The therapist
Psychotherapy was delivered by the first author of the paper (TP), a 45
years old woman, a licensed CBT therapist with 15 years of experience in
MIT. She is specialized in treating PD, with a special focus on using
mindfulness, experential techinques and body oriented work for treating
co-morbid post-traumatic symptoms.
Current problem and client description
Lia is 40 years old, lives in Florence and is employed in an
international company. She enters therapy filled with fear, alarm, and
confusion to which she cannot give an explanation. She feels anxious,
but when the therapist tries to understand what she fears and why, