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Psychiatry Research 190 (2011) 60–71
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Psychiatry Research
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Metacognitive mastery dysfunctions in personality disorder psychotherapy
Antonino Carcione a,⁎, Giuseppe Nicolò a, Roberto Pedone a,b, Raffaele Popolo a, Laura Conti a,Donatella Fiore a, Michele Procacci a, Antonio Semerari a, Giancarlo Dimaggio a
a Terzo Centro di Psicoterapia Cognitiva - Scuola di Psicoterapia Cognitiva (SPC)/Training School in Cognitive Psychotherapy, Rome, Italyb Department of Psychology, University of Naples II, Italy
⁎ Corresponding author at: Via Ravenna, 9/c, - 00161 –
fax: +39 0644251928.E-mail address: [email protected] (A. Carcione
0165-1781/$ – see front matter © 2011 Elsevier Irelanddoi:10.1016/j.psychres.2010.12.032
a b s t r a c t
a r t i c l e i n f oArticle history:Received 29 August 2010Received in revised form 27 November 2010Accepted 29 December 2010
Keywords:Personality disordersMetacognitionMasteryCoping
Individuals with personality disorders (PDs) have difficulties in modulating mental states and in coping withinterpersonal problems according to a mentalistic formulation of the problem. In this article we analyzed thefirst 16 psychotherapy sessions of 14 PD patients in order to explore whether their abilities to master distressand interpersonal problems were actually impaired and how they changed during the early therapy phase.We used the Mastery Section of the Metacognition Assessment Scale, which assesses the use of mentalisticknowledge to solve problems and promote adaptation. We explored the hypotheses that a) PD patients hadproblems in using their mentalistic knowledge to master distress and solve social problems; b) theimpairments were partially stable and only a minimal improvement could be observed during the analyzedperiod; c) patients’mastery preferences differed from one another; d) at the beginning of treatment the moreeffective strategies were those involving minimal knowledge about mental states. Results seemed to supportthe hypotheses; the patients examined had significant difficulties in mastery abilities, and these difficultiespersisted after 16 sessions. Moreover, the attitudes towards problem-solving were not homogenous acrossthe patients. Lastly, we discuss implications for assessment and treatment of metacognitive disorders inpsychotherapy.
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© 2011 Elsevier Ireland Ltd. All rights reserved.
1. Introduction
A feature of individuals with personality disorders (PDs) is theirfailure in various ways to modulate their subjective suffering andadaptively cope with problems arising from living with others. Tomaster distress, PD patients frequently use dysfunctional strategies,e.g. self-harm or substance abuse. In their social relationshipsthey lack strategies for acting effectively and adaptively, such asnegotiating their goals with others, flexibly altering their aims asthe relational context changes or adapting to the rules of theirenvironment. It is useful to possess a varied and flexible set ofmentalistic problem-solving strategies, from themore behavioral (e.g.taking an adequate dose of drugs or doing physical activity), to themore complex, requiring greater reflective abilities (e.g. divertingone's attention from a thought causing suffering or handling arelational problem by resorting to a mature theory of the other'smind). Persons who possess a wide and flexible range of masterystrategies are better at handling stressful events; those who cope lessflexibly with events tend to overrate their distress level and perceiveminor obstacles as being as difficult to cope with as more serious ones
(Cheng and Cheung, 2005). Proactive coping, i.e. adopting an activeattitude towards problem-solving, without restricting oneself todescribing them in solely factual terms, predicts outcomes such asfunctional independence, life satisfaction, and engagement (Green-glass et al., 2005; Uskul and Greenglass, 2005; Gan et al., 2007; Sohland Moyer, 2009).
In a sample of individuals treated for suicidal behavior, Joiner et al.(2001) tested the links between problem-solving attitudes, positiveaffect and suicidal behaviors; they found that improvements inproblem-solving attitudes partiallymediated symptom remission. In arandomized controlled trial chronically self-harming individuals, Sleeet al. (2008) found that improvements in emotional regulation wereassociated with reductions in self-harm.
We stress that in order to understand whether a mentalisticallyconducted in based mastery strategy is adaptive it is necessary toconsider if the means-ends relationship is appropriate and to analysecosts-benefits. Perceiving that one is anxious and deciding to takebenzodiazepine to calm one's increasing anxiety is an appropriate andeffective means of reaching an end, i.e. soothing anxiety in the shortterm; taking a whole box is a similar strategy, but dysfunctional and,moreover, the costs (negative effects of the drug over-usage)overcome the benefits (soothing anxiety). Again, perceiving thatone is tense and tired and trying to relax physically by taking a hotbath is an appropriate and effective means of reaching the goal offeeling calm; burning oneself with a cigarette or cutting oneself may
61A. Carcione et al. / Psychiatry Research 190 (2011) 60–71
stop a dissociative state, but the costs largely exceed possible benefits.Patients may display many difficulties in using mentalistic knowledgeto master symptoms and improve social adaptation. This may be dueto poor mentalistic skills, uncorrected planning because means-endsrelationships and costs-benefits ratios have not been carefullyconsidered, or a combination of both factors. Such patients maypossess only a limited ability to manage complex mental states – forexample, understanding the triggers activating one's emotions, takinga critical distance from one's ideas or forming a mature theory of theother's mind, a set of skills we henceforth term metacognition(Semerari et al., 2003) – using suitable problem-solving strategies.
Various problems arising from deficient self-knowledge contributeto hindering the ability to carry out of effective problem-solvingstrategies. Without the ability to identify the factors provoking adistressing emotion, it is difficult to soothe the related suffering bytackling the cause of the problem. If an individual cannot understand,for example, that a somatic symptom is a sign of an emotion caused by adear one's leaving, he may become prey to hypochondriacal rumina-tions, which itmay only be possible to interrupt if he is aware of the linkbetween the loss and his consequent sadness and distress.
Without an awareness of one's own role in causing problems, it isnot possible to solve them: if an individual does not perceive that hishumble attitude is what makes others tend to underestimate him, hewill not change it in order to be more appreciated. If people do not seethat they are suffering on account of their own expectations and notthe current state of things, they are unable tomodify their problematicbeliefs. Finally, symptoms like depressive ones, such as apathy and asense of failure, can arise from not acknowledging one's desires andgoals and acting accordingly. An individual not perceiving that he hasgiven up pursuing something that would have made him feel better,cannot as a consequence undertake actions aimed at reaching someinnermost life goal.
In short, good self-awareness helps to provide an individual withmore tools for mastering suffering and handling conflicts. A poorknowledge of others’ minds, another element found to be lacking invarious PDs (Fonagy et al., 2002; Semerari et al., 2007; Allen et al.,2008; Dimaggio et al., 2009a; Domes et al., 2009), is another cause ofthe social dysfunction typical of such individuals. Understanding thatothers will not respond to our requests for attention when they areunder stress helps us to avoid seeking help at inappropriate times. Onthe other hand, inferring, on the basis of a sophisticated theory of theother's mind, which are the best strategies and time for seekingattention increases the likelihood that our goal will be achieved.
