Addressing maladaptive interpersonal schemas, poor metacognition

and maladaptive coping strategies in Avoidant Personality Disorder:

The role of experiential techniques

Work published in open access mode

and licensed under Creative Commons
Virginia Valentinoa, Antonella Centonzea, Felix Inchaustib, Angus MacBethc,
Attribution – NonCommercial
NoDerivatives 3.0 Italy (CC BY-NC-ND 3.0 IT)
Raffaele Popoloa, Paolo Ottavia, Kjell-Einar Zahld, Giancarlo Dimaggioa
a
Centro di Terapia Metacognitiva Interpersonale, Rome, Italy
Psychology Hub (2020)
XXXVII, 1, 19-28
b
Departament of Mental Health, Servicio Riojano de Salud, Logroño, Spain

Centre for Applied Developmental Psychology, Department of Clinical and Health

c

Psychology, School of Health in Social Science, University of Edinburgh, Edinburgh,

United Kingdom

Article info d
District psychiatric center Follo, Akershus University Hospital, Norway
__________________________________________________________________

Submitted: 10 March 2020

Accepted: 21 May 2020
DOI: XXXX
Abstract
Avoidant Personality Disorder (APD) is the most prevalent diagnosis amongst the
personality disorders. However, it remains under-researched, and few psychotherapeutic
approaches have proven effectiveness in treating the disorder. Focusing on specific
elements of psychopathology may therefore help in refining treatments for this
disorder. Here we present a case where Metacognitive Interpersonal Therapy (MIT)
was used to directly address the negative metacognitive schemas held by clients with
APD. We also describe the theoretical background of MIT and why it may be effective
in the psychotherapeutic treatment of APD.

Keywords: Maladaptive interpersonal schemas; Poor metacognition; Coping; Experien-

tial techniques; Imaginative techniques; Avoidant Personality Disorder.

*Corresponding author.
Virginia Valentino
Centro di Terapia Metacognitiva
Interpersonale
Piazza Dei Martiri Di Belfiore, 4,
00195, Rome, Italy.
Phone: +39 351 993 1390
E-mail: [email protected]
(V. Valentino)

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20 Virginia Valentino, Antonella Centonze, Felix Inchausti, Angus MacBeth, Raffaele Popolo, Paolo Ottavi, Kjell-Einar Zahl, Giancarlo Dimaggio

Introduction structures are mostly sequelae of one’s developmental history.

