Metacognitive Interpersonal Therapy for Treating Persecutory Delusions in Schizophrenia

A persecutory delusion (PD) is a false belief that other persons are focusing their attention on one with malevolent intentions and programs. Such beliefs result in significant disruption of daily life. PDs are common in schizophrenia, and their content may take a bizarre or highly implausible form (1). For example, a patient with paranoid schizophrenia might believe that her neighbors are spying on her with sophisticated devices and removing her internal organs because she does not have a boyfriend. Persistent PDs cause considerable distress and impairment, and many patients with schizophrenia who experience PDs do not respond well to current pharmacological or psychological treatments (2). Therefore, effective forms of psychological treatment need to be developed to accompany drug therapy.

The most well-known intervention for PDs is cognitive-behavioral therapy (CBT) (3–5). CBT involves first working with patients to reconstruct life events preceding the emergence of their delusions and to analyze any aspects of psychological vulnerability that they may have. Then, in as cooperative an atmosphere as possible, patients (and their families) are educated about the delusion phenomenon, with the aim of normalizing it—for example, by explaining that delusions can result from strong emotional stress (6). The main purpose of this intervention is to reduce stigma and then, by using logical arguments, to help patients question their delusional meaning attributions. Other recent approaches in CBT involve focusing on factors that are thought to play a part in maintaining delusional convictions, such as worry mechanisms (for example, perseverative thinking or intolerance of uncertainty [7, 8]) and cognitive biases (for example, the “jumping to conclusions” data gathering bias [9]).

The merit of this therapeutic approach notwithstanding, we hypothesize that it is possible to improve the effectiveness of psychotherapy for PDs by helping patients understand what delusions mean in their personal experience. This perspective is in line with the work of Chadwick (10), who gave relevance to the personal experience of persons with psychosis and to the meaning they ascribe to that experience. Chadwick emphasized the role of negative self and other schemata in determining the personal meaning of relational events and the implantation of the idea of being threatened. Our work looked at this question in greater detail, on the basis of two main principles. The first is that delusions have a meaning that is connected to the life of the individual experiencing them. In our previous work (11), we proposed that the onset of PDs in the acute phase of schizophrenia—and their reemergence once they have been formed—may be correlated with a fundamental experiencing of the self as being ontologically vulnerable, often elicited by potentially stressful interpersonal situations either real or imagined. This experience of the self as being vulnerable can involve seeing oneself as being unable to both successfully engage others and maintain intact boundaries around a sense of oneself as differentiated from others (12). The individual is not necessarily aware of his or her vulnerable self, which is experienced generally in the form of anxiety, physical weakness, or a vague threat.

The second principle regards metacognition. This refers to a spectrum of mental activities ranging from discrete acts in which individuals recognize specific thoughts and feelings to more sophisticated acts in which an array of intentions, thoughts, feelings, and links between events are combined into larger and more complex representations. Metacognition includes “mastery,” namely the ability to use metacognitive knowledge to solve the psychologically or emotionally challenging events and social problems occurring in daily life (13, 14). All aspects of metacognition are impaired among persons with schizophrenia, and these impairments are linked with greater levels of social and vocational dysfunction (15). These problems are key to understanding how PDs arise. Patients do not understand that, for example, in a certain situation they automatically perceive themselves as being vulnerable and inadequate and others as intending to subjugate them and that this is the antecedent of psychological distress (for example, anxiety), which then leads to the emergence of PDs. They also display low levels of mastery. For example, they do not know how to respond to their PD, or they tend to respond in a dysfunctional way (for example, by attacking the other). In this perspective, a PD is the outcome of difficulties in making sense—in the context of interpersonal exchanges—of the antecedent of a negative emotion and a negative self-perception connected to the emergence of a PD.

