Metacognitive Interpersonal Therapy in a Case

of ObsessiveCompulsive and Avoidant

Personality Disorders
m

Donatella Fiore, Giancarlo Dimaggio, Giuseppe

Nicolo, Antonio Semerari, and Antonino Carcione
Terzo Centro di Psicoterapia CognitivaAssociazione di
Psicologia Cognitiva, Rome, Italy

Metacognitive interpersonal therapy (MIT) for personality disorders is

aimed at both improving metacognitionthe ability to understand
mental statesand modulating problematic interpersonal representa-
tions while building new and adaptive ones. Attention to the
therapeutic relationship is basic in MIT. Clinicians recognize any
dysfunctional relationships with patients and work to achieve
attunement to make the latter aware of their problematic interperso-
nal patterns. The authors illustrate here the case of a man suffering
from obsessivecompulsive and avoidant personality disorders with
dependent traits. He underwent combined individual and group
therapies to (a) modulate his perfectionism, (b) prevent shifts towards
avoiding responsibilities to protect himself from feared negative
judgments, and (c) help him acknowledge suppressed desires. We
show how treatment focused on the various dysfunctional personality
aspects. & 2008 Wiley Periodicals, Inc. J Clin Psychol: In Session
64: 168180, 2008.

Keywords: psychotherapy; obsessivecompulsive personality disor-

der; avoidant personality disorder; comorbidity

Each personality disorder (PD) has many facets, emotional reactions, and
information processing styles. Each PD patient is not a monolith, as in most
diagnostic manuals, but an individual reacting differently according to several
environmental variables (Millon & Davis, 1996; Westen & Shedler, 2000).
Consequently, a single diagnosis is often insufcient and inaccurate (Westen,
Shedler, & Bradley, 2006). When there are two or more co-occurrent PDs, the variety

This article was written with the support of a grant received by Fondazione Anna Villa e Felice Rusconi.
Correspondence concerning this article should be addressed to: Giancarlo Dimaggio, c/o Terzo Centro di
Psicoterapia Cognitiva, via Ravenna 9/c 00161 Rome, Italy; e-mail: gdimaje@libero.it

JOURNAL OF CLINICAL PSYCHOLOGY: IN SESSION, Vol. 64(2), 168--180 (2008) & 2008 Wiley Periodicals, Inc.
Published online 9 January 2008 in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/jclp.20450
 MIT in a Case of OCPD and APD 169

of self-aspects is obviously greater and makes the clinicians task of conceptualizing

the case and planning treatment more complex.
Metacognitive interpersonal therapy (MIT; Dimaggio, Semerari, Carcione,
Nicolo, & Procacci, 2007) appears suited to tackling the problems arising from the
copresence of distinct PDs. Metacognitive interpersonal therapy aims to dene PD
prototypes with their multiple facets. For each disorder, MIT describes (a) the
predominant forms of subjective experience and their shifts, and (b) the patterns
causing certain trends in interpersonal relationships and leading individuals to
behave in line with expectations about how others will react to their wishes (Safran &
Muran, 2000). In line with its constructivist origins (Neimeyer & Mahoney, 1995),
MIT also creates a model of (c) each single case using the construct system that
underlies subjective experience and assists in ascribing meaning to relationships, and
(d) the way in which thought processes are organized. If a patient displays a co-
occurrence, a therapist tries to understand the hierarchical relationship between the
disorders and their inuences on each others functioning processes.
In this article, we review the central premises of MIT in treating comorbid
personality disorders and then present a clinical illustration of its uses and typical
outcomes.