From a psychopathological perspective, experiences of abuse and
Avoidant Personality Disorder (APD) is characterized by abandonment are predictors of personality disorders (Johnson
withdrawal from social relationships, social isolation, a sense et al., 1999). Emotional neglect is particularly associated with
of the self as inadequate, hypersensitivity to social judgement, the former Cluster C PDs, including APD (Zhang et al., 2012;
and feelings of group exclusion. Individuals presenting with Johnson et al., 2000). That said, research into the formation
APD simultaneously long for inclusion but fear connection. of schemas in APD has thus far only investigated attachment
This anxiety is underpinned by maladaptive cognitions related-schemas, whereby the presence of attachment figures
such as chronic self-doubt, a poorly integrated sense of self- perceived to be neglecting or lacking attunement are related
identity, difficulties in managing negative emotions and poor to an individual’s sense of self as unworthy and unlovable
agency (Sorensen et al., 2019). In terms of psychotherapeutic (Eikenaes et al., 2016).
treatment, evidence for the effectiveness of psychological The structure of schemas that we adopt here (Dimaggio
interventions for APD is limited (Simonsen et al., 2019), et al., 2020) is derived from the formulation described by the
and studies report mixed results. A number of therapeutic Core Conflictual Relational Theme (CCRT) (Luborsky &
models, including Interpersonal Therapy (IT), Acceptance and Crits-Christoph, 1990) and takes into account the concept of
Commitment Therapy (ACT), Dialectical Behavior Therapy relational testing proposed by Control Mastery Theory (CMT;
(DBT) and Schema Therapy (ST) have yielded positive results Weiss, 1993; Gazzillo, Genova et al., 2019; Gazzillo, Kealy et
for symptom reduction, with evidence of stability at follow- al. 2020). They include a) a core wish, which corresponds to
up (e.g. Chan et al., 2015; Bamelis et al. 2014). There is also the activation of basic evolutionarily selected motives (Gilbert
evidence that group-CBT was associated with better outcomes & Gordon, 2013; Liotti, et al. 2017; Panksepp & Biven,
than short psychodynamic psychotherapy (Emmelkamp et al., 2012); b) core self-images, with prominent negative self-
2006). However, CBT for this group has also been associated images, e.g. self as unworthy, or unlovable, which go alongside
with high relapse rates (Seemüller et al. 2014). The emotion over-modulated but still accessible positive self-images, e.g. the
regulation difficulties that APD-diagnosed patients present self as worthy, self as lovable. The schema also include Other
with may also have influenced early drop-out rates (Weinbrecht Responses, (expected or perceived) e.g. rejecting, neglecting,
et al., 2016). Overall, psychotherapy can be effective in this critical. Again, positive types of Other Responses often exist
population, but results are generally reported for specific, but are overshadowed by the negative appraisals. Finally, after
targeted outcomes, and taken in the context of elevated rates assessing the Other Responses, there is a Self-Response which