In this article, we describe the stages in the treatment of a young man at the onset of paranoid schizophrenia and with a pervasive PD. The patient was treated with metacognitive interpersonal therapy (MIT) (16, 17) adapted for psychosis (18, 19), which aims at progressively fostering metacognition until patients are able to understand what kind of interpersonal events or ideas about interpersonal interactions trigger their PDs and what delusions mean in their personal experience. Because the PD was too pervasive and the patient’s metacognitive capacity too low in the very first sessions, the therapist regulated the therapeutic relationship to avoid any potential ruptures and to promote the best relational atmosphere achievable in the sessions and tried to reduce the emotional suffering caused by the PD and to teach the patient behavioral strategies for coping with this suffering while simultaneously promoting an improvement in the patient’s ability to reflect on his own mind. At the second stage, when it was possible to elicit the autobiographical episodes during which the PD emerged, the therapist tried to reduce the symptoms by promoting a further improvement in the patient’s ability to reflect on his own mind, using a precise intervention hierarchy (18, 19) that aimed at stimulating identification of problematic feelings and understanding the link between interpersonal activating events, problematic feelings, and the onset of the PD; making more complex psychological links between problematic interpersonal schemata and the PD; and promoting a more sophisticated metacognitive mastery of the PD. At the third stage, the therapist promoted a more nuanced understanding of the other’s mind so that the patient’s reading of others’ intentions would be less exclusively driven by the expectation—typical of the schema—that others will be dominant and ill intentioned.

MIT Basic Principles

MIT was originally designed for personality disorders (16, 17) and then adapted for the treatment of psychosis (19), in line with the principles established by Lysaker and colleagues (20, 21). Its main goal is to progressively promote metacognition and awareness of problematic forms of subjective experience and of the schemata driving social behavior. Once this is achieved and patients are better able to think about mental states, a therapist should help them question their rigid and maladaptive ideas about the self and others and find new meanings in order to fulfill previously suppressed wishes that they thought beyond their reach. With both personality disorders and schizophrenia, MIT uses step-by-step procedures to stimulate metacognitive skills throughout therapy (19, 20, 22); however, with patients who have schizophrenia, the therapist often has to begin by promoting the functioning of the most basic levels of metacognition. For example, if a patient is not able to recognize that the thoughts in his head are his own (rather than thinking that the thoughts are introduced into his mind by an outside entity), the therapist needs to first carry out some minimal interventions aimed principally at "restoring" the patient’s agency over his own thoughts. Moreover, for persons with schizophrenia, the therapist should know that the patient’s level of metacognitive functioning fluctuates over time, from session to session and at different moments in the same session.

Eliciting specific narrative episodes is a method MIT uses to further improve metacognition (22). A narrative episode—namely, the detailed account of a personally relevant event—is the most fertile soil for collecting examples with which to explore patients’ subjective experience, problematic emotions, meaning-making style, and biased interpretations of the self’s and others’ ideas and intentions. Such episodes bear information about what a patient thinks and feels while engaging in an intersubjective transaction and also about what self-image the patient has and how the patient relates to others and metacognitively represents their minds (22, 23). Therapists should tactfully divert patients from narratives that are abstract and intellectualized.

Finally, MIT considers regulating the therapeutic relationship and working to prevent and repair alliance ruptures; this is essential throughout the course of treatment, because any intervention, no matter how technically correct, risks failing if carried out at a moment of relationship rupture (24). A fundamental part in regulating the relationship is played by maintaining a constantly validating attitude (17, 18, 25). Validating consists in constantly expressing empathetic understanding, acceptance, and support and in transmitting the following idea: “I can manage to grasp what you’re telling me (or what you’re doing), I can see the reasons, motivations, and emotions causing it, even if it’s questionable for your well-being or counterproductive.”

MIT for psychosis bears many similarities with metacognitive reflection and insight therapy (MERIT) (14, 26), because they both draw on similar practice elements (for example, attention to the patient’s agenda, exploration of narrative episodes, and interventions to promote both self-reflectivity and metacognitive mastery) for progressively promoting metacognition in a context of tactful regulation of the therapy relationship (22). The key difference is that unlike MERIT, MIT assumes that persons with significant psychopathology attribute meaning to events according to a series of maladaptive interpersonal schemas and that a major task of therapy is making them aware of such schemas while promoting different and more flexible interpretations of personal events. A second difference is that whereas MERIT has been developed to be theoretically integrative and technically eclectic, MIT is integrative and adopts more specifically techniques drawn from CBT for treating symptoms of psychosis in its procedures.

Case Illustration

At the start of therapy, Oscar was a 22-year-old Caucasian male from a small town in southern Italy. His maternal grandmother was diagnosed as having schizophrenia at about age 30. He is an only child. From his infancy, his parents, who were socially retiring and anxious, had been very protective of his independence and of his relations with his peers, which contributed to his gradual social isolation. Oscar has been “shy” since childhood, avoided social relationships, and felt different from others and an outcast. He had never had a girlfriend. He had not developed any hobbies or interests beyond his school work, in which he had done well until half way through his final year at high school, when he began to experience prodromal symptoms of psychosis. He began to frequently play truant and spent a lot of time shut in his room. He managed to get his diploma with help from his teachers. His relatives gave little importance to this behavior and allowed Oscar to spend years totally socially isolated.

