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

Introduction

Many patients with personality disorders (PDs) display emotional over-regulation (EOR). This is particularly true for those with narcissistic disorders (both overt and covert), and avoidant, paranoid, obsessive-compulsive, dependent, schizoid, passive aggressive and depressive disorders. They have limited awareness of their feelings, tend to suppress feelings, and do not give feelings due importance in decision-making (Fonagy & Target, 1996; Semerari, Carcione, Dimaggio et al., 2003; Dimaggio, Salvatore, Nicolò et al., 2010; Dimaggio, Attinà, Popolo & Salvatore, 2012a; Dimaggio, Salvatore, Fiore et al., 2012b; Dimaggio, Montano, Popolo & Salvatore, 2015). Other patients are prone to emotional dysregulation (ED), that is heightened sensitivity to emotional stimuli; they require more time to return to baseline and have difficulty adopting adaptive strategies for toning down arousal (Linehan; 1993; Garner & Spears, 2000; Gross & John, 2003; Philippot & Feldman, 2004; Linehan, Bohus, & Lynch, 2007). Though ED is a hallmark of borderline PD (Linehan, 1993; Linehan et al., 2007; Carpenter & Trull, 2013), and is central to antisocial PD (Litt, Hien & Levin, 2003; Scott, Stepp & Pilkonis, 2014), it has been documented in almost all the other PDs (Sarkar & Adshead, 2006), such as dependent (Bornstein, 2012), narcisisstic (Fossati, Borroni, Eisenberg & Maffei, 2010; Twenge & Campbell, 2003; Ronninstam, 2009; Centifanti, Kimonis, Frick & Aucoin, 2014), paranoid (Salvatore, Russo, Russo et al., 2012), and avoidant (Popolo, Lysaker, Salvatore et al., 2014; Taylor, Laposa & Alden, 2004).

To date, most treatments have been focused on patients with tendencies toward ED, in particular, borderline PD (Linehan, 1993; Gunderson, 2008), with just a few treatments focusing on EOR (Lynch & Cheavens, 2008; Dimaggio et al., 2012a, b; 2015). However, many PDs feature both EOR and ED. Patients swing from periods in which they are mostly unaware of their feelings (avoiding or suppressing them) to times during which they are overwhelmed by feelings. Typical examples are patients with avoidant PD: they inhibit their feelings (Taylor et al., 2004; Popolo et al., 2014) and enter states in which they are overwhelmed by shame or anger. Persons with narcissism are usually detached and aloof but swing to ED when others fail to provide the admiration they need. Patients with such complex disorders need help not only accessing in feelings but also in expressing feelings and regulating them when they spiral out of control.

Metacognitive interpersonal therapy ([MIT] Dimaggio et al., 2012a,b; 2015) has been manualized for treating patients with PD with a tendency towards EOR. In this paper, we describe an adaptation aimed at working with patients whose symptoms swing from EOR to ED. We first describe the MIT model of personality pathology, followed by a summary of the main procedures used to treat patients with prominent EOR. We then describe how to adapt these procedures when patients are affected by ED and finally, illustrate how to use these with a patient who had a complex PD.

Personality Pathology According to Metacognitive Interpersonal Therapy

The assumptions underlying MIT are that PD features

Individuals with PD exhibit poor metacognition, and have difficulties identifying and describing inner experiences and the psychological causes of their behavior and emotions. It is also difficult for such individuals to achieve a sophisticated understanding of what drives others to act, feel, or think (Dimaggio, Lysaker, Carcione et al., 2008; Fonagy, 1991; De Rick & Vanheule, 2007; Lawson, Waller, Sines, & Meyer, 2008). Another significant feature is the inability to use knowledge about mental states—termed metacognitive mastery—for purposeful problem solving, when dealing with both interpersonal issues and problematic mental states. Given this inability, patients with PD lack the capacity to calm themselves when they experience emotional suffering.