Metacognitive Interpersonal Therapy

According to MIT, patients with a PD have difculty thinking about thinking
(see also Bateman and Fonagy, this issue, 181194). For instance, it can be
problematic for them to recognize their own thoughts and feelings or examine the
accuracy of something they hold to be true. They can nd it impossible to divine
others feelings or recognize the requirements of a social situation. Moreover, they
can nd it difcult to grasp that self is not always at the heart of others thoughts.
Metacognitive system dysfunctions can explain a variety of pathological forms
(Dimaggio et al., 2007): For example, limited access to own affects appears to be a
pathogenetic mechanism common to disorders such as obsessivecompulsive,
avoidant, narcissistic, and dependent. Decits in metacognition may obstruct
courses of action driven by emotions in all of them; affects are a fundamental
decision-making tool and, without awareness of ones affects, actions are less prompt
and spontaneous and there can be serious indecisiveness (Damasio, 1994).
Metacognitive interpersonal therapy for PDs rests on several assumptions. First,
interpersonal relationships among patients suffering with personality disorders are
dysfunctional and, consequently, patients nd it hard to build up a good alliance
with their therapist. Second, there are specic interpersonal cycles in line with the
diagnosis of PD. Very early in treatment, clinicians can foresee the major alliance
rupture patterns and take action to reduce their impact and the risk of early
dropouts. Third, metacognition among patients with a personality disorder is
probably impaired. Patients thus nd it difcult to carry out several operations
which, in classical forms of treatment, including standard cognitivebehavioral
therapy, are taken for granted: identifying their thoughts and emotions of their own
accord or as the result of specic questions from their therapist, understanding
others intentions, and developing a collaborative relationship with a problem-
solving attitude. Clinicians who practice MIT tackle the impaired aspects of patients
metacognition and improving those specic aspects of self-reection or under-
standing others mind in which they fail.
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170 Journal of Clinical Psychology: In Session, February 2008

To interrupt patients self-perpetuating pathological circuits, therapists who

practice MIT rst need to attune with them and make the relationship as little
disturbed as possible. To do so, it is important to avoid allowing themselves to get
involved in or contributing actively to the perpetuation of any interpersonal cycles,
and to encourage, instead, a discourse based on the themes with which patients nd
themselves most at ease. Once such a position is reached, therapists can work at
improving metacognition.
Psychothrapists can look in each session to build a strong therapeutic relation-
shipin which it is possible to discuss states of mindto interrupt patients self-
perpetuating cycles and to help them to enrich their inner and relational lives.
Another MIT focus is constructing new and more adaptive forms of experience.
Patients with one or several PDs have difculty switching into pleasant states,
feeling, for example, immediately guilty each time they relax. Metacognitive
interpersonal therapy attempts to facilitate identication of warded-off or
unrecognized states of mind (Horowitz, 1987) and their integration into patients
daily social action. For example, in the case of a narcissistic patient with borderline
and paranoid characteristics, a therapist encouraged the emergence of previously
unidentied fragile parts seeking help (Nicolo, Carcione, Semerari, & Dimaggio,
2007).
Metacognitive interpersonal therapy operates within multiple modalities, for
example, the individual plus group format. Through peer feedback, group therapy
helps in perceiving aspects of experience. Other group members may, for example,
observe that a patient portrays herself or himself as inept, incapable, and clumsy, but
is able to express herself or himself well, with sensible and useful comments. A
therapist can reinforce this feedback and integrate this new self-aspect into the
patients self-image during individual therapy. Role-playing in groups can improve
metacognition. In fact, patients receive feedback on their posture and body signals
and the extent to which they differ from their self-descriptions. The patient we
mentioned, for example, described himself as clumsy and awkward. During role-
playing, another group member chose him as a salsa teacher and he confessed that he
really had taught this dance. The idea of being skilled at dancing was not integrated
into his self-image and had not surfaced during individual therapy.