When he was 22, his parents found him a job in a firm through a relative in a big city, who provided him with accommodation. After one week of work, Oscar started thinking that some of his colleagues were making fun of him. Over the following days, Oscar became convinced that the firm’s “secret agents” were after him and were leaving him signals (for example, a purple towel in the toilet of a café near where he lived), which were intended to tell him that they wanted him dead. His delusional ideas totally restricted his freedom of action. At this stage, Oscar’s symptoms included bizarre behavior and a serious sleep disorder. For example, he would cover his head with a saucepan to prevent the secret agents from monitoring his mind with “radiation”; although not often, he also experienced insulting auditory hallucinations, enough for a diagnosis of a first episode of psychosis. He was taken to therapy by his parents. The therapist, one of the authors (GS), prescribed olanzapine, sodium valproate, and lorazepam, which improved Oscar’s sleep quality and diminished his bizarre behavior and hallucinations but did not eradicate his delusional beliefs.

Oscar met criteria for schizophrenia (27) and had no insight about his illness. Oscar had poor metacognitive skills. This dysfunction in metacognitive capacity was assessed by using the Metacognition Assessment Scale–Adapted (MAS-A) (13, 28). The MAS-A contains four scales that reflect various forms of metacognitive activity: self-reflectivity, the comprehension of one’s own mental states; understanding the mind of the other, the ability to comprehend other individuals’ mental states; decentration, the ability to see a world in which others have independent motivations; and mastery, the ability to use knowledge of one’s mental states to respond to social and psychological problems. The MAS-A assessment of Oscar’s self-reflectivity at the beginning of his psychotherapy showed that he was able to identify his anxiety and tendency to ruminate over negative thoughts, such as, “There’s no escape; the secret agents are coming to kill me,” consequent to his PD. However, the assessment also showed that he was entirely unable to detect the thoughts and perceptions of himself and others that triggered the anxiety and rumination. Similarly, he managed to recognize the anxiety he felt in social interactions at work but was not able to recognize the situational and cognitive variables generating his anxiety. In regard to understanding the mind of the other, Oscar displayed a poor ability to grasp others’ emotions and thoughts, because he attributed them, even if in a sophisticated manner, without any decentration—that is, in social interactions, Oscar was convinced that he was the center or cause of others’ behavior. A cordial expression by a colleague would be interpreted as dissimulating malicious intentions. Finally, Oscar displayed a mastery dysfunction; in response to his PD and to social situations that caused him emotional distress, his only solution was to avoid social interaction.

Oscar’s psychotherapy in a private outpatient clinic was conducted under routine conditions and lasted for almost two years; follow-up (one session every two months) is ongoing. Sessions were weekly and, at the client’s request, lasted 30 to 40 minutes. The psychotherapy was conducted in line with MIT principles, adapted to schizophrenia, which we describe below.

Regulation of the Therapeutic Relationship

In his first session Oscar appeared very reserved toward the therapist and wary because he feared that he would be considered “crazy” by the therapist. Because he had no insight into his own illness, he could not understand why his parents had taken him to a psychiatrist or why there was an urgent need for drug therapy. To positively regulate the relationship, the therapist was guided by three principles: maintaining a constantly validating attitude; achieving as much attunement as possible with the patient’s agenda (29)—that is with the overriding need that the patient brings to the relationship with the therapist at the start of a session; and establishing a cooperative atmosphere by working with the patient to put together a representation of the psychological problem that is acceptable to him and by making the first goal that of agreement on a drug therapy.

In regard to the first point, when the therapist was faced with Oscar’s prolonged silence and lowered gaze at the start of the first session, the therapist grasped that the patient was scared and in need of emotional soothing and reassurance. The therapist knew that patients with schizophrenia are often so marginalized and stigmatized that care is needed to not only avoid taking charge of their delusions but also to ensure that the patient is not just “going along with” the more powerful other (the therapist). Finally, the therapist diagnosed that Oscar had problems understanding others’ minds and thus tried first to evaluate this with regard to his (the therapist’s) own mind and then to reduce the impact of any difficulty of this sort. “I believe I can see how it’s very difficult for you to keep up this interview with me,” the therapist said. “After all, it wasn’t your choice, and in your shoes, I too wouldn’t be very willing to be with a stranger I imagined was there in order to analyze me.”