We use “Metacognitive Mastery” to describe the use of mentalisticknowledge to solve problems, cope with stressors and symptoms, andpromote adaptation. It includes the ability to recognize emotions andtheir triggers, and to use appropriate strategies to achieve emotionalregulation. The latter ranges from autonomous self-regulation toresorting to help from others whose minds are accurately portrayedas able and willing to lend help or cooperate (Carcione et al., 2008,unpublished). To a certain extent this definition overlaps with thenarrower use of the term “metacognition” by others (Nelson andNarens, 1990; Wells, 2000) to describe the conscious processesbehind emotional regulation. There is growing evidence that theseregulatory processes are involved in the ability to cope with distress,for example, by interacting with affects in the self-regulation ofbehavior (Salonen et al., 2005; Efklides, 2008). A link between pooremotional awareness and emotional regulation has been found ineating disorders (Harrison et al., 2009) and also hypothesized inschizophrenia (Ochsner, 2008). As regards major depression, Stilesand colleagues (Stiles et al., 1990; Brinegar et al., 2008) noticed thatduring psychotherapy clients passed from a poor awareness ofproblems to states in which they were more able to identify affectsand distressing contents. Only when, in good-outcome therapies, suchawareness is achieved can patients develop suitable and effectivemastery strategies.
Barber and DeRubeis (2001) found that after 12 weeks of cognitivetreatment clients with major depression became more capable ofemploying compensatory skills and displayed a more “optimistic”attributional style in the presence of negative events. Compensatoryskills are cognitive coping skills for dealing with distressing eventsand thoughts, and these authors found in their research that they canbe taught by a therapist.
In a case of depression analyzed with the MetacognitionAssessment Scale (MAS; Semerari et al., 2003) Carcione andcolleagues (2008) found the patient displayed overall good metacog-nitive skills but featured difficulties in activating compensatorystrategies. Wells (2000) noted that distracting oneself by deployingone's attentional resources underlies the strategies for controllingworry in generalized anxiety disorder (GAD). Clients’ difficulties inusing their knowledge of their cognitive processes to control themplay a role in causing and perpetuating GAD.
In clientswith schizophrenia it was found that better self-reflectiveskills correlated with greater awareness of their illness (Lysaker et al.,2005a, b); this could lead them to cope betterwith distress or to bettersocial function (Lysaker et al., 2010a). Metacognitive mastery fullymediated the impact of neurocognition on socially functioning(Lysaker et al., 2010b).
In the PD field, to our knowledge, only a few studies haveinvestigated the use of psychological knowledge for problem-solving purposes. Semerari and colleagues (2003) analyzed thepsychotherapies of two clients, one with borderline (BPD) and theother with narcissistic PD (NPD), with the Metacognition Assess-ment Scale. In the BPD client they found that construction duringtherapy of a better ability to integrate different mental statescorrelated with an increase in mastery. On the contrary, in the NPDclient improvements in mastery were linked to an increased abilityto identify inner states.
An increase in awareness, together with attention and acceptanceof the present moment, was studied, analyzed and used whenapplying Mindfulness techniques in Borderline PD in BPD (Salsmanand Linehan, 2006). Mindfulness training promotes the awareness ofall emotional and cognitive events as they occur in the present - aconcept clearly related to what we term metacognition – so thatindividuals can recognize the warning signs of tension build-up(Schreiner and Malcolm, 2008). Developing mindfulness involvespurposefully directing one's attention to internal and externalexperiences, as they occur on a moment-by-moment basis, withoutevaluating or judging them. Recent data show that mindfulness, whenpracticed correctly, aids the development of cognitive skills oftenassociated with acceptance, objectivity, and metacognition (Baer,2003; Brown and Ryan, 2003; Hayes and Kelly, 2003). Once such‘metacognitive insight’ skills have been acquired, it becomes easier tocontrol previously difficult safety behaviors and cognitions (Kristellerand Hallett, 1999). A mindfulness deficit can account in BPD forvariability in personality features, characteristic difficulties in emo-tional regulation and interpersonal effectiveness, and impulsivity.Such difficulties appear to explain borderline pathology even whencontrolling for negative affectivity, behavioral dyscontrol, andemotional and interpersonal dysfunctions (Salsman and Linehan,2006; Wupperman et al., 2008).
In this article we analyze some PD clients’ session transcripts todiscover whether their ability to master problematic mental states andinterpersonal problems was impaired and how it changed duringtherapy. We have explored a number of hypotheses. The first is that PDclients display problems in using their mentalistic knowledge tomasterdistress and solve social problems (Dimaggio et al., 2007; Dimaggio etal., 2009b; Liotti and Prunetti, 2010). Secondly, consistent with studiesshowing that some forms of psychotherapy are associated withimprovements in self-reflective skills (Semerari et al., 2003; 2005;Levy et al., 2006; Dimaggio et al., 2007; 2009b) and the ability to readothers’minds (Dimaggio et al., 2009a), we expected PD clients’mastery
62 A. Carcione et al. / Psychiatry Research 190 (2011) 60–71
skills to be dysfunctional at the beginning of psychotherapy and topartially improve in the early treatment stages.
More specifically, we expected clients with PD to have an overalldifficulty in adopting an active problem-solving stance and animpairment in their ability to use mentalistic knowledge to copewith distress and solve interpersonal problems. We then expected, inline with preliminary observations (Semerari et al., 2007), that thedysfunction would not be homogenous, with some clients displayinggreater problems and others milder ones. We also hypothesized thatat the beginning of treatment the most efficient strategies would bethose involving minimal knowledge about mental states, whilea mentalistic problem-solving stance, requiring sophisticated meta-cognitive skills, should rarely be attempted and would be expected tohave minimal chances of success.
As regards psychotherapeutic change,we expected, in linewith theidea that PD clients’ symptoms decrease but certain basic dysfunctionsare more enduring (Morey et al., 2007), that mastery problems wouldbe long-lasting, although aminimal amount of early changemight stillbe found. The idea is that a limited degree of swift improvement ispossible: for example, when patients switch from a passive to aproblem-solving stance, or they draw benefit from their therapist'soptimistic attitude and start to develop a vague awareness that theirproblems lie in their minds and something can be done to solve them.This would be consistent with studies showing how some copingskills are acquired early and are associated with positive outcomes(Greenglass et al., 2005; Dimaggio et al., 2007; Carcione et al., 2008;Sohl andMoyer, 2009). However, to achieve a complex understandingof one's own and others’ mental states and of what the mentalisticsources of distress are, and, eventually, use this knowledge toconstruct problem-solving strategies, much time and therapy effortare then necessary. We therefore hypothesized that only a minimal ormoderate degree of change could be observed during the earlymonthsof therapy.
