality disorder among persons in treatment of substance use disorders.

OBJECTIVES: Borderline personality disorder traits have been observed to be linked with both insecure attachment styles as well as deficits in mentalizing and metacognition. Less is known, however, about how attachment style does or does not interact with deficits in mentalizing and metacognition to create, sustain, or influence levels of borderline personality disorder traits. In this study, we examined the hypothesis that metacognitive mastery, which is the ability to use knowledge about mental states of self and others to cope with distress and solve social problems, moderates the relationship of anxious attachment style with the severity of borderline personality disorder traits. METHODS: Concurrent assessments were gathered of metacognitive mastery using the Metacognitive Assessment Scale Abbreviated, anxious attachment style using the Experiences of in Close Relationships Scale, and borderline personality disorder traits using the Structured Clinical Interview for DSM-IV Axis II Disorders. Participants were 59 adults in an early phase of recovery from substance use disorders in a residential setting. RESULTS: Multiple regression revealed that metacognitive mastery moderated the relationship of anxious attachment style with the number of borderline personality disorder traits. A median split of the anxious attachment and metacognitive mastery scores was performed yielding 4 groups. An analysis of covariance revealed that participants with higher levels of anxious attachment and poorer metacognitive mastery had more borderline personality disorder traits did than the other groups after controlling for levels of psychopathology. CONCLUSION: Insecure attachment may be associated with higher number of borderline personality disorder traits in the presence of deficits in metacognitive mastery. Patients with substance use and borderline personality disorder traits may benefit from treatment which addresses metacognitive mastery.

Theory of Mind in Schizophrenia: Associations With Clinical and Cognitive Insight Controlling for Levels of Psychopathology.

Poor insight in schizophrenia is a risk factor for both poor outcomes and treatment adherence. Accordingly, interest in identifying causes of poor insight has increased. This study explored whether theory of mind (ToM) impairments are linked to poor clinical and cognitive insight independent of psychopathology. Participants with schizophrenia (n = 37) and control subjects (n = 40) completed assessments of ToM with the Hinting Task and the Brüne Picture Sequencing Task, clinical insight and psychopathology with the Positive and Negative Syndrome Scale, and cognitive insight with the Beck Cognitive Insight Scale. Results indicated that the schizophrenia group had greater impairments in ToM relative to control subjects. In the schizophrenia group, the Hinting Task performance was related to both cognitive and clinical insight, with only the relationship with cognitive insight persisting after controlling for psychopathology. Picture Sequencing Task performance was related to cognitive insight only. Future research directions and clinical implications are discussed.

Cluster B Personality Disorder Traits as a Predictor of Therapeutic Alliance Over Time in Residential Treatment for Substance Use Disorders.

While poor therapeutic alliance is a robust predictor of poor outcome in substance abuse treatment, less is known about the barriers to therapeutic alliances in this group. To explore this issue, this study examined whether the severity of cluster B personality disorders predicted therapeutic alliances concurrently and prospectively in a residential substance treatment program for homeless veterans. Participants were 48 adults with a substance abuse disorder. Personality disorder traits were assessed using the Structured Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Personality Disorders, whereas therapeutic alliance was assessed at baseline using the Working Alliance Inventory. Partial correlations controlling for overall symptom severity measured with the Symptom Checklist 90 and education, revealed cluster B traits at baseline predicted all 4 assessments of therapeutic alliance even after controlling for initial levels of therapeutic alliance. Results suggest that higher levels of cluster B traits are a barrier to the formation of working alliances in residential substance treatment.

Metacognitive Interpersonal Therapy for Personality Disorders Swinging from Emotional Over-Regulation to Dysregulation: A Case Study.

Many patients with personality disorders (PD) display emotional inhibition or over-regulation (EOR); others display emotional dysregulation (ED)- heightened sensitivity to emotional stimuli with difficulty toning down arousal. To date, most treatments focus on patients with ED, particularly those with borderline disorders, though some focus on EOR. Patients with complex PD often swing from periods of EOR to ED. In this paper, we describe an adaptation of metacognitive interpersonal therapy (MIT), which has been manualized for treating PD with prominent EOR and is aimed at dealing with patients fluctuating from EOR to ED. We first describe the MIT model of personality pathology and offer a summary of the procedures used in MIT to treat patients with prominent EOR. Then, through the analysis of the case of a patient swinging between EOR and ED, we describe how to adapt these procedures to complex cases.

Metacognitive Deficits in Schizophrenia: Presence and Associations With Psychosocial Outcomes.

Early formulations of schizophrenia suggested that the disorder involves a loss of ability to form integrated ideas about oneself, others, and the world, resulting in reductions in complex goal-directed behaviors. Exploring this position, the current review describes evidence that persons with schizophrenia experience decrements in their ability to form complex ideas about themselves and to ultimately use that knowledge to respond to psychological and social challenges. Studies are detailed that find greater levels of these impairments, defined as metacognitive deficits, in persons with schizophrenia in both early and later phases of illness as compared with other clinical and community groups. Furthermore, studies linking metacognitive deficits with poorer psychosocial functioning and other variables closely linked to outcomes are summarized. Clinical implications are also discussed.

Metacognitive interpersonal therapy for co-occurrent avoidant personality disorder and substance abuse.

Many patients with substance abuse problems present with co-occurrent cluster C personality disorders. Focusing on both disorders disrupts the maintenance mechanisms and the vicious cycle between the 2 conditions; however, treatment teams often neglect this issue. In this work, we describe the features of metacognitive interpersonal therapy as applied to a man with avoidant and depressive personality disorders and heroin, cocaine, and alcohol abuse. Psychotherapy proceeded through the following steps: (a) conducting drug therapy to deal with symptoms of abstinence from heroin; (b) forming a therapeutic bond to overcome the patient's severe emotional withdrawal; (c) fostering basic metacognitive capacities such as awareness of emotions and their triggers; (d) sharing formulations of maladaptive interpersonal schemas and descriptions of the associated states of mind; (e) conveying an understanding of the link between interpersonal events (recent ones and traumatic memories) and substance abuse; (f) facilitating the acquisition of critical distance from maladaptive schemas; and (g) promoting the use of adaptive coping skills instead of resorting to substance abuse. Implications for generalizing these procedures to the treatment of other patients with co-occurrent personality disorders and substance abuse are described.

Metacognitive reflective and insight therapy for people in early phase of a schizophrenia spectrum disorder.

Schizophrenia often involves a loss of metacognitive capacity, the ability to form complex and integrated representations of self and others. Independent of symptoms and neurocognition, deficits in synthetic metacognition are related to difficulties of engaging in goal-directed activities in social and vocational settings. Within this backdrop, we provide a case report of the effects of Metacognitive Reflective Insight Therapy (MERIT) that assisted a patient suffering from first episode schizophrenia during 2 years of individual psychotherapy. A total of 8 elements of MERIT that stimulate and promote metacognitive capacity are presented. As illustrated in this report, these procedures helped the patient move from a state in which he had virtually no complex ideas about himself or others to one in which he had developed integrated and realistic ideas about his own identity and the identity of others. He then could use these representations to understand and effectively respond to life challenges.

Metacognition-oriented social skills training for individuals with long-term schizophrenia: methodology and clinical illustration.

PURPOSE: There is much evidence indicating the presence of social deficits in schizophrenia and the detrimental effect of these deficits on global functioning in this population. As a result, social skills training (SST) has emerged as a legitimate psychosocial treatment, although effectiveness research has revealed small effect sizes and limited generalizability regarding the benefits of this treatment. METHODS: In light of the strong evidence of metacognitive deficits in schizophrenia and the importance of metacognition to successful social functioning, we propose a novel therapeutic intervention wherein metacognitive remediation is integrated into SST: metacognition-oriented social skills training (MOSST). In the current paper, we present MOSST, an adapted SST programme wherein clients are also encouraged to have mindful contact with their own thoughts and to better consider and understand the mental states of others as well as the connection between mental states and behaviour. RESULTS: We present a case wherein an individual with schizophrenia successfully completed the MOSST programme. CONCLUSION: We outline directions for future research, starting with the logical next step of empirically testing the efficacy of MOSST. KEY PRACTITIONER MESSAGE: Currently social skills training is considered to be the elected psychosocial treatment for people affected by schizophrenia, although evidence indicates limited benefits. People with schizophrenia have metacognitive deficits, which interfere with proper social functioning. A metacognitive-oriented social skills training (MOSST) intervention has been developed by the authors.A treatment such as MOSST, which integrates social skills training and metacognitive training, promises to improve social skills through improving the metacognition.