Oscar replied with a slight smile, which encouraged the therapist to go on. “I can see how difficult it can be for you to open up with me,” he said. These empathetic validation interventions helped Oscar loosen up and openly reveal to the therapist his belief that if he told the therapist the things that were happening to him, the therapist would consider him “crazy” and give him drugs to take. At this point the therapist openly revealed his point of view and the rationale for his procedures by saying, “I don’t think you’re crazy at all, Oscar. Generally, ‘crazy’ is a word with not much meaning to me. My attention is entirely concentrated on what is agitating you. I can feel you are afraid of speaking about what makes you suffer because you fear you’ll be considered ‘crazy,’ but precisely not speaking about it could be making you suffer even more. What can I do to make you realize you have no reason for worrying about what I think?” Oscar seemed calmer and told that he felt persecuted by the secret agents who were in contact with the management of the firm where he worked.

Oscar needed drug therapy, but if the therapist had imposed it while using the bizarreness of the delusional beliefs as the reason, he would have confirmed Oscar’s fear about being considered “crazy” and would have undermined Oscar’s trust in the therapist and the relationship. Consequently, the therapist said, “Oscar, I listened very carefully to your story. I noticed that while you were telling it, you were ever more agitated and that the expression on your face was tense and distressed. I reckon that what I saw was a reflection of what you live through constantly. You showed me yet more clearly how much all this, even when you just think back on it, literally takes over your mind.”

Oscar answered, “It’s true. But do you believe in these things I told you?” This is a very delicate moment in the regulation of the relationship—the moment when the patient asks the therapist to “take sides” about the patient’s delusional contents. The therapist’s reply was an example of the second of the interventions listed above and was based on the principle that we define as “being nonjudgmental about the delusions and diversion in the direction of a shared therapeutic goal.” “Listen Oscar,” the therapist replied. “I’ll clearly explain my position on this question, and I’ll be happy to go back to it every time you want. I can imagine how important it can be for you to feel that your therapist agrees with you on what you feel to be threatening in your life at this moment, but both on account of my turn of mind and because of my role as a therapist who needs to help you to understand your mental states, it’s not obvious to me that I should be concentrating on whether it’s true or not that the firm’s secret agents have got it in for you that much. What interests and strikes me most are two things. The first is that, as I said, this thinking about the secret agents takes up your mind very, very often.”

When Oscar nodded sadly, the therapist continued, “In technical terms you have what’s called ‘ruminative thoughts.’ It happens to all of us when we are very worried. We can’t manage to think about anything else, and the more we think about it, the more we get worried. The insistence of these thoughts at many different moments in your day causes you a state of profound agitation, as we can see even now. You told me that thinking constantly about those secret agents stops you sleeping almost completely. If I put myself in your shoes, I could imagine I’d feel I was under the sway of these thoughts, a bit powerless, vulnerable, and also worn out by having to experience this fear so very often.”

When he saw Oscar’s positive reaction, the therapist concluded, “I’d like to help you immediately with this. Could we consider a drug therapy to help you to reduce the invasiveness of these thoughts and get back to sleeping enough?” Oscar accepted, and on this basis, a drug therapy was agreed upon.

PD Interventions: First Stage

Medications helped Oscar sleep better and reduced his bizarre behavior and hallucinations, but they did not have any significant effect on his delusional beliefs, which were reactivated especially when he went out. As a result, social withdrawal persisted. Thanks to the positive regulation of the therapy relationship, at this initial stage in his therapy Oscar still worried about the threats by the secret agents but was more open with the therapist and asked him less frequently whether he believed that these threats really existed. Oscar was making urgent pleas for help and reassurance from the therapist. During the second session, for example, he said with a pained expression, “The firm’s secret agents have got some very sophisticated ways of spying on me. The films you see at the cinema . . . all true. They haven’t invented anything. The devices you see in James Bond films . . . they’re now closing in on me.” Moreover, because his intense negative arousal and low level of self-reflectivity seemed to prevent him from focusing on any specific activating situation, at this stage Oscar was incapable of reporting specific narrative episodes during which the PD emerged. Only once, in one of the first sessions, did he manage to relate that a car parked near the clinic was linked to the secret agents, but he was incapable of performing an articulated reconstruction of the scene and the thought links and emotions preceding his delusional perception. He was capable only of reporting the emotional distress caused by the persecutory idea, which made him seek refuge by shutting himself at home. With this scenario, the therapist took the following series of measures: empathetically soothing the patient's emotional suffering regarding the delusional ideas, promoting behavioral mastery, and promoting self-reflectivity.