Another core feature of PD pathology is the tendency to be driven by a set of maladaptive interpersonal schemas. Among the predominant self-representations are feeling unlovable, unworthy, guilty, omnipotent, and betrayed. Individuals with PD easily construct the other as rejecting, abusing, mistrusting, and deserving punishment. When some basic human motivations, such as attachment, social rank, group inclusion or sexuality are activated, patients with PD tend to imagine themselves as being unable to fulfill their wishes because of a negative self-image coupled with a negative representation of the other. As a consequence, they end up forecasting that their wishes will be unmet and then tend to react with a series of dysfunctional coping strategies, such as withdrawal, reactive anger, motivation loss. As a result their interpersonal live are filled with problems and missed opportunities.

The third domain is poor affect regulation. To date MIT has focused on EOR, treating patients who often are either unaware of their feelings, suppress them because they are scared about how others will react if they display them, or underrate their importance. This often deprives them of any true contact with other people. Flat affects may also be the result of affect-avoidance. Patients find arousal discomforting so that they swiftly disregard any emerging affects (Helmes, McNeill, Holden, & Jackson, 2008; Tayor et al., 2004).

MIT: Step-By-Step Procedures

Metacognitive interpersonal therapy for PD with EOR (Dimaggio et al., 2010; 2012a,b; 2015) consists of two parts:

Shared formulation of functioning is the complete set of operations aimed at reconstructing patients’ inner worlds. Therapists pass from initially promoting lower levels of self-reflection, such as emotional awareness, to higher-order ones, such as forming plausible hypotheses about psychological cause-effect relationships among elements of subjective experience (e.g., recognizing feeling hurt by a boss refusing a raise and then angrily withdrawing from all social contacts).

The operations for shared formulation

Schema reconstruction in MIT is based on the core conflictual relationship theme (CCRT; Luborsky & Crits-Christoph, 1990) template. The CCRT reconstructs an interpersonal schema based on the goal—wish—that a patient pursues and fears will fail because of others’ responses. Once the wish is activated, the patient thus expects a response from the other, which is followed by the self’s response to the other’s response. Thanks to the reconstruction of the schema, it is possible to infer the self-image underlying the wish (e.g., self not worth anything).

Change promoting includes various strategies and techniques: fostering patients’ ability to question their ideas and distinguish between fantasy and reality; focusing on adaptive self-aspects formerly overshadowed by dominant problematic experiences; promoting new behaviors in an exploratory manner; forming an integrated view of the self capable of making sense of contradictions and lapses; decenter, that is achieve a nuanced understanding that others’ minds are different from one’s own. A therapist should move between shared formulation of functioning and change-promoting in line with the needs and abilities displayed by the patient during a session. Metacognitive interpersonal psychotherapy does not follow a predefined agenda. Therapists attune themselves to what patients are telling and to the level of metacognitive abilities displayed. During a single session, a therapist may focus on shared formulation of functioning operations if the patient brings up a new issue that requires the evoking of narrative episodes, and then later in the session if the patient shifts to issues already dealt with for some time, problem-solving strategies may be more appropriate.

Therapists should pay the greatest attention to emotional markers, as displayed both by themselves and by the patient, from the very beginning of therapy. Therapists need to focus on the patient’s non-verbal signals, such as a facial expressions, prosody, and posture to identify what the patient is feeling about the therapist and thus be able to detect and assess any problematic transference aspects. Therapists also need to monitor their inner states to see if they are reacting to the patient in ways that could create, sustain, or amplify any arising relational issues. If therapists see a dysfunctional relational pattern, they need to focus on the therapy relationship as a priority until the problem is solved, any alliance rupture repaired, and a shared focus on therapy goals restored (Safran e Muran, 2000; Dimaggio et al., 2012a, b; 2015).

Adapting MIT to Arising Emotional Regulation Problems

Some patients with complex PD, who usually control their affects can lose control over their emotions and become dysregulated by interpersonal triggers, such as social rejection or abandonment. At moments of dysregulation, they lose their capacity to explore their inner worlds and are instead caught in a spiral of negative and uncontrolled thoughts and of impulsive behaviors, such as self-harming or harming others (e.g. unprotected sex, reckless driving or substance abuse). Therefore, MIT requires adaptation for a patient who usually displays inhibition but shifts into a state featuring ED.