2. Method
Given that the research described above is pioneering, a design based on a series ofsingle case studies (Stiles, 2005) appears appropriate. Unlike large sample research,studies like these are not aimed at theory-testing but represent theory-buildingheuristics. Analyses of a series of cases allow for detailed descriptions of a phenomenonstill requiring accurate knowledge (Osatuke and Stiles, 2011). We will, therefore, onlyprovide descriptions on a client-by-client basis (Dimaggio et al., 2009a). Such a formatmakes it possible to gather data from a number of intensively analyzed cases andformulate inferences on which processes are likely to be common among them(Osatuke and Stiles, 2011); this information then makes it possible to formulatehypotheses to be applied for statistical hypothesis-testing with larger samples.
2.1. Participants
The participants were 14 Caucasian adults (3 male and 11 female), all diagnosed ashaving a PD with the SCID II (First et al., 1997). Clients had been receiving long-term
BASIC REQUIREMENTS (MBR)M1 The subject discusses his own behaviour and psychological
of-fact dates but as tasks to be done and problems to be solplausible way.
FIRST-LEVEL STRATEGIES (1st LS)M2 The subject tries to act directly on the problematic state by moM3 The subject avoids the cropping up of problematic states andSECOND-LEVEL STRATEGIES (2nd LS)M4 The subject faces the problem voluntarily imposing or inhibitinM5 The subject faces the problem voluntarily adjusting his mentaTHIRD-LEVEL STRATEGIES (3rd
LS)M6 The subject faces the problem acting upon the evaluations
problem itself and/or using his general knowledge of his own M7 The subject faces the interpersonal dimension of the probl
other people's mental functioningM8 The subject faces the problem accepting his own limits in
influencing events
Fig. 1. Mastery (M) scale of the Me
Metacognitive Interpersonal Therapy (Dimaggio et al., 2007), with one session weekly,from clinicians with at least 5 years of experience in a private outpatient center. Mostclients had a high school diploma and about half a university degree. The mean age andeducation years of the sample were, respectively, 29.4 (SD=7.2) and 14.9 (SD=3.8).Clients with mental retardation or active substance abuse were excluded from thestudy. There were diagnoses in all DSM-IV clusters: 4 BPD, 3 NPD, 2 avoidant (APD), 2dependent (DPD), 2 obsessive-compulsive (OCPD) and 1 paranoid (PPD). Three raterswere involved in the process. Rater A was a male psychotherapist with 15 years,experience. Rater B was a female psychotherapist with 10 years, experience. Rater Cwas a male psychotherapist with 25 years, experience.
2.2. Measure
2.2.1. Tool: The Mastery Scale from the Metacognition Assessment Scale (MAS)The MAS is a rating scale for assessing metacognition, as manifested in individuals’
verbalizations. It is designed to detect changes in psychotherapy transcripts in theability of persons to think about thinking. In this article we use only the MAS MasterySection which assesses the use of information about mental states to take decisions, solveproblems or psychological and interpersonal conflicts, and master distress (Fig. 1)(Semerari et al., 2003; Carcione et al., unpublished).
Metacognitive mastery is a conscious and purposeful use of mentalistic strategies tosolve problems. Mastery is defined as the ability to: a) represent psychological spheres interms of problems to solve, passing from the simple representation of mental and socialevents to being able to actively use knowledge of mental states to change the state ofthings; b) use psychological knowledge as a source of information for planning problem-solving strategies, coping with suffering, achieving desires and adapting to social life; andc) form increasingly complexmentalistic strategies for solving tasks (Semerari et al., 2003;Dimaggio et al., 2007; Carcione et al., unpublished).
The Mastery scale includes 4 sections:
1) Basic Requisites (MBR): the ability to represent mental states involving suffering orconflictual relational situations as problems to be solved, and to adopt an activestance aimed at solving these.
2) First Level Strategies (1st LS): are essentially behavioral and require an extremelymodest reflective effort, such as simply recalling the effectiveness of the samestrategies when used on other occasions. Such strategies include attempts tomodifyone's mental state with direct physical actions (e.g. taking appropriate medication)or the conscious avoidance of feared situations. They include resorting tointerpersonal support and asking for help or exploiting interpersonal relationshipsfor a way out of problematic states (for example, inviting a friend to go out and havea beer because one has been left by one's girlfriend). Resorting to interpersonalcoordination at this level does not necessarily imply complex attributions ofintentions and mental contents to others or their willingness and suitability tosupply the necessary help. It involves only the simple awareness that askingsomeone for help can be useful. For these strategies to be considered metacognitiveit is essential that subjects have voluntarily and deliberately behaved in a certainway in order to cope with a negative mental state.
3) Second Level Strategies (2nd LS): require the ability to voluntarily make oneselfperform or avoid particular behaviors or to autonomously regulate one'sconsciousness by diverting attention from a problem, whether intrapsychic orinterpersonal. This level too does not require a particularly detailed analysis of orreflection about mental states, although greater reflective skills are necessary thanfor the previous strategies. A person needs to be good at identifying his thoughtsand emotions, and to have a clear idea of the content from which to divert hisattention, and also needs to suitably exploit any self-exhortations or self-impositions. This greater awareness of one's inner state distinguishes suchstrategies from first level ones, in which the mental state to be managed is notnecessarily clear to a subject and reflection is limited to an awareness that aparticular behavioral action is capable of positively modifying a suffering state.
processes and states not as simple matter-ved,defining the terms of the problem in a
difying the general state of the organism/or uses the relational context as a support
g a behaviour on himselfl order
and beliefs which are at the basis of the mental functioningem using his own general knowledge of
the management of his own self and
Score
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
tacognition Assessment Scale.
Mastery TOT 1-16
0 10 20 30 40 50 60 70 80 90 100 110 120 130 140 150 160 170 180 190 200 210
NPD 1
NPD 2
NPD 3
BPD 1
BPD 2
BPD 3
BPD 4
PPD 1
DPD 1
DPD 2
APD 1
APD 2
OCPD 1
OCPD 2
Fig. 2. Mastery: sessions 1-16. Note: White lines indicate the raw number of successes and black lines indicate the raw number of failures in mastery for each patient. White linesindicate the raw number of successes and black lines indicate the raw number of failures. OCPD=obsessive-compulsive personality disorder. APD=avoidant personality disorder.DPD=dependent personality disorder. PPD=paranoid personality disorder. BPD=borderline personality disorder. NPD=narcissistic personality disorder.
Mastery TOT 1-8
0 20 40 60 80 100 120 140
NPD 1
NPD 2
NPD 3
BPD 1
BPD 2
BPD 3
BPD 4
PPD 1
DPD 1
DPD 2
APD 1
APD 2
OCPD 1
OCPD 2
Mastery TOT 9-16
0 20 40 60 80 100 120 140
NPD 1
NPD 2
NPD 3
BPD 1
BPD 2
BPD 3
BPD 4
PPD 1
DPD 1
DPD 2
APD 1
APD 2
OCPD 1
OCPD 2
Fig. 3. Mastery: sessions 1-8 versus sessions 9-16. Note: The graph above indicates the raw number of successes and failures in mastery in sessions 1-8 for each patient. The graphbelow indicates the raw number of successes and failures in mastery in sessions 9-16 for each patient. White lines indicate the raw number of successes and black lines indicate theraw number of failures. OCPD=obsessive-compulsive personality disorder. APD=avoidant personality disorder. DPD=dependent personality disorder. PPD=paranoidpersonality disorder. BPD=borderline personality disorder. NPD=narcissistic personality disorder.