Case Illustration
Client Description and Presenting Problem
Alberto was a 48-year old, married man with a 3-year-old daughter. His daughter
suffered from psychogenic language retardation. Alberto had an engineering degree
and had been working a few months as a computer manager in a large rm. His new
job had jeopardized his uneasy balance and led him to seek psychotherapy again.
Alberto had terminated psychoanalysis after 8 years, when his daughter was born.
There was no reported history of psychiatric or major physical illness in the family of
origin.
Alberto displayed a depressed mood, anxious worries, and derealization. With his
professional responsibilities, he had found himself again in a feared situation:
making rapid decisions with consequences for other people. His fear of making a
mistake and being judged negatively or harmful by others led to constant self-
criticism, indecisiveness, and inefciency. He neglected his family, sacricing it for
his job. His wife reproached him for being absent, and their sex life was
unsatisfactory. One strategy to which he resorted for avoiding criticism was to
Journal of Clinical Psychology: In Session DOI 10.1002/jclp
 MIT in a Case of OCPD and APD 171

ingratiate himself with others and pass decisions to them. This reinforced Albertos
sense of inadequacy: He was ashamed of being awkward and cowardly.

Case Formulation and Diagnosis

Diagnostic interviews using the Structured Clinical Interview for DSM-IV
Personality Disorders (SCID-II; First, Gibbon, Spitzer, Williams, & Benjamin,
1997) resulted in obsessivecompulsive personality disorder, avoidant personality
disorder, and dependent personality traits (four criteria met). The various disorders
were not independent entities; the description of the underlying self-structure
explains how they were probably interlinked.
In his rst individual session, Alberto began by asking about the characteristics,
conditions (length, frequency, cost), and applicability of cognitive therapy. He
inquired specically about its differences compared to psychoanalysis and proof of
its efcacy. He added that immediately after the session he had an appointment with
a psychoanalyst his wife had suggested. He was fretting over the decision and asking
himself which treatment might be more suited to his case and how to decide which
therapist was better. He was worried about the consequences of the decision: If he
opted for cognitive therapy, he imagined that his wife would rightly reproach him,
while, if he opted for psychoanalysis, he was afraid of offending the cognitive
therapist.
Alberto set himself high and rigid standards. He conceived all actions and
emotions in dichotomous terms: right/wrong, correct/incorrect, perfect/imperfect,
irreproachable/guilty. In his behavior, he was scrupulous, attentive to details and
rules, and devoted to duty. This part of his worldview was ego-syntonic; Alberto
dened himself proudly as conscientious and superior to others, whom he considered
immoral. He paid dearly for this sense of superiority, by not excusing any
shortcoming or transgression, which provoked feelings of guilt and self-depreciation.
In this, Alberto corresponded to the obsessivecompulsive personality disorder
(OCPD) prototype.
He was emotionally cold and had difculty identifying his inner statesin MIT
terms a lack of metacognitive monitoringand, when they surfaced in his
consciousness, they frightened him. He could not access pleasant states and
considered his desires shameful and dangerous. He was also unaware of the
relational causes of his emotions; for example, that he was depressed because he was
exhausted by overworking and trying to avoid criticism. He would mix his different
emotional states, saying he felt guilty without realizing that he, in fact, felt pleasure,
and confusing joy with shame, sense of belongingness with fear of exclusion and need
to be cared for with fear of being neglected. His narratives were thus disorganized
(Dimaggio & Semerari, 2004) and his nonverbal signals inconsistent with his speech.
In this, Alberto expressed characteristics typical of avoidant personality disorder
(APD; Dimaggio et al., 2007; Dimaggio et al., in press).
His limited perception of his emotions made his indecisiveness worse: He could
not see that, if he felt emotion, it indicated the goal to be pursued. He only trusted
his value system and his reasoning, following the think-rather-than-feel pattern. This
generated a powerful pathogenic circuit: resorting to his value system for choices
increased the blacking out of his emotional experience. If he became aware of an
emotion, he ignored it and considered it a sign of moral lth; he, therefore, kept his
attention focused deliberately elsewhere, forgetting emotional language yet more.
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172 Journal of Clinical Psychology: In Session, February 2008