Beginning in the assessment phase, MIT works through regulation of the therapeutic relationship (Safran & Muran, 2000). For example, a therapist used to a patient’s over-controlled stance may react with alarm, self-blame, or criticism of the patient for losing control. Throughout treatment a therapist needs to modulate these inner tendencies, as a negative interpersonal environment in the therapy relationship would further increase ED in the patient. Emotional dysregulation is targeted in session when it arises, with the goal of re-establishing a patient’s sense of safeness and calm with the therapist (Livesley, 2005; Linehan, 1993; Gunderson, 2008; Kernberg, 1984; Bateman & Fonagy, 2004). Validation is an important part of this soothing intervention. It entails a therapist communicating to the patient that the subjective experience, no matter how much it is felt to be out of control, is an inherent and meaningful part of human nature (Linehan, 1993).

Once the therapeutic relationship is restored, the therapist assesses with the patient previous episodes of lost control to avoid being surprised by sudden dysregulated affects. The therapist explores the typical triggers of a patient’s dysregulated affects and behaviors, such as a partner threatening separation. Once the patient and therapist form a shared understanding of these triggers, a therapy contract is informally drafted, including strategies to calm the storms caused by the dysregulated affects (Linehan,1993; Bohus, Haaf, Stiglmayr et al., 2000). Therapist and patient try to agree on the latter abstaining from risky behaviors (e.g. drug abuse or reckless driving) and from therapy-interfering ones, such as missing sessions during periods in which the patient feels out of control. A series of affect-modulating strategies is then programmed. These can consist of simple strategies, such as physical exercise, calling a friend, or watching a movie, aimed at diverting attention from emotion-eliciting stimuli (Linehan, 1993). If the patient is unable to adopt these strategies without support, the patient may call or text message the therapist (Kernberg, 1984; Gunderson, 2008; Linehan, 1993). Another intervention is the use of mindfulness techniques, such as mindful breathing and noticing thoughts and letting them go (Kabat-Zinn, 2004; Linehan, 1993; Bohus et al., 2000). Finally, pharmacotherapy is discussed if there is prominent and treatment-resistant ED.

If the above strategies prove helpful, and the patient returns to either a normal baseline emotional tone or to EOR, MIT reverts to its core procedures: eliciting detailed autobiographical episodes, searching for affects and their link with thought and actions, and collecting associated autobiographical memories to reconstruct any underlying maladaptive interpersonal schemas. For example, the schema may be illustrated by the following:

The response of the self is driven by a “not-deserving-love-and-unworthy” core self-image. In this case the patient may resort to perfectionistic strategies to gain the other’s approval and lose control over her separation anxiety. This can provoke anger, which can spiral out of control. Written formulations or diagrams can be of help for a shared understanding (Dimaggio et al., 2015; Salvatore et al., in press). Once a shared formulation is reached, including an understanding of the triggers of ED, it can be used as a mentalistically complex emotional regulatory strategy. The patient can try to adopt a critical stance before losing control over an emotion by remembering that what is happening does not necessarily mirror the truth, but rather reflects his or her own schema-driven vulnerability. For example, a patient criticized by his brother may guess the criticism was a sign of hatred. Consequently, the patient’s moods start swinging between anger and sadness, both emotions intense enough to spiral out of control. He resorts to substance abuse. If he were able to realize the problem was not hatred from his brother, but a problem linked to the reactivation of his vulnerability-to-criticism schema, he could use this awareness to divert his attention from his brother’s words and use regulatory strategies other than substance abuse.