63A. Carcione et al. / Psychiatry Research 190 (2011) 60–71
64 A. Carcione et al. / Psychiatry Research 190 (2011) 60–71
4) Third Level Strategies (3rd LS): require a strong reflective commitment, aknowledge of the recurring and stereotyped features of one's reactions andsymptoms and of what triggers them, and the ability to adopt a different point ofview on the basis of this knowledge. They also require a good knowledge of theother's mind and the ability to insert this knowledge into one's problem-solvingstrategies when the problems are of an interpersonal nature. They include: a) arational criticism of the beliefs underlying a problematic state, like “I know I tendto be afraid of fainting when I get on a bus but I realize that it won't happen anddepends on my usual sensation of being restricted, which makes me feelsuffocated. I can overcome it because I've grasped that I won't really faint.”; b) ause of our knowledge of our own and others’ mental states to regulateinterpersonal problems, for example when perceiving that a friend has thespecific ability, due to his skills and the nature of our relationshipwith him, to helpus to see things differently; c) a mature acceptance of one's limitations as regardschange in oneself and others and influence on events, and the ability to forecastthe effect one's actions will have on oneself and others.
2.2.2. MAS assessment and ratingMAS assessments are based on the evaluation of a sequence of units in each
psychotherapy transcript. In each speaking turn (i.e. all a client says between twotherapist speech passages) a rater has to identify any attempts by the client to exercisemetacognition and, if this is the case, whether it has been used correctly andcongruously or not: in the first instance we rate it a success (marked with a score=1:yes) and in the second a failure (markedwith a score=0: no). As an example, when, in aunit, a client manages to carry out distractor strategies to cope with distress, a raterregisters a success (marked with a yes). If a client tries to impose a behavior on herself(“Come on, stop checking the gas again and again”) but fails to, a rater marks a failure(marked with a no). Consequently successes and failures are evaluated separately foreach function; the MAS does not evaluate the definitive presence or absence of a skill,but only the successful or unsuccessful use of a skill at a particular moment in
Table 1Mastery successes and failures: sessions 1-8 versus sessions 9-16. Note: The table indicates tthe Mastery Section of the Metacognition Assessment Scale. OCPD=obsessive-compulsive pdisorder. PPD=paranoid personality disorder. BPD=borderline personality disorder. NPD
FIRST PERIOD (1-8)
Basic Requirements Mastery Strategies
Patients (PD) 1st Level 2nd Lev
Successes Failures Successes Failures Success
NPD1 10 (90.91%) 1 (9.09%) 2 (100.00%) 0 (0.00%) 6 (30.0NPD2 13 (54.17%) 11 (45.83%) 0 (0.00%) 2 (100.00%) 10 (34.4NPD3 1 (100.00%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 1 (10.0BPD1 32 (47.76%) 35 (52.24%) 20 (74.07%) 7 (25.93%) 15 (29.4BPD2 27 (29.67%) 64 (70.33%) 15 (88.24%) 2 (11.76%) 3 (50.0BPD3 17 (36.17%) 30 (63.83%) 12 (75.00%) 4 (25.00%) 12 (41.3BPD4 31 (60.78%) 20 (39.22%) 1 (50.00%) 1 (50.00%) 0 (0.00PPD1 0 (0.00%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 6 (85.7DPD1 13 (44.83%) 16 (55.17%) 7 (53.85%) 6 (46.15%) 5 (11.6DPD2 24 (68.57%) 11 (31.43%) 14 (87.50%) 2 (12.50%) 10 (10.9APD1 0 (0.00%) 2 (100.00%) 6 (60.00%) 4 (40.00%) 4 (66.6APD2 5 (35.71%) 9 (64.29%) 3 (100.00%) 0 (0.00%) 5 (21.7OCPD1 31 (39.24%) 48 (60.76%) 11 (61.11%) 7 (38.89%) 9 (64.2OCPD2 39 (44.83%) 48 (55.17%) 1 (11.11%) 8 (88.89%) 1 (20.0
SECOND PERIOD (9-16)
Basic Requirements Mastery Strategies
Patients (PD) 1st Level 2nd Leve
Successes Failures Successes Failures Successe
NPD 1 8 (100.00%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 7 (31.8NPD 2 8 (57.14%) 6 (42.86%) 1 (100.00%) 0 (0.00%) 6 (35.2NPD 3 0 (0.00%) 1 (100.00%) 1 (100.00%) 0 (0.00%) 4 (40.0BPD 1 23 (65.71%) 12 (34.29%) 10 (100.00%) 0 (0.00%) 15 (71.4BPD 2 41 (43.16%) 54 (56.84%) 13 (81.25%) 3 (18.75%) 20 (90.9BPD 3 32 (50.79%) 31 (49.21%) 7 (87.50%) 1 (12.50%) 16 (61.5BPD 4 4 (57.14%) 3 (42.86%) 0 (0.00%) 0 (0.00%) 0 (0.00PPD 1 0 (0.00%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 1 (50.0DPD 1 7 (41.18%) 10 (58.82%) 1 (25.00%) 3 (75.00%) 21 (38.1DPD 2 19 (65.52%) 10 (34.48%) 10 (100.00%) 0 (0.00%) 11 (22.9APD 1 1 (20.00%) 4 (80.00%) 1 (50.00%) 1 (50.00%) 3 (42.8APD 2 12 (44.44%) 15 (55.56%) 6 (100.00%) 0 (0.00%) 4 (20.0OCPD 1 5 (33.33%) 10 (66.67%) 3 (75.00%) 1 (25.00%) 7 (100.OCPD 2 7 (30.43%) 16 (69.57%) 4 (57.14%) 3 (42.86%) 2 (50.0
conversation. If there is no clear attempt at using metacognition, then there is nothingto score.
2.3. Analysis
For each client the first 16 therapy sessions were recorded, transcribed in full andanalyzed. After subdividing them into score units, two raters marked them inaccordance with the MAS manual rules and the data were analyzed with SPSS Inc.(1999). Reliability was assessed using a balanced set of units scored by two raters (Aand B). The scoring was blinded and tested over a subset (30%) of randomly selectedtranscription material.
Refinements in the coding system with the revision of the MAS (Carcione et al.,2008) have led to an acceptable inter-judge reliability. In the present study, as regardsthe MAS Mastery subscale we obtained 89% (Cohen's kappa = 0.797). Where ratersdisagreed, a joint rating was given after a group discussion with a consensus rater (C).
