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.