Once therapy is at a more advanced stage, all the strategies listed above can be used progressively according to the needs of the moment. A well-internalized image of the therapist is used as a self-regulatory tool between sessions. For example, a patient can be invited to remember what her therapist did during a session to make her feel safe. Various strategies, ranging from distraction to sending a message to the therapist, physical training, or mindfulness meditation can be used at this stage. If the patient has a developed self-awareness, he can read a schema diagram at home as a memory-supporting device to remember that inner processes, more than interpersonal events, are the causes of his ED. At more advanced stages of therapy, therapists can invite patients to form a more nuanced and mature theory of the other’s mind and thus distinguish between the guesses leading to their dysregulation, moving for example, from “she wants to abandon me” to a more realistic reading, “she needs to be alone at times but always comes back to me”. Finally, memories of positive self-aspects can be used as another regulatory strategy, with, for example, patients trying to recall the sense of worth and lovability experienced during previous sessions in order to divert their attention from ideas of failure or rejection.

We now describe the case of a patient with complex PD swinging from EOR to ED as a detailed illustration of the adapted MIT protocol described above.

Jacob’s Case

Presenting Complaints

Jacob had problems separating from his girlfriend, though he no thought he longer loved her and was attracted to another woman. He was unsure whether he still loved his girlfriend or if he just needed her because she gave his life balance. He swung from feeling the relationship was constricting him to having anxiety outbursts about breaking up and losing a “safe haven.” He feared that when the relationship ended he would be out of her mind, which evoked intense fears of loneliness, as she was his only social contact as he had no friends.

He asked for therapy because he needed help in choosing between the two women. His therapist (GS) had 10 years of experience in MIT and therapy was weekly. Lamotrigine (75 mg) was used at the start of his treatment to reduce impulsivity and dysregulation. The client attended more than 90% of the scheduled weekly appointments.

History

Jacob was a 45-year-old medical doctor. He lived with his father, described as authoritarian and aloof. His mother had died two years before treatment began. Jacob described her as loving and able to soothe him during his frequent bouts of sadness and to make him feel special, even when compared to his two younger brothers. However, she was also harsh, critical, and controlling. To not lose her caring presence, he tried to please her and comply with her perfectionistic standards. When, at 18 years old, Jacob wanted to go out with a girlfriend of whom his mother did not approve, she stopped speaking to him. Jacob felt abandoned and dismayed, and he blamed himself for the distress he feared he was causing his mother. Consequently, he stopped seeing the girlfriend. He concealed his next love affair, at 20 years old, from his mother. His new girlfriend was “a very attentive and caring girl” and a “landmark in all ways” for him, even if he was systematically unfaithful to her.

Diagnosis and Psychopathology

Jacob met 22 criteria for PD in the Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II). He suffered from depressive, avoidant, and narcissistic PD, and subthreshold dependent and borderline PD. His symptoms, as measured with the Symptom Checklist-90 (SCL-90), were severe. On the Emotional Inhibition Scale ([EIS] Kellner, 1986; Grandi et al., 2011), he was emotionally inhibited. All the subscales of the Difficulties in Emotion Regulation Scale ([DERS] Graetz & Romer, 2004; Giromini et al., 2012) pointed to severe problems in regulating emotions, ranging from emotional unawareness to inability to form strategies for adaptive self-control. As regards his metacognitive skills, his descriptions of emotions were poor as he was barely able to name anxiety and anger, thus making it hard to communicate what he felt to the therapist. At the same time, he lacked a good empathetic understanding of what the other felt. During moments of dysregulation he also lost the distinction between fantasy/reality. This occurred when faced with a threat of abandonment by either his girlfriend or his lover. Not receiving a return call meant he was going to be left alone forever, and there was no way he could question this idea.

He was unable to use an understanding of mental states, both of the self and the others, to soothe suffering. When in distress the only way he had of calming himself was with impulsive or dysregulated physical behaviors, such as kicking or punching a wall. He often stood outside his girlfriend’s home and yelled so loudly she had to call the police. When he was not dysregulated, Jacob isolated himself because he felt others to be alien to him, and he tended towards being a workaholic because he experienced gratification when admired and thanked by his patients.