The analysis began with an evaluation of the total mastery score in the sessionsinvolved (16); we then arbitrarily divided the period analyzed into two equal sub-periods (sessions 1-8 and 9-16) to pinpoint whether there was any problem at the startand how it evolved during treatment. The main goal of the analysis procedure was to(a) obtain a homogeneous observation period for all the clients and (b) keep thetherapy effects to a minimum. To check the latter, we performed a data comparison ofthe first 8 and the second 8 sessions in order to see whether therapist interventionsmight have reduced dysfunctional aspects, which we expected to be clearly evidentearly in the therapy. Initially we calculated the total score and then we divided masteryinto the sub-functions of which it is composed (i.e. the attitude towards problem-solving — basic requirements — and the different strategies used for masteringsuffering and interpersonal problems – 1st, 2nd and 3rd level strategies).
We calculated the total number of times each client (a) succeeded or failed indefining a problem, (b) managed to adopt an active attitude towards problem-solvingand (c) succeeded in carrying out effective and adaptive mastery strategies. At each
he raw number and the percentage of successes and failures for all the sub-functions ofersonality disorder. APD=avoidant personality disorder. DPD=dependent personality=narcissistic personality disorder.
MASTERY TOTAL
el 3rd Level
es Failures Successes Failures Successes Failures
0%) 14 (70.00%) 0 (0.00%) 2 (100.00%) 18 (51.43%) 17 (48.57%)8%) 19 (65.52%) 0 (0.00%) 0 (0.00%) 23 (41.82%) 32 (58.18%)0%) 9 (90.00%) 0 (0.00%) 3 (100.00%) 2 (14.29%) 12 (85.71%)1%) 36 (70.59%) 6 (14.29%) 36 (85.71%) 73 (39.04%) 114 (60.96%)0%) 3 (50.00%) 2 (4.44%) 43 (95.56%) 47 (29.56%) 112 (70.44%)8%) 17 (58.62%) 12 (32.34%) 25 (67.57%) 53 (41.09%) 76 (58.91%)%) 15 (100.00%) 1 (50.00%) 1 (50.00%) 33 (47.14%) 37 (52.86%)1%) 1 (14.29%) 3 (27.27%) 8 (72.73%) 9 (50.00%) 9 (50.00%)3%) 38 (88.37%) 1 (3.03%) 32 (96.97%) 26 (22.03%) 92 (77.97%)9%) 81 (89.01%) 2 (8.33%) 22 (91.67%) 50 (30.12%) 116 (69.88%)7%) 2 (33.33%) 3 (50.00%) 3 (50.00%) 13 (54.17%) 11 (45.83%)4%) 18 (78.26%) 0 (0.00%) 0 (0.00%) 13 (32.50%) 27 (67.50%)9%) 5 (35.71%) 7 (87.50%) 1 (12.50%) 58 (48.74%) 61 (51.26%)0%) 4 (80.00%) 5 (62.50%) 3 (37.50%) 46 (42.20%) 63 (57.80%)
MASTERY TOTAL
l 3rd Level
s Failures Successes Failures Successes Failures
2%) 15 (68.18%) 0 (0.00%) 6 (100.00%) 15 (41.67%) 21 (58.33%)9%) 11 (64.71%) 5 (45.45%) 6 (54.55%) 20 (46.51%) 23 (53.49%)0%) 6 (60.00%) 2 (25.00%) 6 (75.00%) 7 (35.00%) 13 (65.00%)3%) 6 (28.57%) 11 (36.67%) 19 (63.33%) 59 (61.46%) 37 (38.54%)1%) 2 (9.09%) 9 (42.86%) 12 (57.14%) 83 (53.90%) 71 (46.10%)4%) 10 (38.46%) 14 (43.75%) 18 (56.25%) 69 (53.49%) 60 (46.51%)%) 1 (100.00%) 0 (0.00%) 1 (100.00%) 4 (44.44%) 5 (55.56%)0%) 1 (50.00%) 2 (11.11%) 16 (88.89%) 3 (15.00%) 17 (85.00%)8%) 34 (61.82%) 6 (25.00%) 18 (75.00%) 35 (35.00%) 65 (65.00%)2%) 37 (77.08%) 7 (20.00%) 28 (80.00%) 47 (38.52%) 75 (61.48%)6%) 4 (57.14%) 1 (50.00%) 1 (50.00%) 6 (37.50%) 10 (62.50%)0%) 16 (80.00%) 0 (0.00%) 3 (100.00%) 22 (39.29%) 34 (60.71%)00%) 0 (0.00%) 6 (100.00%) 0 (0.00%) 21 (65.63%) 11 (34.38%)0%) 2 (50.00%) 4 (50.00%) 4 (50.00%) 17 (40.48%) 25 (59.52%)
0
10
20
30
40
50
60
70
80
90
100
Sessions 1-8 Sessions 9-16
Fig. 4. Trend of Mastery failures and successes in sessions 1-8 versus sessions 9-16.Note: The line indicates the trend of the mean score of the successes and the dotted lineindicates the trend of the mean score of the failures.
65A. Carcione et al. / Psychiatry Research 190 (2011) 60–71
step in the analysis we first considered the total Mastery Scale score and then analyzedany specific sub-scale.
3. Results
Our first analysis covered all 16 sessions; we calculated the totalnumber of times each client succeeded or failed in defining a problem,he or she succeeded in adopting an active attitude towards problemsolving and he/she succeeded in carrying out effective and adaptivemastery strategies (Fig. 2). The ability to carry out mastery strategies
Mastery: Basic
0 10 20 30
NPD 1
NPD 2
NPD 3
BPD 1
BPD 2
BPD 3
BPD 4
PPD 1
DPD 1
DPD 2
APD 1
APD 2
OCPD 1
OCPD 2
Mastery: Basic R
0 10 20 30
NPD 1
NPD 2
NPD 3
BPD 1
BPD 2
BPD 3
BPD 4
PPD 1
DPD 1
DPD 2
APD 1
APD 2
OCPD 1
OCPD 2
Fig. 5. Basic Requirements: sessions 1-8 versus sessions 9-16. Note: The graph above indicatpatient. The graph below indicates the raw number of successes and failures in Basic Requisiteblack lines indicate the raw number of failures. OCPD=obsessive-compulsive personalityPPD=paranoid personality disorder. BPD=borderline personality disorder. NPD=narcissi
ranged from 34 overall attempts by NPD3 (9 successes vs. 25 failures)to 313 attempts by BPD2 (130 successes vs. 183 failures). In all thecases analyzed the use of mentalistic knowledge to solve socialproblems and cope with symptoms was problematic the majority ofthe times it occurred, with 12 out of the 14 clients failing more oftenthan succeeding. The exceptions were the two OCPD clients, whoapplied mastery with more successes than failures. Fig. 4 shows themean and the median score of failures and successes for each singlemastery sub-function for all 14 subjects. The average for all 14subjects was: 89 (58%) failures v. 64.29 (42%) successes; the medianwas 66.5 failures v. 52 successes.