Albertos moral rigidity compounded his relationship difculties. The idea of

being morally superior led him to isolate himself. Fear of mistakes, on the other
hand, led him at other times to delegate all responsibility, which he called Pontius
Pilate syndrome. Overall, he portrayed others as supercial, but efcient. They
reacted to his moral criticism aggressively or by going away, and to his delegating by
criticizing. This, in turn, reinforced his feeling of ineptitude and core impression of
others as immoral. His feeling guilty and ridiculous made his self-efcacy collapse
and thus his performance. At this point, he was afraid of being reproached, and this
made him obsequious and submissive both with his wife and at work. This reinforced
others tyrannical attitudes, which in turn provoked an anger that was afraid to
express itself.
During assessment, Alberto recalled playing sex games at 5 years old with two
older cousins. After 3 years he stopped, saying he had just been to confession and
could not sin any more. During the narrative, Alberto swung between shame at the
idea of being dirty and depraved and stied anger both at his submissiveness and at
those abusing his innocence. He said he had been the unconscious victim of his
idealized cousins, whom he tried to emulate, and had consented for fear of
disappointing them or being mocked. However, his face and posture betrayed a
mixture of curiosity and pleasure when recalling these games. The combination of
shame and self-criticism are APD characteristics, triggered by the perfectionism
typical of OCPD.
In short, Albertos various disorders reinforced each other: the incapable or guilty
self/critical other schema triggered his feeling of inadequacy and led to avoiding
decisions or being obsequious (avoidance and dependence). To avoid accusations or
derision, Alberto took no risks and avoided social activities (avoidance). His
obsequiousness made him feel ridiculous and different from others. Unlike simple
APDs, who, when they avoid responsibility, feel temporarily relieved, Alberto felt
guilty and therefore pondered for hours over whether to delegate or not. The
solutiona compromise between perfectionism and avoidancewas dependency on
others help: Alberto asked others incessantly for advice and reassurance. This way
he felt he was committing himself and avoided others depending on him. He was
never autonomous and did not act according to his own desires.

Course of Treatment
We had two primary treatment goals. The rst was to modulate his excessive
scrupulousness and moral perfectionism, which appeared to activate pathological
forms of relationship and regulation of choices. The main tool was to encourage
awareness of the inner statesthoughts, emotions, and desiresthat Alberto
avoided or suppressed because he deemed them immoral. The second was to identify
the dysfunctional interpersonal cycles in his therapeutic relationship and daily life
and nd an alternative style of relating with others.
After 3 months of weekly individual psychotherapy with one of the authors (DF),
Alberto started weekly group psychotherapy conducted by both his individual
therapist (DF) and another of the authors (GD). The goal of adding group therapy
to the individual psychotherapy was to improve his metacognition, in particular
recognizing that certain bodily signals indicated emotional experiences. This was
possible with the group due to, for example, the peer feedback and to Albertos
observing his own behavior towards the others. Role-playing was particularly useful.
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 MIT in a Case of OCPD and APD 173

In MIT, tackling problematic interpersonal cycles is a priority because they harm

relationships, prevent the achievement of life goals, and jeopardize the therapeutic
alliance. With their careful handling in sessions, it is possible to gain privileged access
to relationship schemas and the rigid and stereotyped manner in which they drive
behavior. We now describe the therapeutic process from when the group therapy
started.
Albertos theorizing narrative style had always made it difcult for the therapist to
access his experiences. The group, instead, represented a privileged viewpoint.
Entering the group was distressing for Alberto; he felt rejected and tended to detach
himself, as illustrated by his story of how he reacted to the telephone call in which he
asked the therapist for details about the group. The therapist suggested talking about
it in the next session.