Regulating Emotions through the Therapy Relationship

Jacob arrived at his first session with a polite but detached attitude. He started immediately to describe himself as a tower of strength for his patients; consequently, it was “very difficult now to find himself in a position in which he was asking for help.” In compliance with the MIT intervention style, the therapist respected this difficulty. The therapist modulated the therapeutic relationship by validating Jacob’s ability to be a landmark for others and by talking about how Jacob’s job had a lot in common with his own. This created a positive atmosphere, which made it easier for the patient to open up so that he recounted “moments in which he succumbed” in his romantic relationships, a topic he elaborated on in the next session.

In his third session Jacob cried out of despair. The therapist was very surprised and upset by this unexpected change. But the therapist felt irritated when he considered that a grown man should not lose his dignity in this way. However, as the therapist analyzed his own state of mind, he realized that his irritation towards Jacob emanated from a fear that he had underestimated the case and had failed as a therapist. As the therapist regulated this state of mind, it became possible for him to empathize with Jacob’s suffering and concentrate interventions on trying to soothe his patient. The therapist then said with a warm, but firm, tone, “Jacob, I’m sorry for what you’re going through, and I can see how intense and painful your suffering is. I’m profoundly motivated towards being of help to you, and I’m sure this therapy’s going to be of great use to you. What’s important to start with is to try and make this suffering less intense. Join me in taking a nice deep breath”. When Jacob stopped crying, the therapist asked him: “Are you able to tell me when you started feeling like this? Where were you? What were you doing?” At this juncture he proposed that the patient, to the best of his ability, reconstruct the scene in which this emotional suffering began. Jacob pinpointed that it had started when his girlfriend refused to see him, and this had made him feel irremediably abandoned. The therapist validated him again: “Jacob, in this case you experienced intense distress linked to your wish to be loved and your fear that a person important for you could abandon you. Putting myself in your shoes and seeing things as you did at that moment, I can utterly understand you”. As he saw this encouraged Jacob, the therapist enquired whether he had felt the same way in other situations and found that Jacob’s fear of being abandoned had driven him to carry out impulsive self-harming actions. So he said: “Jacob, in these episodes you’ve always felt abandoned for understandable, human reasons. But it would appear that the intensity and duration of this distressing emotion have been particularly large. This problem’s termed emotional dysregulation. When it hits us, our mind is unable to analyze the distressing emotion and this makes our pain all the worse; and if we lack strategies for tackling it, we’re capable of actions that are dangerous for both ourselves and others, because our organism searches for a kind of motor discharge in its attempt to somehow soothe the pain. We need to tackle this problem immediately so that, when it surfaces again, we’ll be prepared”. Jacob agreed with this proposal and appeared motivated.

Enacting Basic Regulation Strategies between Sessions

The therapist proposed a contract: Jacob was to limit, as much as possible, his dysregulated behaviors. The therapist was to provide him with suitable strategies for overcoming his periods of ED. In this context and in a non-authoritarian manner the therapist explained the need for drugs as an auxiliary tool. Then he told Jacob: “It can be helpful to opt for some activities you’d do willingly when you’re not suffering, for example physical exercise, going for a walk, or calling a friend. However, remember that when there’s dysregulation we can look at such strategies as being unnatural. So we need to be prepared to make an effort to start using them and then let ourselves be slowly captivated by them. A bit like getting on a carousel without being eager to and then starting to enjoy it once it’s turning. Over time they turn out to be very good at diverting our attention from our suffering”.