Given that we found an overall mastery dysfunction, we madefurther investigations to see whether this occurred very frequently insessions 1-8 and whether, if this was the case, it improved in sessions9-16 (see Table 1).
A comparison of the first 8 and second 8 sessions (Fig. 3) showsthat in the first 8 failures in mastery were higher than successes for allthe clients, except APD1 (successes=13; 54.2% vs. failures=11;45.8%), NPD1 (successes=18; 51.4% vs. failures=17; 48.6%), withsuccesses slightly higher than failures, and PPD for whom failureswere equal to successes. In any case, both APD1 and NPD1 onlyoccasionally attempted mentalistic problem-solving.
Overall the clients engaged less often in using mentalisticknowledge for problem-solving during the second stage of therapy(9-16) (Fig. 3). Failures remained higher than successes for themajority of the clients (10 out of 14). With 4 clients there was an
Requirements 1-8
40 50 60 70
equirements 9-16
40 50 60 70
es the raw number of successes and failures in Basic Requisites in sessions 1-8 for eachs in sessions 9-16 for each patient.White lines indicate the raw number of successes anddisorder. APD=avoidant personality disorder. DPD=dependent personality disorder.stic personality disorder.
66 A. Carcione et al. / Psychiatry Research 190 (2011) 60–71
inversion of the ratio so that successes exceeded failures: OCPD1successes=21 (65.6%) vs. failures=11 (34.4%); BPD1 successes=59(61.5%) vs. failures=37 (38.5%); BPD2 successes=83 (53.9%) vs.failures=71 (46.1%); BPD3 successes=69 (53.5%) vs. failures=60(46.5%). In 3 clients (NPD1, PPD1, APD1) there was the opposite ratioinversion, with failures exceeding successes. One group (4 clients),therefore, tended to succeed more than fail in mastering problematicexperiences in the second 8 sessions. Overall there was an increase insuccesses and a reduction in failures during the second 8 sessions,although with the analyses that were carried out it is not possible toevaluate the significance of this variation. On average (Fig. 4)successes were 33.14 (38.9%) and failures 55.64 (61.1%) in the earlierperiod, whereas in sessions 9-16 successes were 29.14 increasing onaverage to 43.4% and failures 33.36 (53.6%). Considering the meansuccess/failure ratio, in the 2nd period we can observe an increase insuccesses and a reduction in failures (Fig. 4). As we found thatmasterywas dysfunctional overall in the majority of the clients in the earlierperiod, we performed a more detailed analysis to see whether anyspecific aspect of the mastery problemwas prominent and, if this wasthe case, whether it was subject to any change during the second8 sessions.
We analyzed the four sub-functions in the scale separately; asregards MBR, we found that in the earlier period failures were higherthan successes for 8 out of 14 clients (Fig. 5). The average was 17.36(median 15) successes vs. 21.07 (median 13.5) failures. In the later
Mastery I Le
0 5 10 15 20
NPD 1
NPD 2
NPD 3
BPD 1
BPD 2
BPD 3
BPD 4
PPD 1
DPD 1
DPD 2
APD 1
APD 2
OCPD 1
OCPD 2
MAstery I Lev
0 5 10 15 20
NPD 1
NPD 2
NPD 3
BPD 1
BPD 2
BPD 3
BPD 4
PPD 1
DPD 1
DPD 2
APD 1
APD 2
OCPD 1
OCPD 2
Fig. 6. First Level Strategies (1st LS): sessions 1-8 versus sessions 9-16. Note: The graph above8 for each patient. The graph below indicates the raw number of successes and failures in Firstsuccesses and black lines indicate the raw number of failures. OCPD=obsessive-comppersonality disorder. PPD=paranoid personality disorder. BPD=borderline personality dis
period the overall number of MBR occurrences diminished for 9 out of14 clients. The mean was 11.93 (median 7) successes vs. 12.29(median 10) failures. However, four clients (BPD2, BPD3, APD 1 andAPD 2) displayed a greater inclination towards problem-solving in thelater period. For two clients (BPD1 and BPD3) successes came toexceed failures in the later period: BPD1 65.7% successes vs. 34.3%failures; BPD 3 50.8% successes vs.. 49.2% failures. (see Table 1).
Even if First Level Strategies (Fig. 6) are the most elementary ones,with the least reflective effort (solutions to problems consist here ofmodifying the bodily state or resorting to others’ help or to avoidance),overall their presence was limited. The mean was 6.57 (median 4.5)successes vs. 3.07 (median 2) failures in the 1st period and 4.07 (median2) successes vs. 0.86 (median 0) failures in the latter period (see Table2). With almost all the clients the number of successes was alwayshigher than that of failures during both therapy periods (see Table 1).The only exceptions were NPD2 (2 failures vs. 0 successes) and OCPD2(8 failures vs. 1 success) in the earlier period and DPD 1 (3 failures vs. 1success) in the later period.
Second Level Strategies (Fig. 7), i.e. a conscious use of strategies tomodify one's mental state and to devote one's cognitive resources toproblem-solving (diverting attention from a disturbing thought orexhorting oneself to tackle a task), were found, in the earlier period, tobe impaired in 10 out of 14 clients. The highest impairmentswere found in particular in three clients: DPD1 (failures=38; 88.4%vs. successes=5; 11.6%), DPD2 (failures=81; 89% vs. successes=10;
v Strategies 1-8
25 30 35 40 45 50
Strategies 9-16
25 30 35 40 45 50
indicates the raw number of successes and failures in First Level Strategies in sessions 1-Level Strategies in sessions 9-16 for each patient.White lines indicate the raw number ofulsive personality disorder. APD=avoidant personality disorder. DPD=dependentorder. NPD=narcissistic personality disorder.
Mastery: II Lev Strategies 1-8
0 10 20 30 40 50 60 70 80 90
NPD 1
NPD 2
NPD 3
BPD 1
BPD 2
BPD 3
BPD 4
PPD 1
DPD 1
DPD 2
APD 1
APD 2
OCPD 1
OCPD 2
Mastery: II Lev Strategies 9-16
0 10 20 30 40 50 60 70 80 90
NPD 1
NPD 2
NPD 3
BPD 1
BPD 2
BPD 3
BPD 4
PPD 1
DPD 1
DPD 2
APD 1
APD 2
OCPD 1
OCPD 2
Fig. 7. Second Level Strategies (2nd LS): sessions 1-8 versus sessions 9-16. Note: The graph above indicates the raw number of successes and failures in Second Level Strategies insessions 1-8 for each patient. The graph below indicates the raw number of successes and failures in Second Level Strategies in sessions 9-16 for each patient. White lines indicate theraw number of successes and black lines indicate the raw number of failures. OCPD=obsessive-compulsive personality disorder. APD=avoidant personality disorder.DPD=dependent personality disorder. PPD=paranoid personality disorder. BPD=borderline personality disorder. NPD=narcissistic personality disorder.