* Alberto: When you replied: Well talk about the group on Friday, I felt as if I
wasnt to go to the group any more.
* Therapist: How did you imagine it?
* A: As if Id been rejected by the group and had already distanced myself from
everything.
* T: Why rejected? What images did you see?
* A: The technical term is being on your guard.
* T: You mean then that it makes you angry? That you might be rejected?
* A: y as if Id been ejected from the groupy
* T: When you speak of rejection, what might the others see?
* A: Im afraid theyll discover Im a not very practical person y
Alberto embodied APD functioning: He had felt inadequate and therefore at risk
of negative opinions and exclusion, so that he distanced himself angrily and froze his
emotions. He then began to theorize, but the therapist asked for further episodes to
retrace the scenario and increase the detail in the self-narrative:

* A: Coming here I was thinking about slave/mastery about the armmind

dichotomyy of people able to take decisions unperturbed and others who
instead wait to be told how things should be done.
* T: Can you give me some specic examples of when you felt like that?
Alberto continued to reply with abstract speculations, a series of premises and
logical explanations full of useless details, to the therapists attempts to draw out
some self-narratives. His talking was simultaneously unexceptional and psycholo-
gically incomprehensible. What did Alberto feel? What experiences had generated
this self-representation?
To access Albertos emotions, the therapist was attentive to her own reactions. She
felt confused and irritated by Albertos style and tended to criticize him. She realized
that displaying such inclinations would conrm to the patient that he was (a) so inept
that he did not know how to explain himself, (b) rejected by the therapist too, and (c)
at the mercy of an aggressive therapist. She found therefore that she was potentially
involved in a problematic interpersonal cycle (Safran & Muran, 2000) that would
conrm the patients schema.
The therapist noted that her sensations coincided precisely with Albertos
impression: Other people reject and subjugate me. At this point, she managed
to identify herself with Alberto and imagine what she would experience if she felt
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174 Journal of Clinical Psychology: In Session, February 2008

criticized. She thus gained an empathic position in which evading a problem or

seeking logic in ones actions are escapes from painful criticism. From this position,
she told Alberto she wanted to understand him better and for this reason asked him
for other episodes. Alberto reacted positively by evoking a memory:

* T: Alberto, Im sorry but Im having trouble understanding you. Its important we

share some specic episodes from your life so I can understand how you feel y
* A: Someone coming to me for advice, because I was in charge of that section and I
had to replyy I passively accepted what my colleague did because I found it
very practical and functionaly I very often extinguish my decision-making
ability y because Im frightened of making mistakes and badly letting down
others. I always have an eye for the best way of doingy
* T: Today, based on your experiences with the group, you introduced an abstract
metaphor, mind and arm, slave and master, and now youre telling about an
episode at work where you didnt feel able to be either the arm or the mind in
the end it appears youre not incapable of doing things, but looking for the best
way to do them. You freeze and delegate the task of telling you what to do to
others. You then feel inadequate, but preserve your perfect self-image by saying
others are competent but in the end I could do better.
The core role of his perfectionist self-image in generating dysfunctional behavior
and painful emotions was now clear to both. To tackle criticisminternal and
externalAlberto avoided the task, while at the same time feeling superior to others,
or was submissive and delegated responsibility. His self-esteem fell internally and in
the social arena others reproached him.
The next group session shed further light on the reactions Alberto provoked in his
peers. One patient, Carmela, spoke of being paralyzed during university exams and
feeling desperate and angry at the idea of feeling she had little help.
Albertos reaction was to provide an interminable series of vague reassurances and
clumsy attempts to organize her life for her, without showing any affective empathy.
Carmela rst pointed out how boring and moralistic Alberto was, youre like a
priest, always precise and sensible! She was pleased with the attention she got, so
she then burst into laughter and urged him to release his anger and rebel against
things he didnt agree with.
The group therapist intervened by hypothesizing that Alberto tried to help
Carmela because he was distressed at the idea of having a responsibility towards the
other group members and not because he had identied himself with her. Thanks to
Carmelas feedback, which had very clearly, but without rejecting him, pointed out
that she hadnt felt helped, he acknowledged that, to handle others distress, he
always tried compulsively to nd the best solution.
In the next individual session, Alberto relaunched the question of choosing in
intensely emotional situations, in this case, his daughters language problems. The
pediatrician had advised going to a specialist to understand the reason for the
retardation, but Alberto and his wife were hesitating. What Alberto said was
incomprehensible, with phrases like Im an adult in a childs body, which made it
impossible for the therapist to even understand what he was talking about. Alberto
did not mention emotions and was not looking for any solution. However, the
therapist perceived in herself both a concern for the girlnot expressed by Alberto
and a sensation that the girls health depended on hera typical theme of the
patient. She also felt a tendency to swing between dysfunctional modes typical of the
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 MIT in a Case of OCPD and APD 175