Empathetically soothing and normalizing.

Faced with Oscar’s dramatic pleas for help, the therapist bore in mind that such a vulnerable and scared patient tends to pay attention first and foremost to the nonverbal signals (intonation, prosody, posture, facial expressions, and proxemics) from the therapist’s inner disposition and that the degree to which this disposition is regulated will have the greatest weight in regulating a patient’s emotional reactions in session (30). Accordingly, the therapist regulated his own sense of urgency with respect to the patient’s agitation. First, he listened to Oscar and avoided interrupting him. When Oscar stopped speaking, he modulated his nonverbal behavior by, for example, maintaining a calm vocal tone and tried to sooth him. “Oscar, I can see very clearly from the expression on your face how much you are suffering when you feel threatened and encircled by the secret agents. Don’t worry because I’m going to make every effort and use all my professional skills to help you.”

Promoting behavioral mastery.

This intervention calmed Oscar sufficiently to let the therapist promote a reattribution of meaning with regard to his emotional suffering. At this point, the therapist invites the patient to consider the emotional suffering triggered by the emergence of the delusional ideas as a problem that the patient has the power to act upon, as in the following session excerpt:

In such a situation, a therapist can take the next step and, while still adopting a validating attitude, negotiate strategies for behaviorally mastering the emotional suffering resulting from the delusional thought. At this stage, we prefer two types of strategy: first, those based on a resort to the therapist figure to seek reassurance and solace, and second and simultaneously, behavioral strategies based on activities potentially effective at distracting the mind as much as possible from the suffering caused by the delusional thought. The therapist said to Oscar, “Let’s establish together how to tackle this worry. When it becomes insistent and makes you agitated, you could try and remember my words. Perhaps this won’t be enough to calm you down, so then you might try calling me to discuss it, a bit as if we were in a session, just as we did today. Today it worked. By talking about it, you calmed down a bit. I reckon it could work on the phone too. If you can’t get through to me, you can send me a text or an e-mail and wait for me to call you back. In the meantime, you could try distracting yourself by doing something you like. To find what is most likely to work we need to think a bit together.”

Oscar agreed. At this stage in his therapy, Oscar called the therapist several times when he was in the grip of the delusions, and the therapist adopted the very same position toward the problem that we have just described. Oscar managed to calm down, at least partially, by talking with the therapist. At this stage, a therapist should expect the frequent emergence of negative emotions to make the patient forget what has been discussed in session and the patient to repeat the delusional contents in the form of a frightening factual event, a reality causing dismay and fear. In other words, very often at this stage in his therapy, Oscar asked the therapist for help because he was threatened by the secret agents and not because his worrying about the secret agents had become too unrelenting. In these cases, the therapist did nothing other than repeat the series of operations we have just described: he pointed out that the pervasiveness of these contents was causing suffering, helped Oscar to identify this suffering, and validated it—to then reach agreement with Oscar on how to handle it. At a more advanced stage, after noticing that Oscar relied on him at moments of emotional distress, the therapist attempted to expand Oscar’s set of regulation strategies: “Should you not manage to get me, you could try calming down another way, with, for example, physical activity, like gymnastics or walking or else something you usually like doing, like listening to music. They’re things we all do habitually to divert our attention from some negative state of mind that’s tormenting us, and they usually work even if they require a bit of effort at the beginning.”

Constantly promoting patient’s self-reflectivity.

While promoting Oscar’s behavioral mastery skills at the times when he was not suffering from the PD, the therapist also worked continuously at stimulating his self-reflectivity at the level he was capable of. More specifically, Oscar showed the basic capacity to recognize that the thoughts in his head were his own, so the therapist tried to stimulate the more complex ability to identify and label his own thoughts and emotions in the here and now of a session. For example, he often asked what Oscar thought and felt after each intervention. In this context, he helped Oscar label the thoughts and the emotional suffering emerging over a session. In one session, Oscar was silent and looked sad. The therapist asked him what he thought, and Oscar answered:

A therapist’s aim in this case is first of all to validate the patient’s emotional suffering and promote a representation of the former that is welcoming, accepting, supportive, and able to soothe and then stimulate the patient’s ability to see his or her own mental representations and emotions, and the links between the two, together with the ability to differentiate these representations from reality—namely, to perceive that they are hypothetical and fallible.