67A. Carcione et al. / Psychiatry Research 190 (2011) 60–71
11%), BPD1 (failures=36; 70.6% vs. successes=15; 29.4%). For threeclients (OCPD1, APD1 and PPD1) successes were higher than failures,while in BPD2 the scorewas3 for both successes and failures. In the laterperiod there was a reduction in the overall number of occurrences andsuccesses exceeded failures in 4 clients out of 14 (OCPD1, BPD1, BPD2,BPD3). In the other 10 clients, where failures remained higher than (orequal to) successes, therewasnevertheless almost always a reduction inthe total numberof failures and increase in that of successes. In fact, ifweconsider the mean score, we can see 6.21 (median 5.5) successes vs.18.71 (median 14.5) failures in the 1st period and the average ofsuccesses increasing to 8.36 (median 6), while the average of failuresdecreases to 10.36 (median 6), in the 2nd period.
Third Level Strategies (Fig. 8) are those requiring the greatestreflective effort, e.g. managing to adopt a critical distance from one'sbeliefs or using theory of mind for solving interpersonal problems. Theiruse was limited in 12 out of 14 clients in the earlier period. They were,however, used the most by BPD1, BPD2, BPD3, DPD 1 and DPD 2. Thenumber of failures was higher than successes in 8 out of 14 clients,ranging from 67.6% with BPD3 to 97% with DPD1 (see Table 1). In theother clients, 2 of them (NPD2 and APD2) did not use them, and BPD4and APD1 rarely used them and had the same score for successes andfailures. In 2 other clients (OCPD1 and OCPD2) successes exceededfailures. During this period, therefore, some clients frequently attemptedto use metacognitively sophisticated strategies to solve problems, but
succeeded only rarely. In the later period there was an increase inoccurrences, but with a predominance still of failures, except with OCPD1 where, albeit with a very limited number of occurrences, there was apredominance of successes starting in the earlier period. Themean scorewas3 (median2) successes vs.12.79 (median3) failures in the1st periodand 4.79 (median 4.5) successes vs. 9.86 (median 6) failures in the 2ndperiod.
We lastly analyzed which mastery strategies each client preferredto use (Fig. 9), totaling successes and failures for each single strategy.NPD clients tended to use in particular Second Level Strategies andthen Third Level ones; BPDs used mainly Third Level Strategies andthen Second Level ones, and were found to use First Level ones moreoften than any other PDs analyzed. DPD and APD clients usedprimarily Second Level Strategies. The two OCPD clients behavedslightly differently: OCPD1 used First and Second Level Strategies toalmost the same extent, while OCDP2 used primarily Second Levelones.
4. Discussion
We hypothesized that clients with PD would have problemsduring psychotherapy in using mentalistic knowledge for problem-solving. The results obtained seem to support this hypothesis: thepopulation examined had significant difficulties using their
Mastery: III Lev Strategies 1-8
0 5 10 15 20 25 30 35 40 45 50
NPD 1
NPD 2
NPD 3
BPD 1
BPD 2
BPD 3
BPD 4
PPD 1
DPD 1
DPD 2
APD 1
APD 2
OCPD 1
OCPD 2
Mastery: III Lev Strategies 9-16
0 5 10 15 20 25 30 35 40 45 50
NPD 1
NPD 2
NPD 3
BPD 1
BPD 2
BPD 3
BPD 4
PPD 1
DPD 1
DPD 2
APD 1
APD 2
OCPD 1
OCPD 2
Fig. 8. Third Level Strategies (3rd LS): sessions 1-8 versus sessions 9-16. Note: The graph above indicates the raw number of successes and failures in Third Level Strategies in sessions1-8 for each patient. The graph below indicates the raw number of successes and failures in Third Level Strategies in sessions 9-16 for each patient. White lines indicate the rawnumber of successes and black lines indicate the raw number of failures. OCPD=obsessive-compulsive personality disorder. APD=avoidant personality disorder. DPD=dependentpersonality disorder. PPD=paranoid personality disorder. BPD=borderline personality disorder. NPD=narcissistic personality disorder.
68 A. Carcione et al. / Psychiatry Research 190 (2011) 60–71
mentalistic knowledge for problem-solving. The data also supportedthe idea that the difficulty does not diminish rapidly; in fact, masterydysfunctions persisted throughout the 16 psychotherapy sessionsanalyzed, even if there was a general trend towards an improvementin their use, with a reduction in the number of failures in the later8 sessions.
More specifically, in the first 8 sessions failures almost alwaysexceeded successes. In sessions 9-16 the difficulty persisted except for4 clients out of 14, who displayed an inversion in the success/failureratio. Only in the case of a patient with narcissism (NPD1) was thetrend the contrary: she had more successes than failures in the earliersessions but deteriorated in the later ones.
The overall trend, however, as shown by Fig. 4, was towards anincrease in the effectiveness of the mentalistic problem-solvingstrategies used. Nevertheless, although effective mastery increasedoverall, during the later 8 sessions the clients continued to poorly useinformation about their own and others’ mental states to cope withdistress or day-to-day and interpersonal problems.
This finding is consistent with studies performed on a series ofsingle PD client cases (Semerari et al., 2005; Dimaggio et al., 2007;2009a), studies of small samples (Davidson et al., 2007) andrandomized clinical trials (Bateman and Fonagy, 2009) which showedthat the ability to think about mental states takes time to grow during
therapy and a treatment focused on promoting mentalizing needs upto 1 year to become fully effective.
A third hypothesis was that the mastery problems were nothomogeneous, but that different clients, with different pathologies,might have different dysfunctions and different preferences abouthow to cope with social problems and distress. This hypothesis alsoappears to be backed by evidence. In fact, if we consider the generalproblem-solving attitude, we can see that the BPD clients (except forBPD4) and DPD were those making the hardest attempts at solvingtheir problems, albeit with limited success; the others, in particularAPD1, PPD and NPD3, tended to be passive. Various types of masterystrategy were used by the different clients: the three NPD clients, andthe one with PPD too, tried mainly to manage suffering independentlywith self-exhortations or active distraction (2nd LS). Albeit failingoften, the four BPD clients tended to employ autonomous regulationstrategies (1st LS) and use self-knowledge to adopt a critical distancefrom dysfunctional beliefs, and knowledge of others to manageinterpersonal problems (3rd LS). Themajority of their successes in theearlier period occurred with the use of more behavioral strategies (1stLS); metacognitively more complex strategies tended to work betteronly in the later period.
With the two DPD clients, we found that, contrary to expectations,the most numerous attempts at mastery – for the most part failures –
Table 2Mean and Median scores of mastery successes (Y) and failures (No), session 1-8 versussession 9-16 and total period (1-16).