patient: delegating responsibility or assuming it fully. Thanks to her private inner

dialogueIs it my full responsibility or would a child neuropsychiatrist better deal
with the problem and its nothing to do with me?she realized that she was
reasoning like Alberto. She therefore managed to adopt a new position, trying to
make a contribution without claiming she could solve the problem for good. She
suggested Alberto contact several specialists she knew, stressing that she was keen to
help the girl, but not adequately equipped. She thus presented herself as a role
model: A person who accepts responsibilities but who also knows her limits.
Alberto found this suggestion reasonable and, more relaxed, he described his inner
state better: He felt guilty about his daughters language retardation and incapable
of looking after her. To mitigate his guilt feelings he either ruminated about the
impossible, perfect solution (OCPD characteristic) or avoided thinking about it
(APD characteristic).
Soon thereafter, Alberto arrived 20 minutes late for his individual therapy
appointment; the day before he had missed his group therapy. He was off sick and
could thus devote himself to his hobbies, but without enjoying them because of guilt
feelings. He watched a lm, but thought constantly that this was precious time he
ought to devote to the home. He was worried sick; he had not realized that the
morning was over without him doing any cooking, which would enrage his wife. The
anger conrmed his idea of guilt and reinforced his idea that enjoying life was
immoral. He did not realize that his inefciency depended on his ruminating rather
than on his moments of diversion.
There was the same situation with the therapist. Alberto was late for the session
because he had been playing on his computer. After a long and confused story about
the problems he had encountered recently, he confessed that he had been very
frightened about being criticized for being late and had wanted to miss the
appointment. The therapists response was a simple noncritical smile and a comment
along these lines: Lucky you if you had time to play today, which calmed Alberto
immediately.
At this point, he rst observed that he felt he belonged more to the group and then
dened the guilt question better:

* A: I met Maria (a group member) today at the supermarkety I too was glad to
give her a hug but at a certain point I had to leave her, I was tensey The
experience was as if I wasnt free to give a disinterested hug to a person. Im
glad to get a hug from her, from the group too, because Im able to make a
contribution to sessions but I sense this difculty with the group.
The therapist replied by demonstrating the link between pleasure and guilt:

* T: Today, contradictory images are emerging: rst, you say you feel at ease in the
group, then that theres a difculty, you were glad Maria hugged you but
tense. You always talk guiltily about pleasurable moments because you
neglect your duties.
* A: yesterday I enjoyed the wedding, I danced, then this morning the bubble
collapsedy For me its like
* T: A heavenly retribution!
After about 2 months, there was a visible change; Alberto gained access to his self-
parts and emotions, previously not acknowledged or suppressed because deemed
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amoral. Anger was among the rst. In the group Paola, expressed irritation with
Alberto:

* Paola: I could hit Alberto yits annoying when he doesnt conclude!

* A: You irritate mey you provoke people.
* T: Alberto, how much would you like to react like Paola?
* A: Ive suppressed my ability to act because I wouldnt know how to react.

Alberto not only expressed his anger, but saw the link between lack of access to it
and his inability to act. In MIT language, a passage like this is typical of an increase
in metacognition; the patients access to his emotions, their relational causes and
their consequences for mastery of problems, improved. Alberto worked on the affect
further in the next group session, referring to Paola.

* A: I was lividy about her haughtinessy wanting to nd a solution for everybody

except herself.
* T (ironical): and this is youy having to preach about everythingy
* Maria: How would you have liked to reply to Paola?
* A (smiling): Go to hell!
* Maria: Her hitting you has done you a world of good!