of treatment non-responses and drop-outs. Therefore, there includes cognitive, affective, behavioral and somatic reactions.
is significant room for improvement in the specification and In this model, the presentation of APD is driven by a
effectiveness of interventions. range of different schemas, depending on the core motive at
We propose that in order to increase effectiveness, stake in a specific episode. For example, when driven by an
psychotherapies for APD need to better attend to: a) attachment schema, patients may hold a core self-belief of the
maladaptive interpersonal schemas, both implicit/automatic self as unlovable and others as rejecting or disengaged. The Self-
and conscious; b) impaired metacognition, which hampers Response is one of sadness, as the core self-belief is confirmed,
the understanding of cognitive-affective processes that lie leading to anergia and apathy. Therefore, the individual may use
behind maladaptive schemas; and c) dysfunctional behavioral behavioral avoidance in order to prevent ongoing frustration,
coping strategies such as avoidance, submissive compliance or for example, where the individual suppresses their tendency to
perfectionism. Unaddressed, each or all of these elements may ask for care in order to avoid rejection.
reduce therapy adherence, reducing potential for achievement When social rank schema are active, the dominant core
of broad, stable therapeutic outcomes both in terms of self-image is of the self as unworthy and inferior, vis-à-vis a
symptoms and social functioning. critical and contemptuous other. After being confronted
with impending or actual rejection, or when the individual
interprets others’ reaction as signs of impending rejection, the
individual may feel ashamed. In this situation, they experience
their core-idea of being unworthy and flawed as being made
Maladaptive interpersonal schemas, metacognition
public. This leads to coping strategies including avoidance,
and maladaptive behavioral coping strategies submissive compliance (in order to please the other and avoid
in Avoidant Personality Disorder further criticism), or perfectionism. At times, when the positive
Maladaptive interpersonal schemas self-image of self-as-worthy comes to the fore, APD diagnosed
individuals react with anger to criticisms that they perceive as
Schemas are stable meaning-making structures. Humans use unfair.
them to select relevant information in order to meet their When autonomy/exploration schema are active, individuals
goals, and to make predictions about how others may react to diagnosed with APD represent themselves are impotent,
their requests and wishes. Examples of such schema include paralyzed or deprived of energy. They imagine that the other
core ideas about the self and others - with cognitive, affective will not support them, will constrain them, set limits upon
and embodied aspects - as well as relational procedures for them, or will suffer because of their independent deeds, e.g.
fulfilling wishes or to manage predicted negative responses of the mother will get depressed if the son with APD expresses the
others (Dimaggio et al., 2020; Odgen & Fisher, 2015). These idea of moving to a different town for study or work. Typical

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self-responses are frustration, increased impotence, a sense perfectionism (Hewitt & Flett, 1991; Dimaggio et al., 2018,
of constriction and guilt. These individuals tend to abandon being highly concerned with their perceived mistakes or may
their plans, but harbor resentment because they expected to be hold significant self-doubt regarding their actions (Taylor et
supported or blame themselves for their passivity. Alternatively, al., 2004). Furthermore, individuals may also harbor ideas that
they still pursue independence, but lie in order to avoid facing others hold negative views of them (Hewitt & Flett, 1991) - a
the predicted or actual negative reactions of the others. Finally, further trigger for behavioral avoidance (Shahar et al., 2003).
when the individual is driven by the wish for group inclusion, The outcome of most of these behavioral strategies
they may portray themselves as different, alone, and alienated; is reduced emotional experience and an accompanying
and others as rejecting and linked by bonds that they (the diminished capacity to label emotion arousal – consistent with
individual diagnosed with APD) will never be able to share. alexithymia (Constantinou, et al, 2014; Nicolò et al., 2011).
Moreover, individuals with APD also tend to disconnect
themselves from positive affect, thus leaving them less likely to
Metacognition seek out new experiences (Wilberg, et al. 1999).

Metacognition denotes the capacity to identify mental states,

both in oneself and in others, reason about these states, and
to regulate them (Dimaggio & Lysaker, 2015; Semerari et al.,
2003). It is broadly impaired in personality disorder (Semerari Targeting interpersonal schemas,
et al., 2014). For individuals diagnosed with APD, there is metacognition and coping in avoidant
a pronounced difficulty in the individuals awareness of their
personality disorder
feelings, identification of these feelings and labelling of them
(Bach et al., 1994; Nicolò et al., 2011). Patients with comorbid Based on our understanding of APD psychopathology,
social phobia and APD also have poorer self-reflective capacities an effective treatment will likely need to: a) counteract
compared to individuals with social phobia only (Eikenaes et behavioral coping; b) promote metacognition to the point
al., 2013). In addition, a reduced capacity to identify one’s of understanding that one is guided by schemas; and c) help
own thoughts and feelings hampers the capacity to identify patients realize they are guided by schemas, both at the level
and integrate the interpersonal trigger of their distress in a of cognitive representations of their social interactions and
given situation. In therapeutic interactions this is reflected with regard to automatic procedures for relational behavior.
in the individual struggling to effectively convey their inner The aim for treatment is that intervention yields incremental
experience, speaking in abstract, vague and confusing ways, benefits in terms of adherence and outcomes.
and often resorting to intellectualization (Colle et al., 2017; Metacognitive Interpersonal Therapy (MIT; Dimaggio et
Dimaggio et al., 2007a). Individuals with APD presentations al., 2015a; 2020) follows a series of semi-structured procedures,
tend to have problems in realizing that their ideas about the self divided into two phases: a shared formulation of functioning and
and others are mostly subjective hypotheses, instead are likely change promoting. Therapists first collect and explore narrative
to consider them as objective facts – evidenced via deficits autobiographical episodes, with the goal of forming a shared
in metacognitive differentiation (Dimaggio et al., 2007b; understanding of their maladaptive interpersonal schemas
Semerari et al., 2003). They also have difficulties in forming a with their clients. In the early phase of therapy, behavioral
mature and decentered theory of others’ minds (Moroni et al., experiments are designed to counteract coping strategies such
2016; Pellecchia et al., 2018). as avoidance, perfectionism or procrastination. The explicit
goal here is to explore the inner experience of clients when they
abstain from using these coping strategies, thus strengthening
Maladaptive bahavioral coping strategies their metacognitive self-awareness. Once patients with APD
become aware that they are guided by a set of ideas of self
In response to interpersonal stressors, individuals with APD and others, the next step, change promoting, is to promote
diagnoses often display emotion dysregulation (Dimaggio et differentiation. Here the patient’s goal is to realize that these
al., 2018), enacting a series of dysfunctional coping behaviors ideas are mostly subjective, and are schema-driven, rather
(Lynch et al., 2016). In particular, they tend to over-use than actual representation of real-life interactions. In parallel,
avoidance and emotion inhibition (Arntz, 2012a; Dimaggio therapists help patients to become aware of their positive ideas
et al., 2018; Popolo et al., 2014); or alternatively disguise their about self and others, to connect to their underlying schema-
feelings to avoid negative judgments (Grandi et al., 2011). driven thoughts and to form a sense of agency. This enables
These strategies both increase alienation and loneliness and them to act based on preferences that they themselves endorse
may also precipitate negative reactions from others (Lampe & and take ownership of, whilst simultaneously developing a
Malhil, 2018). sense of self as worthy of pursuing these goals.
In order to distance themselves from negative emotions, There is growing evidence for the effectiveness of MIT
individuals with APD also tend to procrastinate, which may in the treatment of APD using small case and small sample
reduce the impact of shame or inadequacy related cognitions approaches. With regards to individual therapy, in a first case
(Dimaggio et al., 2015b); or they may overuse online study one client with APD was treated successfully (Dimaggio
videogames (Li et al., 2016) to numb themselves from the et al., 2017). In a second study, all three patients with APD
impact of distressing cognitions. Individuals may also resort to treated in a multiple-baseline case-series no longer met criteria

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22 Virginia Valentino, Antonella Centonze, Felix Inchausti, Angus MacBeth, Raffaele Popolo, Paolo Ottavi, Kjell-Einar Zahl, Giancarlo Dimaggio

APD diagnosis after 1 year of treatment (Gordon-King et rescripting was associated with more effective change in
al., 2018; 2019). Furthermore, for patients with mixed PDs autobiographical memory content than simple imaginal
including APD, there are also outcomes from two non- exposure or supportive counseling, with the latter condition
controlled studies and one pilot Randomized Controlled Trial generating no change at all.
of MIT delivered in a semi-structured psychoeducational/ With regard to APD, the rationale for the use of experiential
experiential program (MIT-Group) (Popolo et al., 2018; 2019; techniques is that these clients resort to emotional and
Inchausti et al. 2020). Summarizing across these treatment behavioral avoidance to the point that it is: a) difficult for the
studies, patients with PDs (including APD diagnoses or clinician to understand their cognitive-affective processes; and
prominent APD traits) demonstrated robust adherence to b) they are unable to pursue behaviors in real-life that will help
therapy and therapeutic improvements in terms of symptoms, them break their schema-driven patterns and fulfill life goals
social functioning, and metacognition. - such as working productively, engaging in stable romantic
relationships, or belonging to groups. As a consequence, the
combination of in-session experiential work such as guided
Experiential techniques in MIT for APD imagery and rescripting, and of in-vivo behavioral experiments
has two goals.
In its most recent manualized form, MIT adopts a wide First, these techniques help individuals with APD to better
array of experiential techniques, including guided imagery understand their cognitive-affective processes, to the point that
and rescripting (Hackmann et al., 2011), role-play and two- they can understand that their predictions of how others will
chair approaches (Moreno, 1975; Greenberg, 2002; Perls et respond to them are schema-driven; and that these cognitions
al., 1951), bodily exercises (Lowen, 1971; Ogden & Fisher, lead to behavioral coping strategies that hamper the fulfilment
2015) and behavioral experiments (Dimaggio et al., 2020). of their core wishes. Second, experiential techniques have
Selection and use of appropriate techniques is guided by a the purpose of both helping patients with APD connect to
shared decision-making process within therapy and the goal of healthier self-aspects and adaptive schema; and in facilitating
using these techniques changes through the course of therapy the individual to adopt different, more benevolent perspectives
via an ongoing re-evaluation of the case formulation. towards both the self and others.
One example of this is the extensive use MIT makes of For the sake of brevity, we illustrate the above position with
guided imagery and rescripting. Usually we first ask the patient a clinical vignette of how MIT adopts experiential techniques
to focus on a specific autobiographical memory. We ask him/ in order to address the aforementioned aspects of APD
her to return to the episode ‘as if ’ it was happening in the psychopathology. Specifically, we focus on how techniques
here and now. During the first recollection we try to increase counteract behavioral coping, improve metacognition and
emotional arousal by guiding the patient towards greater change maladaptive interpersonal schemas whilst also fostering
connection with the specific distressing emotion (such as fear, access to healthy self-aspects.
sadness, grief, guilt or shame), generating a richer awareness
of how an interaction with the other has impacted upon the
client. Then, during rescripting we ask the client to a) abstain
from maladaptive coping strategies, for example reducing
tendencies towards avoidance, perfectionism, overcompliance, The case of Gianluca
inverted attachment, and over- dependence; b) connect
Gianluca is 32 years old man who works in a warehouse and
himself/herself with ones primary wishes, such as the desire to
lives alone. He reports that he is depressed and also anxious
be valued, cared for, being autonomous, or playful; c) express
about the idea of meeting people, therefore he spends most
the primary wish to the other(s) in the episode until they
of his time at home. He lost his mother when he was 18.
experience emotion resolution, or to the point that they realize
He describes his father as always humiliating him, aggressive
they have agency over their actions, even if it is difficult to
and frequently neglectful. Consequently, they have minimal
enact different behaviors; and finally d) we often ask the client
contact. He referred himself to psychotherapy with one of us
to acknowledge a more benevolent, supporting, compassionate
(V.V.) because he longed for a richer and more fulfilling social
self-aspect, counteracting the influence of the negative self-
life. He had a few acquaintances, mostly relating to biking (his
aspect in sustaining dysfunctional schema.
passion), but he rarely toured with them as he avoided group
MIT has also adopted experiential techniques on the
meetings. Furthermore, he had never managed to establish an
basis that emerging evidence suggests that they yield a unique
intimate long-term romantic relationship.
contribution to psychotherapeutic change, beyond focusing
on relational factors alone. For example, Stiegler et al. (2018)
reports that adding two-chair work was associated with greater
Therapeutic relationship
change in depression and anxiety compared to a baseline
phase where it was not used. Arntz (2012b) noted how guided Gianluca had difficulties forming a connection with his
imagery rescripting may be as effective as imagery exposure therapist, who in turn felt estranged, distant and at times
and has less potential for adverse effects, though dismantling felt bored and confused. She did not know how to help him.
studies are still needed to evaluate its unique contribution to For example, during the first few sessions, he abruptly stood
psychotherapeutic change. Recently, Romano et al. (2020) up before time was up and asked for the next appointment
noted that, for patients with social anxiety disorders, imagery without giving any explanation for the premature termination.