Jacob put walking at the top of the list as this was one of the most likeable activities for him. The therapist pointed out that one of the possible options, especially if this strategy failed, was for Jacob to contact him (the therapist advised about when he would realistically be available). During the first two months of therapy Jacob called the therapist several times in tears as he had not been able to calm down by walking. Each time the therapist first soothed Jacob, then helped him to recall the activating episode and pinpoint the factors causing ED, and finally, suggested Jacob try again one of the strategies listed in the contract. The telephone calls became less frequent during the third month as Jacob resorted more to e-mail to contact the therapist, and the patient happily accepted that there would be a delay in the reply. Once, when Jacob found himself in an ED situation caused by an argument with his girlfriend, he managed to go for a long walk without calling the therapist, and when he spoke about it in a session, he displayed much satisfaction. The therapist congratulated Jacob and helped him to see that it had been pleasurable for him to feel he was good at independently managing his emotional suffering. To promote this aspect, the therapist taught Jacob some mindfulness techniques, such as mindful breathing, focusing on one’s awareness of physical sensations, thoughts and mental images at that moment and letting them go. During in-session ED situations after this, the therapist first retraced the triggering episode, then tried to help Jacob describe, to the best of his ability, his inner state, and to undertake mindfulness exercises, in order to self-soothe his suffering. When Jacob had mastered these techniques, the therapist advised him to employ these exercises in ED situations outside sessions too.

By his sixth month of therapy, Jacob displayed an ability to use flexibly all the strategies described above, in line with the needs of the moment. For example, one evening when his girlfriend stopped answering his calls, he managed to regulate his state of distress with a long walk. However, while he walked, his distress did not lessen, and he felt tempted to turn up crying at her flat. He regulated this impulse by calling the therapist, who encouraged Jacob to tell about what happened and soothed him. Two hours later Jacob sent the therapist a text message to say that after their phone conversation his distress had increased again, even if it was less intense, but he had been able to regulate it with the mindfulness exercises. Apart from the benefit arising from less use of maladaptive coping strategies, the overall result at this point, was an increase in Jacob’s mastery over his mental states.

When Jacob was not dysregulated during the first three months of therapy, it was difficult for the therapist to elicit any autobiographical narrative episodes and to explore Jacob’s inner states. At this stage Jacob described his job and his romantic relationships in an abstract fashion. For example, he talked with satisfaction about how scrupulously he treated his patients and how grateful they were. At such moments the therapist adopted the MIT procedures for PD with prominent EOR. First he tried to ask for some specific autobiographical episodes, but Jacob just answered “more or less as usual.” The therapist then decided to pick up any non-verbal signals in the therapeutic relationship as cues for exploring Jacob’s inner states. The latter was silent and had a gloomy expression. The therapist therefore asked him: “Based on your facial expression, you seem sad. Has something happened?” Jacob told him that what had hurt him was the therapist not answering a call he had made two days earlier. The therapist got Jacob to perceive that his sadness was due to seeing the former as being concentrated on his own life and no longer interested in Jacob. He showed Jacob that in truth he had not felt that way at all, and that the real reason for him not answering was tiredness. This seemed to reassure the patient. The therapist then asked Jacob if he could think of any other episodes where he had had a similar fear of being abandoned and not being important for the other. Jacob related a recent episode where a patient of his, of whom he was very fond, unexpectedly cancelled an appointment and he had felt anxiety and sadness. Now he could better understand that such emotions depended on his feeling abandoned and not important for the other. He could see that this feeling also underlay his fear of “vanishing” from his girlfriend’s mind.