Alberto nally managed to express his anger spontaneously without feeling guilty
of hurting others. Peer feedback made him discover that direct communication is
appreciated more and validated his emerging adaptive relational style.
The guilt theme reappeared in the following sessions, again linked to his
relationship with his daughter. In the group, Maria selected Alberto to play her dog,
suffering from a brain tumor, with her looking after it. During the role-playing the
emotional atmosphere was intense, but with some surprising nuances. When Maria
washed the dog/Alberto, dirty with excrement, this was full of a sexual tension that
made the other group participants and therapists smile. This atmosphere was even
stronger when the roles were reversed, with Alberto washing the dog/Maria. Alberto
appeared involved, almost excited, but sometimes his distress for the dogs illness
surfaced.
In the next individual session, the therapist suggested Alberto talk about the role-
playing and put the emotional and physical signals into words. The therapist noticed
an important element:

* T: I was struck when, playing the role of Maria addressing the dog, you changed
the text of the story, not saying, as in the original version Why arent
you dead? but Im sorry youre like this, I should have thought about it
before.
* A: I was a bit dissociated. I thought of my daughter. I had the sensation of not
being able to protect Francesca (his daughter)

Alberto acknowledged his guilt feeling and communicated it clearly. The therapist
no longer needed to infer from abstract discourse that Alberto feared irreversible
harm to his daughter. Immediately afterwards, his guilt gave way to sexual
attraction, which had already appeared in the role-playing. Alberto recognized that
he felt involved (remember that contact was simulated).
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 MIT in a Case of OCPD and APD 177

A: Ive thought again about that hugging with Maria at the supermarkety I got
these disturbing imagesy Maria as a sister, then an incestuous sister, as a cousiny
With the setting boundaries clear, Alberto talked of being attracted without self-
accusation; he was troubled, but did not repress the pleasant aspect, now integrated
into his narrative.
It was now clear that Albertos guilt towards others and shame about his sexuality
rested on a single interpersonal pattern: swinging between positions as victim of
abuse and abuser. When he felt sexual desires, he was ashamed because he
considered them deviant and felt guilty because of a fear of causing distress. The
schema surfaced in the therapeutic relationship, where Alberto was by now at ease in
expressing his emotions. The therapist helped him by noting a nonverbal marker
his reaction when she arranged a session at home instead of the clinicand
suggested he explore the contents linked to it.

* T: You were petried.

* A: That you dare to let me come to your home. Im afraid of violating your
privacyy Its like these walls protect me from you.

Alberto was afraid to both violate and be violated. In the group, he had just
spoken for the rst time about his homosexual experiences as a child; the episodes
with his two older cousins, which he saw as abuse, and erotic games with adolescent
contemporaries.

* A: Today Im here with a precise request, for the protection I dont give others.

Alberto was discovering that intimacy can be not dangerous and then shifted to
the question of his failure to protect. He talked about his difculties in intervening in
the group therapy session the day before, when a patient, weeping abundantly,
remembered her father abusing her and her mother not providing support. As usual,
Alberto started with a demonstration of his perfectionist side.

* A: Yesterday I found myself in difculty because I thought of saying some

nonsense of which Id have been ashamed. I was more attentive to the best
intervention one could make.

The therapist links this negative self-image to the abuser/abused schema and his
development memories.
T: On the one hand, you feel incapable of providing protection to others; on the
other, you see yourself as a violator and others too. I propose you come to my
home and you say, Im afraid because these walls protect me from you, but
then If I come, Ill violate your privacy. This is the third time you havent
spoken in group sessions. Im asking myself if what you dont talk about is the
violation the abuse at the hands of your cousin.

* A: That cousins father died this week. In the group, I thought Id said no! to
the proposal to tell the others of it: a no that hid shame. I believe that this
nonprotecting of mine has its roots there; I must tell you another thing:
Ive thought of replay the penetrationy I may have been about 12y with
a peery
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178 Journal of Clinical Psychology: In Session, February 2008

* T: Can you remember how it originated? Was there desire? Curiosity?