PD Interventions: Second Stage

The key features in the second stage of Oscar’s PD treatment were as follows: eliciting a narrative episode in which a PD emerges; in the context of this episode, promoting Oscar’s understanding of the link between his emotional suffering and the PD; promoting awareness that disturbed interpersonal schemas lead to the emergence of the symptom; and promoting high-level mastery strategies for PDs, based on his use of this psychological knowledge.

Eliciting a narrative episode in which a PD emerges.

The key feature of this therapy stage is that the therapist should continue to stimulate self-reflectivity by working on any narratives emerging. On the basis of a narrative episode, the therapist can invite the patient to find a link between his or her subjective suffering elicited by interpersonal situations and the emergence of the PD. When a patient reports even an insufficiently well-organized narrative scene, in which a symptom got activated, the therapist should first help the patient pinpoint details of the scene to retrace more precisely the activating interpersonal event and then promote awareness of the patient’s emotional reactions to the event.

During the fourth month of Oscar’s therapy, the therapist tactfully discussed with him the importance of working on narrative episodes to better understand his emotions. Even if initially with some difficulty, Oscar managed to recall a scene that took place about two days earlier: “I was at the supermarket. . . . We picked up a trolley and went in but . . . at a certain point we saw this big guy. Then we started to do the shopping and to put things in the trolley, and that’s when I really started to tremble. . . . That’s when it became clear that he was there like all the others to make me pay for it. Because these people I was working for were real experts of the human mind. They were totally crazy and during the short period I worked for them I could see everything they were capable of doing to me.”

Promoting the patient’s understanding of the link between emotional suffering and the PD.

The next step consisted in stimulating Oscar’s awareness that the interpersonal events described in his narrative scenes were accompanied by a painful emotional arousal and biased way of reasoning, contributing to the appearance of his persecutory ideas, as can be seen in the following intervention:

If a patient struggles to perceive the links between his cognitive and emotional variables, the therapist can suggest some hypotheses, especially based on what the therapist can infer by identifying with the patient and on anything that can be universally shared in the mental states that take shape in a certain situation:

The therapist’s next intervention had a three-stage structure: reformulating the activating interpersonal event-belief-emotion sequence and asking the patient for his feedback, validating the patient’s emotional experience, and stimulating the patient to see the link between the sequence as identified and the emerging of his delusional ideas. A request for feedback on what has been reconstructed is important for the therapeutic relationship, because it transmits to the patient that the therapist’s purpose is not to coerce the patient into some arbitrary theorizing but to help the patient make contact with the causes of suffering and that this purpose is achievable only with the help of the patient:

Promoting awareness that disturbed interpersonal schemas lead to the emergence of the symptom.

The next step, once the therapist had stimulated an increase in Oscar’s self-reflective skills, was to get him to relate other narrative episodes in which the tendency to ascribe persecutory intentions to another may have emerged in the presence of similar emotional suffering and a negative self-perception. The therapist’s aim was for Oscar to practice—every time he was prepared to do it—identifying in session the general connection between the emotional suffering elicited by interpersonal situations and the emergence of his PD, as in the following excerpt:

At this stage, the therapist helped Oscar to recall a further set of less recent episodes in which a similar schema arose. In one session at this stage, Oscar recalled a prototypical episode originating from when he was about nine, when he was suddenly threatened and then hit at the bus stop by a physically very big bully. Once he got home, he sought comfort from his father, a big, rough man, who replied by shrieking at him and angrily showing him his fists, “You deserved it, because you’re a weakling!” After reminding Oscar of the first episode described above and other similar ones, the therapist helped him—with the assistance of a diagram on the blackboard—to reconstruct a general interpersonal schema. “Oscar, I’ve thought a lot about all the episodes we’ve reconstructed, where you had this paralyzing fear while feeling vulnerable and weak. And I was very struck by that scene at nine years old where you got attacked by that bully much bigger than you and then sought comfort from your father, who reacted just as aggressively. It seems that all these experiences are telling us something important. It’s as if, when he had the desire to be comprehended for his vulnerability—that vulnerability we all experience, that’s part of us—Oscar learned to expect a very different response from what he would have wanted. A response that’s violent and humiliating rather than understanding and comforting. As if the other me told me, ‘How disgusting that you’re vulnerable!’, instead of consoling, reassuring, and letting me know that a person can be valid even if, like everyone, he sometimes feels weak and letting me know that being afraid of being attacked is normal and does not at all mean being unworthy. What do you think?”