Mastery Mean Score
Period 1-8 Period 9-16 Period 1-16 (All)
mean mean mean
MBR Y 17.36 11.93 29.29MBR No 21.07 12.29 33.36M 1st LS Y 6.57 4.07 10.64M 1st LS No 3.07 0.86 3.93M 2nd LS Y 6.21 8.36 16.57M 2nd LS No 18.71 10.36 29.07M 3rd LS Y 3 4.79 7.79M 3rd LS No 12.79 9.86 22.64M Tot Y 33.14 29.14 64.29M Tot No 55.64 33.36 89
Mastery Median Score
Period 1-8 Period 9-16 Period 1-16 (All)
MBR Y 15 7.5 28MBR No 13.5 10 23.5M 1st LS Y 4.5 2 7.5M 1st LS No 2 0 3.5M 2nd LS Y 5.5 6.5 16M 2nd LS No 14.5 6 21.5M 3rd LS Y 2 4.5 6M 3rd LS No 3 6 8.5M Tot Y 29.5 20.5 52M Tot No 49 24 66.5
69A. Carcione et al. / Psychiatry Research 190 (2011) 60–71
were performed using principally autonomous regulation strategies(2nd LS); as could be expected, however, for both clients successeswere higher than failures only for 1st Level Strategies (1st LS),encompassing recourse to interpersonal coordination, in line with thetypical Dependent Disorder style, involving a constant seeking of help,support and reassurance from others. The two Avoidant PD clientsalso had more successes with 1st Level Strategies, including theavoidance of problematic situations, a typical feature of this disorder.
The two Obsessive-Compulsive PD clients had different profiles:starting in the earlier period, OCPD 1 always used all the strategiesemployed with more successes than failures, and resorted more oftento strategies involving avoidance, requests for help and applying
0 20 40 60
NPD 1
NPD 2
NPD 3
BPD 1
BPD 2
BPD 3
BPD 4
PPD 1
DPD 1
DPD 2
APD 1
APD 2
OCPD 1
OCPD 2
Fig. 9.Mastery Strategies: sessions 1-16. Note: Black lines indicate the raw number of M 1straw number of M 3 rd LS Tot. for each patient. OCPD=obsessive-compulsive personalityPPD=paranoid personality disorder. BPD=borderline personality disorder. NPD=narcissi
action to her bodily state (1st LS); in the later period she useddistraction and self-exhortation more frequently (2nd LS). OCPD 2,instead, used primarily 1st Level Strategies in the earlier period butwith limited effectiveness, while, unexpectedly, she had moresuccesses with the metacognitively more complex strategies (3rdLS); in the later period successes exceeded failures for 1st LevelStrategies, while they were equal for 2nd and 3rd level ones.
5. Conclusion
The PD clients in the sample analyzed displayed a generalimpairment of their ability to use mentalistic knowledge of them-selves and others for solving psychological and interpersonalproblems; the problem manifested itself with varying degrees ofseriousness and some clients appeared more impaired than others.Early in the therapy there was a slight improvement but to a greatextent the problem persisted.
To summarize the results obtained: 1) from a quantitative point ofview, we can see that some clients more than others tended to have anactive attitude towards problem-solving; 2) from a qualitative pointof view, the various clients differed both as regards the types ofstrategy they tended to use most frequently (see Fig. 9), and asregards the type of strategy they used most effectively (see Table 1).
This appears in line with the descriptions provided by variousauthors and with personality disorder pathology, in which a corefeature is poor self-regulation and lack of resources for living anadapted life. For example, despite numerous attempts, the two DDPclients were unable to effectively use autonomous regulationstrategies, while they did effectively use 1st Level Strategies, whichinclude resorting to interpersonal coordination (e.g. requesting help),a problem-solving style typical of DDP (APA, 2000; Bornstein, 2005;Carcione and Conti, 2007). The BPD clients had a high number offailures when using 2nd and 3rd LS (both autonomous strategies), inspite of resorting to them very frequently, whereas they were mostsuccessful at applying 1st Level Strategies (strategies with low self-reflective efforts, such as asking someone for help, behavioralstrategies or avoidance of problematic situations). This is in linewith the finding that a core feature of BPD is a mindfulness deficit(Wupperman et al., 2008). Mindfulness includes awareness, attentionand acceptance of the presentmoment, abilities similar to the ones weincluded in our 2nd and 3rd LS.
80 100 120 140 160
LS Tot., grey lines indicate the raw number of M 2nd LS Tot. and white lines indicate thedisorder. APD=avoidant personality disorder. DPD=dependent personality disorder.stic personality disorder.
70 A. Carcione et al. / Psychiatry Research 190 (2011) 60–71
The picture that emerges from our data, therefore, is thatpersonality disorder therapy requires a prolonged period, withoutdoubt more than 16 sessions, to produce durable changes inmentalistic problem mastery skills. Our study contains someimportant clinical implications. As patients with PD have problemsin solving problems and restoring interpersonal attunement oncetensions or obstacles arise, therapy needs to be aimed at a) selectingmastery strategies in the here-and-now appropriate for the mental-istic knowledge patients possess, instead of imposing tasks whichwould be over-demanding for them; b) first promote adequatemetacognitive skills, so that patients have a full-fledged mentalisticproblem-solving base and then c) use this knowledge for achievingbehavioral change or seeing things from a different angle and taking acritical distance from firmly held dysfunctional beliefs.
A recent randomized clinical trial (Bateman and Fonagy, 2009) ofmentalization-based treatment (Bateman and Fonagy, 2004), whichfocused particularly on an increase in awareness of mental states,nevertheless produced data in line with ours. The clients treated inthe group in which a focus on mentalization was foreseen neededmore than 1 year of therapy before demonstrating the superiority of thisvis-à-vis a control group. Thisfinding supports the idea that a prolongedperiod is necessary for clients to start effectively using their mentalisticknowledge for solving social problems and reducing suffering.
Note that there are many limitations in our study. Because of itsqualitative design and the small sample size, any generalization isimpossible; in particular the idea of a disorder-dependent type ofmastery dysfunction is speculative at best. Moreover, all the clientswere treated with the same type of psychotherapy and by a smallnumber of therapists. It can not be excluded that other clients, treatedby other therapists and with a different approach, might respondsooner. Moreover, we did not assess symptoms and interpersonalfunctioning outcome; we therefore still need to investigate whetherany improvement in mastery is a feature of good-outcome therapies.
Despite these limitations, it seems plausible that further investiga-tions of the trend in metacognitive mastery during psychotherapy andits correlations with outcome indicators would bring significant results.
For this purpose it could be useful in further research to introducemeasurements of the therapeutic alliance and other scales to evaluatetherapeutic interactions; it could thus be possible to explore, forexample, what therapeutic activities promote metacognition or howthe therapeutic alliance influences the ability to reflect on mentalstates. Furthermore, in the light of studies about the relationshipbetween attachment and mentalization (Fonagy et al., 2002), it couldalso be useful to investigate attachment style and its correlations withspecific strategies to master distress.
Once the strategies patients use spontaneously and effectivelyhave been assessed, it is possible to aim at reinforcing and stabilizingtheir use as a distress reductionmechanism, while looking at the sametime to implement new strategies with the goal of acquiring greaterflexibility as contexts change (Cheng and Cheung, 2005), which islikely to promote social adaptation and achieve life satisfaction (Sohland Moyer, 2009).
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