Despite this positive shift in his ability to reflect on his own mind, Jacob continued to have moments of ED when he felt abandoned by his lover or by his girlfriend. However, he was still not up to using the awareness achieved in session to grasp the causes of his ED and to regulate his emotional suffering. When Jacob exited an ED situation, the therapist pointed out his core theme of being abandoned. For example, in a session at the start of the fourth month, the therapist said, “Jacob, I can recall that we grasped that you felt abandoned and of little importance for me because I didn’t answer a telephone call and that you found this feeling to be similar to what you had experienced several times with the women in your life.” Jacob recalled it, and he seemed willing to speak about it again. The therapist asked him if there was another moment in his life in which he had felt the same way. Jacob recounted various episodes as a child or adolescent, during which he had felt he was losing his mother’s special love because she reacted coldly when Jacob did not behave in line with her expectations. By now Jacob was able to grasp that, in periods of transition in his life, and in the contexts and people with whom he interacted, situations always followed the same course and activated the same cognitive-affective reactions. At this point, using written diagrams (Dimaggio et al., 2015, Salvatore et al., in press), the therapist reconstructed the following schema together with Jacob: Jacob wishes to be loved but expects the other to love him in an exclusive and special manner only if Jacob complies with the other’s expectations (e.g. being a perfect son); his selfimage is “special” when no wishes diverging from the other’s expectations arise, and “not loveable” when they do. The latter was his feared self-image because it drastically reduced his self-esteem and caused distress. The two self’s responses to the other’s response aimed at preserving self-esteem and avoiding the other’s negative response were: a) lying (e.g. to his mother or to his partner) not to delude the other and lose his/her special love; b) boosting a grandiose self-image (e.g. becoming a tower of strength for others). The latter, in particular, increased his self-esteem and protected him from his feared self-image. Jacob could see himself entirely in this reconstruction. The therapist told him that the next step in the therapy would be to use his awareness of the schema as an additional tool for managing any occurrences of ED. The therapist agreed with the patient that “in the heat of the moment of dysregulation” the he was to try reading the diagram again, recalling the therapist’s words as they were drawing it together, and bearing in mind that what was happening did not necessarily mirror the truth, but rather reflected his schema-driven vulnerability.

Outcome of the First Year of Therapy

After about six months of therapy, Jacob had become better at identifying his own emotions and the activation of the schema, at grasping the difference between the schema and reality, and in adopting a more decentered position towards his periods of ED. At the same time, the therapist managed to promote Jacob’s ability to form a more nuanced theory of the other’s mind and use this metacognitive skill as a regulation tool. For example, Jacob became able to grasp that when his lover did not answer his phone calls, she had not forgotten him but, on the contrary, was trying to protect herself from the suffering he caused her by not deciding to leave his partner. Around the tenth month of therapy, he broke up with his partner, started a steady relationship with the woman he loved, and went to live by himself. During this period the therapist often emphasized Jacob’s positive aspects, as a further, potential regulatory strategy. For example, the therapist suggested that in difficult moments Jacob try recalling the sense of safety he experienced during sessions or in his relationship with his new partner, with a view to diverting his attention from any schema-driven ideas.

After one year, Jacob no longer displayed ED on the DERS and alterations on the EIS. His SCL-90 scores clearly showed symptom reduction. At his SCID-II retest interview after one year he showed only subthreshold dependent and avoidant PD (see Tab. 1). Jacob continued therapy with one session every two weeks.

Conclusions

A PD swinging between emotional over-regulation and dysregulation needs specific treatment. We tried here to adapt MIT to deal with the specific problems these patients present. In summary, the therapeutic steps described are: a) regulating emotions in sessions through the therapy relationship, b) exploring the typical triggers of dysregulated affects and behaviors, c) drafting a therapy contract envisaging strategies for soothing ED, ranging from contacting the therapist to mindfulness techniques; d) proceeding with core MIT procedures when a patient is not dysregulated to reconstruct his underlying interpersonal schemas, e) promoting awareness of the schemas as a mentalistically complex emotional regulatory strategy, f) promoting the achieving of a more nuanced theory of the other’s mind and new positive self-aspects as further high level regulatory strategies.

We described a therapy with a patient treated in accordance with the procedures outlined. Its good outcome encourages further exploration of the use of MIT adapted for emotional dysregulation. Nevertheless, there are important limitations to this study. By its very nature the single case qualitative design prevents any generalization. The patient was under medication and we are unable to distinguish the effects of the psychotherapy from those of the pharmacotherapy.

Overall, we hope to have provided the reader with a rationale and a set of strategies for promoting the ability to regulate emotions in people with both over-regulation and dysregulation of emotions. How much the MIT procedure described here can be applied to patients with prominent ED is a matter of current research. A final consideration is that this procedure is going, we hope, to be manualized in detail, so that session transcripts can be proofread and checked to see whether progress in session actually mirrors the concepts we have devised here. Training clinicians in the application of the procedures is possible irrespective of their preferred school, so that they can be considered a potential tool for an integrative PD psychotherapy.