* A: Curiosity, like when you make a plan about how to steal jamy like Lets
transgress.

Albertos metacognitive skills have increased as evidenced in this exchange. He

describes his inner world in detail and establishes unifying links between his various
self and other representations. The relations between his PDs are now clear. The
central theme is that intimacy is dangerous and he could hurt others or be subjugated
by them. He feels guilty and fears being criticized for this; he thus swings between
perfectionism (OCPD) to try to repair the damage caused and shame for his actions,
the latter inducing him to avoid relationships and not talk about himself (APD). His
representation of sexuality is systematically problematical, either violent or deviant,
which explains the inhibition Alberto displayed at the start of therapy in his
relationship with his wife. This, too, was a core part of his OCPD, where even
pleasant thoughts are suppressed because they are seen as immoral.
In the next group session, the therapist suggested Alberto role-play a memory in
which he met the cousin who had abused him. Alberto said that he felt humiliated by
the others haughty attitude then. During the role-play, however, it appeared evident
to the therapists and group-peers that he admired his cousin and was still fond of
him. Anger and shame gave way to the desire to become close again.
After this passage Alberto started a new stage in his therapy, which he called gut
experiencesattempts to avoid making perfect choices and live in tune with his
desires and instincts, no longer seen as threatening.

Outcome and Prognosis

After one year of therapy31 individual sessions and 36 group sessions Alberto is
less scrupulous and less a perfectionist. He is more productive professionally,
managing to keep to timetables and thus devote more time to his family and
daughter. He has launched investigations into the causes of the latters language
retardation. His sex life with his wife has improved, and he talks about it with
satisfaction. He still suffers from shame and worries, in which he depreciates himself,
but less frequently or intensely. He is more spontaneous with others, as witnessed by
peer feedback. A SCID-II control showed he no longer met full criteria for any PD.
Only traits were still present, in particular of OCPD (three criteria met), of APD (one
criterion met), and DPD (four criteria met).

Clinical Issues and Summary

Albertos co-occurrent PDs appeared more comprehensible owing to two underlying
elements. Dominant interpersonal patterns were abuser/abused and judge/guilty,
and in both schemas he swung between the opposite positions. If he felt he was
abusing, he tried to make up by adopting perfectionist, obsessivecompulsive
strategies. If sexual desires surfaced, he felt deviant, dangerous, and ashamed, and
activated APD-type behavior. His continuous self-criticism also explained his
dependent traits and the delegating to others who were better at deciding than he,
unworthy and inept. Alberto also displayed poor metacognition, i.e., serious
difculty in perceiving his emotions, integrating them into his narratives, and an
egocentric construction of others, systematically described as tyrannical.
The combined individual and group therapy helped Alberto to perceive that these
schemas were surfacing in the relationships with both his individual therapist and
Journal of Clinical Psychology: In Session DOI 10.1002/jclp
 MIT in a Case of OCPD and APD 179

other group members. He gained a better access to his experiences thanks to the
feedback from the therapists and group-peers. He discovered that others were
neither criticizing him nor feeling harmed by him: The real criticism he received
derived not from his moral qualities, but from the dysfunctional strategies he
adopted, like his obsessive ruminations, to avoid this very criticism. Thanks to his
integration of the pleasurable dimensions of experience, Alberto discovered more
spontaneous ways of relating, free from both his obsessivecompulsive and avoidant
styles. Acting spontaneously promoted his perception of group inclusion, which, in
turn, reduced his sense of alienation. Access to emotions also neutralized his
dependent traits because when choosing more instinctively, he no longer needed to
ask others for advice.
We believe that the MIT approach with Alberto can be generalized to other
complex PD cases. When clinicians identify underlying liabilities, such as relation-
ship schemas, or poor metacognition, they have a simple picture explaining many
manifestations. They can focus treatment on overcoming a few elements, with a
positive inuence on various personality aspects and an increase in adaptation.

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