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 Experiential techniques and Avoidant Personality Disorder 23

By the third session the therapist directly enquired about what would invoke fear in him, which served as a further trigger
Gianluca felt was happening between them. Gianluca said he for behavioral avoidance. Gianluca noted that there were
felt ridiculous, unworthy and was convinced that therapist times in which he was cognizant of a healthy sense of his self
despised him. He revealed this was the reason why he avoided as interesting, worthy and deserving to belong, but he still
greeting her, as he mostly wanted to avoid contacts where he appraised others as rejecting and humiliating, triggering a
might experience humiliation. The therapist tactfully explored cognitive appraisal of unfairness, accompanied by anger.
if she had given any signs of condescending or shaming him and
Gianluca acknowledged she had not. By the second month of
therapy he started feeling more relaxed in therapy and realized Application of experiential techniques
that he could enjoy talking with her about things that interested
In order to counteract behavioral coping and open a more
them both, e.g. their shared interest in a TV series.
in-depth exploration of Gianluca’s inner world, the therapist
proposed several behavioral exercises. Gianluca agreed to try
and stay with his colleagues by the table during lunch break,
Therapeutic contract: goal setting and tasks
instead of eating alone. Staying with others enabled themes
Gianluca requested therapy in order to overcome his depression, relating to group exclusion, unworthiness, weakness and shame
have more social contacts and form a romantic relationship. to emerge into the therapeutic space. However, Gianluca’s
In order to reach these goals, the therapist introduced an improved metacognitive capacity also gave him a clearer
intermediate goal: improving awareness of inner states (i.e. picture of his inner world, licensing the therapist to ask him
metacognitive monitoring) in order to better understand his for associated autobiographical memories. He remembered
inner functioning. She also pointed out that one relevant an episode in which his father lectured him in front of his
psychological goal within therapy was to explore whether the friends when he was 7 years old, and also episodes in which his
negative ideas Gianluca held about himself and others were primary school friends isolated him or mocked him because
incontrovertible facts or whether he was able to access more of his physique. When describing these memories in session
benevolent alternatives. he re-experienced a sense of powerlessness – relating that he
During the drafting of the therapy contract, the therapist stayed silent and did not react.
and Gianluca agreed that counteracting avoidance through The therapist proposed a guided imagery and rescripting
graded exposure was necessary, both in order to break exercise around the experience of group exclusion at primary
Gianluca’s reliance on maladaptive coping, and to better school, which Gianluca agreed upon. This time the idea was to
understand the cognitive-affective antecedents that Gianluca try and counteract the maladaptive coping of avoidance and
was unaware of. They also agreed to use in-session experiential surrender whilst accessing a different sense of self.
techniques (e.g. guided imagery and rescripting). As therapy The following dialogue is taken from the imagery exercise.
progressed, once Gianluca was aware of how he was driven by Gianluca has just performed a brief mindfulness exercise and is
maladaptive schemas, the contract was updated and he agreed now exploring his memory whilst his eyes are closed.
to commit to actions consistent with his underlying wishes and
to act accordingly. G: “I’m in the classroom, I’m 7. It’s playtime. My schoolmates all sit
at the same table, I enter the room but no-one invites me to have
a snack with them”.
Case formulation T: “What are you thinking at this moment?”.
G. “I want to play with them, but no one wants me. I watch them,
During the first sessions, using the behavioral experiments they play, they have fun, some friends of mine look at me but say
described in the next section, a shared understanding of nothing”.
Gianluca’s functioning was formed. His core wish was for T: “What do you think and feel? How do you see yourself?”
group belonging, but he was guided by a negative core image G: “Alone. I’m so ashamed, my cheeks are on fire, I feel hot, short
of himself as different and an outcast. He portrayed others as of breath. What’s wrong with me? What is it that makes me
superior, spiteful and willing to discriminate. When facing different?”
these perceived aspects of others, he switched to a different T: “... what is happening now? What do you see?”
motive - social rank. He felt inferior, ridiculed and longed for G: “I’m leaving, I can’t go where they are sitting. I go back to my
appreciation, through which he felt he could restore his low classroom, luckily there is not much time to wait, the break won’t
self-esteem. These schema were rigid and shaming, as even last for long”
at times others actually included him, he still worried about
rejection: “What do they think of me? I don’t say anything The therapist now stops the imagery exercise to allow
interesting, I’m dumb, boring”. When he ruminated on these Gianluca and the therapist to jointly reflect on the experience
thoughts and feelings his body became stiff, deprived of and agree the direction of a possible rescripting. They decide
energy, experiencing a sense of alienation and estrangement. that Gianluca will try to rescript the episode acting according
To alleviate these negative states of mind he would retreat from to his wish to belong. In order to do so, the first step is to
the group and avoid further contact. Alternatively, when he counteract avoidance. The therapist offers to speak as an
switched to social rank motives he also experienced a sense ‘off-stage voice’, helping Gianluca to label and regulate his
of self as weak facing another stronger and aggressive. This experiences, and offering suggestions as to how to move

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24 Virginia Valentino, Antonella Centonze, Felix Inchausti, Angus MacBeth, Raffaele Popolo, Paolo Ottavi, Kjell-Einar Zahl, Giancarlo Dimaggio