Oscar agreed. Now that he was certain Oscar had understood the diagram and agreed with it, the therapist helped him to grasp that the PD seemed to arise especially when this schema got activated: “There you are, then! As happens to all of us when we have experiences like that, that leave a bit of a mark on us, a sort of inner rule has got established in you. When you experience that sensation of vulnerability anybody could experience when faced with people that give us the impression of being strong or aggressive, or even simply very sure of themselves, it’s a bit as if one felt one was nine again and found oneself with that bully. You feel very vulnerable, but at the same time you’re very scared by that vulnerability, because you’ve never been able to confide in someone who would reassure you and say, ‘Don’t worry, nothing’s going to happen, it’s happened that I too have felt like that. It’s a sensation experienced even by people who are very big, physically strong and apparently very sure of themselves.’”

Oscar fully identified himself in this reconstruction and thanked the therapist. The therapist added that the next step in the therapy would be "becoming ever better at observing Oscar in situations in which the schema would get activated." The second part of this intervention is explaining from a normalizing standpoint the link between a schema and the contingent activation of delusional symptoms. While continuing to use a diagram on the blackboard to illustrate what he was saying, the therapist told Oscar, “There’s something else very important we’ve learned together. When they feel vulnerable and consequently frightened, it happens with all human beings that they get this sensation of being threatened. Before we were saying that if we are faced with a man who’s very big and strong, a mechanism can get activated that leads us to feel vulnerable and potential victims. But something else important that occurs is that while we feel like that and get this sort of unease or anxiety, we are automatically, through a really age-old mechanism, led to feel a bit threatened by this person. We can also become wary. In reality, what’s happening is merely the consequence of the sensation of vulnerability. In practice feeling vulnerable leads us automatically to think that the other is going to attack us. Could this have perhaps happened several times to you, for example at the supermarket or with the plumber—that is, when you met someone very big and well set?”

Even if a patient gives positive feedback to this type of intervention, carried out tactfully and with a validating attitude, the patient is very likely to feel that his coping strategy—in this case based on diffidence and the hyperactivation of vigilance toward a potential outside danger—is being blocked. Feeling that his coping strategy is threatened could in turn lead a patient to use it to shield himself and to entrench himself behind it. In other words, accepting a therapist’s suggestion of grasping the subjective origins of suffering involves accepting the risk of lowering one’s guard toward an outside world that is perhaps not as dangerous as one thought until now; however, lowering one’s guard can reactivate vulnerability, and with it negative arousal, retriggering the coping strategy.

Oscar at this point answered, “You’re right, I agree. I hadn’t ever seen it like that . . . and for sure that’s what happens to me. . . . However, the other time, in the supermarket those guys really had it in for me. There’s no doubt.” Then the therapist said, “I understand, Oscar. My aim was not to make you change your ideas about those guys at the supermarket. I was just keen to get you to know a practically universal mechanism in which there’s a close link between feeling weak and feeling automatically that the person, vis-à-vis whom we feel weak, is hostile. Sometimes it can happen that we meet someone who really is hostile, but it’s nevertheless extremely important to know this mechanism in which the other seems a priori hostile to us almost every time that this sensation of vulnerability, that we managed to focus on together, emerges from deep inside us. Perceiving this mechanism in ourselves makes it possible for us to continue to be watchful toward outside threats—let’s say to not lower our guard but to learn better to distinguish when these threats are real as compared with when they originate from within ourselves, from our feeling vulnerable.” Oscar relaxed and agreed with the therapist. Yet again, the therapist did not try to refute the delusional perception of the other’s malicious intentions but only to offer the patient a new evaluation perspective, more centered on his subjectivity.

Promoting higher-level mastery strategies.

The therapist should now promote the patient’s use of this high-level psychological knowledge to achieve a more sophisticated mastery of PDs. To facilitate recalling the schema reconstructed in the session, the therapist left Oscar a copy of the schema diagram and a brief memo saying, “Oscar, remember that when you feel threatened, it’s most probably also because you are feeling very vulnerable, and that it happens to all of us to feel very threatened when we feel physically vulnerable.” The therapist and Oscar agreed that when Oscar’s sensation of being threatened returned, he should choose which mastery strategy to use from among those already used (for example, calling the therapist), trying to recall the work done together in the session (for example, by rereading the notes from the therapist), or performing some pleasurable activity, such as going to the gym. On various occasions, Oscar recounted that by using such a strategy, he had managed to switch his attention from his PDs, and the voices disappeared.

