Metacognitive Interpersonal Therapy in a Case of O


Metacognitive はどちらかと言えばCBTの新しい流れであるが
IPTの領域でもMetacognitive でやってみたいと当然思うと思う

ここでは対象疾患がOC-personarity disorderでIPTの得意領域ではないので

Metacognitive interpersonal therapy (MIT)for personality disorders is
aimed at both improving metacognition–the ability to understand
mental states–and 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 obsessive-compulsive 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


Metacognitive interpersonaltherapy (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 define 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 influences on each other’s functioning processes.
In this article, we review the central premises of MIT in treating comorbid
personality disorders and then present a clinicalil lustration of its uses and typical


Metacognitive Interpersonal Therapy

According to MIT, patients with a PD have difficulty thinking aboutthinking
(see also Bateman and Fonagy,this issue,181-194). Forinstance,it can be
problematic forthem to recognize their own thoughts and feelings or examine the
accuracy of something they hold to be true. They can find itimpossible to divine
others’feelings orrecognize the requirements of a social situation. Moreover,they
can find it difficultto grasp that selfis not always atthe 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 obsessive-compulsive,
avoidant, narcissistic, and dependent. Deficits 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 one’s 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 find it hard to build up a good alliance
with their therapist. Second,there are specific 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 theirimpact and the risk of early
dropouts. Third, metacognition among patients with a personality disorderis
probably impaired. Patients thus find it difficult to carry out several operations
which,in classical forms of treatment,including standard cognitive-behavioral
therapy, are taken for granted:identifying their thoughts and emotions oftheir own
accord or as the result of specific questions from their therapist, understanding
other’s 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 specific aspects of self-reflection or under-
standing other’s mind in which they fail.

To interrupt patients’ self-perpetuating pathological circuits,therapists who
practice MIT first 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 find
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-
ship—in which itis possible to discuss states of mind–to 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 difficulty switching into pleasant states,
feeling,for example,immediately guilty each time they relax. Metacognitive
interpersonal therapy attempts to facilitate identification 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
unidentified fragile parts seeking help (Nicolo, Carcione, Semerari, & Dimaggio,

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
patient’s 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 individualtherapy.