towards goal fulfilment whilst still accessing healthy self- while also trying to connect with others. In the above vignette
representations. Gianluca returns to the imagined memory, his he went on to try to do so and was partially successful. He
eyes closed. In the rescripting exercise the therapist asks him to realized that he was able to make contact with others, but when
approach his schoolmates. he did make these connections socially he was non-assertive
and did not speak about very much with his peers. Role-play
T: “So, Gianluca, do you feel like trying this? What do you say to with the therapist was therefore used in order to model a range
them?” of more assertive conversation expressions and approaches,
G: “Hi guys, what are you doing? Are you having a snack? (His which formed the basis for further in vivo exposures. After 12
voice is low and tremulous)” months in treatment Gianluca reported an improved, more
T: “Good. What do you think and feel? How does it feel in your stable sense of belonging and worthiness.
body?”
G: “I feel Ashamed! My hands are sweaty... I can hardly speak, and
I can’t look at them in the eyes, I feel like I’m blushing”. Therapeutic outcome
T: “Ok. Now focus on what they are doing. Are they playing?”
G: “Yes, they are having fun”. Therapy proceeded on a weekly basis for 18 months and was
T: “How does that feel?” then stepped down to one session every three weeks. Gianluca
G: “They are laughing, playing with football cards. I want to join became more aware of his schemas and when they surfaced
them!”. again he labelled them as his “old habits”. With some effort
T: “Very good. So, let’s try. Breathe, take your time and approach he could take a critical distance from them. “I feel unworthy,
them… pay attention to your voice, try to put energy in it, raise but I know it’s not really me, it is something I used to think
your chin. Ok?”. for such a long time, but now I know I’m ok”. He reported
G: “Yes, I can try”. frequent experiences of group inclusion, starting with his bike
group, whom he now frequently tours with. He had not yet
During repeated rehearsals, Gianluca became progressively established a romantic relationship, but felt confident enough
more capable of approaching his friends. With repeated trials to agree to end therapy, albeit with follow-up reviews every 2
his voice became louder, he stands up, raising his shoulders at months.
the suggestion of the therapist. Gianluca notes that the more Six months after therapy termination Gianluca’s
he adopts these attitudes, the more he feels empowered and improvements were sustained. His social network was now
strong. When looking at his schoolmates he notes fewer signs broader, he was no longer depressed and instead reported
of rejection and focuses instead on the observation that they feeling energized. At work he felt better able to express his own
are having a lot of fun. point of view, with a corresponding decrease in expectations
of criticism, social anxiety and shame. He had just started
G: “Hey guys, can I join? I have a new set of cards”. a romantic relationship, which he was positive about, and
T: “What do you notice? How do you feel now?”. was considering moving abroad to improve his employment
G: “They don’t invite me... but... well I’m sitting next them, and prospects.
they are ok, they leave me to play, one of them talks to me and…
well another one asks to see my cards and… we play now”.
T: “How do you feel now?”
G: “It’s like... I’m one of them… just playing the game…”
Discussion
The therapist invites Gianluca to explore the bodily The core psychological elements of APD include maladaptive
components of this experience, and in doing so he develops a interpersonal schemas, poor metacognition and over-reliance
stronger awareness of this sense of belonging and playfulness. on behavioral coping strategies such as avoidance, perfectionism
In response to the therapist checking in with him, Gianluca and procrastination. We hypothesized that including these
says he has experienced a sense of greater confidence, and he elements in case formulation of patients diagnosed with
thinks he can interact better with others. The therapist finishes APD will deliver benefits in the form of improved treatment
the exercise and invites Gianluca to open his eyes, after which adherence and outcomes. We illustrated this with a case
they discuss his awareness of his internal state. He is aware vignette from the course of a 2-year treatment with MIT.
of feelings of shame and inferiority, but he now realizes this We highlighted how adopting experiential techniques, such
awareness does not mean that he will inevitably succumb to as guided imagery and rescripting, body-oriented work,
negative thoughts and feelings, and he can instead access a mindfulness, role-play and behavioral experiments, both in-
healthier sense of self as being motivated, possessing self-worth session and in real life could be fundamental to successful
and able to connect. He also remembers a memory of being treatment. In particular, these techniques help the patient to
included in a group and other instances in which others were change maladaptive interpersonal schemas and incorporate
welcoming towards him. more benevolent and positive images of self and others into
As an example of a typical sequence within MIT therapy one’s sense of identity.
(Dimaggio et al., 2020), the treatment plan continues with in These elements of formulation, besides ongoing regulation
vivo behavioral exposure. Therefore, as homework Gianluca of the therapy relationship (Safran & Muran, 2000) may well
will try to counteract avoidance between his weekly sessions, have been key to treatment success, however the single case,