Advanced Treatment Stages

After 23 months of psychotherapy, Oscar has a good outcome in regard to the PD and is now starting to see the therapist only once every two months. With Oscar, the therapist used the analysis of new narrative episodes to make him aware that his ego-dystonic perception of vulnerability was a recurring one. Thanks to their discussion of the schema, Oscar had managed to identify his perception of vulnerability as at least partly connected to his perception of an outside threat and to understand that this image had taken shape gradually on the basis of negative experiences. For Oscar, his vulnerable self had taken a pervasive hold and his differentiation (that is, of reality from representation) was thus not stable. However, with the therapist’s assistance, Oscar began to understand that each time a situation gave him a sensation of physical vulnerability, he tended to feel threatened. Therefore, the therapist is currently working on encouraging Oscar's exposure to situations that could be a source of well-being for him and on the reinforcement in these situations of Oscar's metacognitive ability to understand others’ minds and decenter in a more sophisticated fashion. For example, in one session during the 20th month of therapy, the therapist proposed an exercise of the imagination focused on reading the mind of another who had looked and smiled at him:

Conclusions

We have described the treatment of a PD in a young man meeting the criteria for schizophrenia and treated with MIT. We have described how in the first stage of the treatment, when the PD was very pervasive, arousal very high, and metacognitive skills very low, the therapist adopted a validating and soothing attitude to stimulate the patient’s behavioral coping with the delusional beliefs. MIT does not try to challenge delusional beliefs, because this requires high-level self-reflection skills, which are very unlikely to be present in patients with psychosis, especially at moments of emotional turmoil. With the support of a validating atmosphere, the goal is for a patient to change his or her idea of not being able to cope with symptom-related suffering. It should be suggested that the patient adopt a set of strategies (metacognitive mastery) for coping with suffering until he or she develops a sense of agency over the symptoms and of self-efficacy. These emerging feelings will then reinforce the patient’s ability to take action to solve his psychological problems.

We then showed that at a more advanced stage in the treatment, the therapist helped the patient to consider the persecutory ideas as an expression of his emotional reactions generated by activating interpersonal situations in which he felt vulnerable. On this basis, the therapist promoted a degree of self-reflection to the extent that the patient could understand the social triggers that, together with his self-schemas, ignited his delusions. This created the conditions for the patient to adopt a critical distance from the schema and use this new psychological knowledge to achieve an advanced metacognitive mastery of his PD.

We do not try to help a patient grasp that a representation “is not true” but rather to help the patient glimpse—with a massive resort to empathetic validation and normalization—the underlying universal agreement about the representation, namely, that it “is not more true for the patient than it is for the rest of the human race.” In other words, we aim to help the patient grasp how much, for example, we all possess a core of vulnerability. On this basis, a therapist should encourage a patient to look at this image, when it emerges in life situations, with a cognizant and accepting eye and should help the patient modulate it, together with the emotional suffering and the symptoms that it tends to trigger. Repeatedly experiencing empathetic validation and normalization in the therapy session will clash dialectically with periods when the negative self-image and the schema triggering the delusions get activated. A therapist should not feel defeated by such negative fluctuations, which are normal.

Here we have described a two-phase sequence for the sake of clarity, but in everyday clinical practice, a therapist is more likely to move back and forth between the two phases until a problem is solved. Patients’ metacognitive abilities tend to fluctuate over time (18, 21), often in the same session, and the therapist has to adjust his or her action to the patient’s current skill level. For example, at one moment, the patient might understand that the activation of an interpersonal schema is the antecedent of the emergence of the delusions. The patient may start questioning his or her own schema. But moments later, when thinking about a distressing episode, the patient may lose this ability and again complain about a threat. In such cases, the therapist must go back, for as long as needed, to interventions belonging to the first phase.

Several important limitations need to be pointed out. The first concerns the generalizability of the good therapy outcome. For example, the effectiveness of the interventions may not have depended exclusively on their technical correctness but on other variables—for example, the therapist’s personal characteristics, such as his self-confidence; the fact that the patient's illness was at its onset; and the patient’s good level of neurocognitive functioning. Consequently, further research is needed on single-case studies to verify the effectiveness of the procedures described when treating patients with PDs, a longer history of illness, chronic symptoms and co-occurring negative ones, and a different neurocognitive profile. Nevertheless, psychotherapy using MIT seems to be effective in stimulating metacognitive skills and reducing PDs, and even if it does not have a definitive impact on self-beliefs, it can stimulate a patient to see that PDs are generated by internal attributions.