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non-structured nature of this approach limits generalization. Bamelis, L.L., Evers, S.M., Spinhoven, P., & Arntz, A. (2014).
The above case presentation suggests that in order to change, Results of a multicenter randomized controlled trial of the
patients with personality disorders, including individuals with clinical effectiveness of schema therapy for personality disor-
APD diagnoses, need to create new experiences which enable ders. American Journal of Psychiatry, 171(3), 305–322. doi.
them to discover that their core wishes can be met, and that org/10.1176/appi.ajp.2013.12040518.
they do not inevitably have to resort to maladaptive coping Chan, C.C., Bach, P.A., & Bedwell, J.S. (2015). An integrative
strategies to protect themselves from the psychic pain of approach using third-generation cognitive-behavioral thera-
expected or actual responses from significant others. The key pies for avoidant personality disorder. Clinical Case Studies,
mechanisms of change may happen both at the level of the 14(6), 466-481. doi.org/10.1177/1534650115575788.
therapeutic relationship (Gazzillo et al., 2019; 2020) or via a Colle, L., Pellecchia, G., Moroni, F., Carcione, A., Nicolò, G.,
wide array of techniques both in-session and between-session Semerari, A., & Procacci, M. (2017). Levels of social sharing
(Arntz, 2012a; Greenberg, 2012; Ecker et al., 2012). and clinical implications for severe social withdrawal in patients
Future work, including structured research designs is with personality disorders. Frontiers in psychiatry, 8, 263.
planned in order to explore whether MIT, as an integrative Constantinou, E., Panayiotou, G., & Theodorou, M. (2014).
third-wave cognitive-behavioral approach, has the potential Emotion processing deficits in alexithymia and response to a
to offer incremental benefits to existing treatments for APD. depth of processing intervention. Biological Psychology, 103,
Therapeutic targets include maximizing treatment adherence, 212-222. doi.org/10.1016/j.biopsycho.2014.09.011.
reducing associated distress; increasing the likelihood that
Dimaggio, G., Procacci, M., Nicolò, G., Popolo, R., Semerari,
individuals with these difficulties can live a richer and more
A., Carcione, A., & Lysaker, P.H. (2007a). Poor metacogni-
fulfilling social life.
tion in narcissistic and avoidant personality disorders: four
psychotherapy patients analysed using the metacognition
assessment scale. Clinical Psychology & Psychotherapy, 14(5),
Author Contributions
386-401. doi:10.1002/cpp.541.
The authors contributed equally to this manuscript.
Dimaggio, G., Semerari, A., Carcione, A., Nicolò, G., & Procacci,
M. (2007b). Psychotherapy of personality disorders: metacogni-
Compliance with Ethical Standards
tion, states of mind and interpersonal cycles. London: Routledge.
Conflict of interest Dimaggio, G., Montano, A., Popolo, R., & Salvatore, G. (2015a).
The authors declare that they have no competing interests. Metacognitive interpersonal therapy for personality disorders: A
treatment manual. Routledge.
Dimaggio, G., & Lysaker, P. (2015). Metacognition and mentali-
Funding zing in the psychotherapy of patients with psychosis and per-
The author(s) received no financial support for the research, sonality disorders. Journal of Clinical Psychology, 71(2), 117-
authorship, and/or publication of this article. 24. doi.org/10.1002/jclp.22147.
Dimaggio, G., D’Urzo, M., Pasinetti, M., Salvatore, G., Lysa-
Ethical approval ker, P.H., Catania, D., & Popolo, R. (2015b). Metacognitive
All procedures performed in studies involving human interpersonal therapy for co-occurrent avoidant personality
participants were in accordance with the ethical standards of disorder and substance abuse. Journal of Clinical Psychology,
the institutional and/or national research committee and with 71(2), 157-66. doi.org/10.1002/jclp.22151.
the 1964 Helsinki declaration and its later amendments or Dimaggio, G., Salvatore, G., MacBeth, A., Ottavi, P., Buonocore,
comparable ethical standards. L., & Popolo, R. (2017) Metacognitive interpersonal therapy
for personality disorders: a case study series. Journal of Con-
temporary Psychotherapy, 47, 11–21. doi.org/10.1007/s10879-
016-9342-7.
Dimaggio, G., MacBeth, A., Popolo, R., Salvatore, G., Perrini,
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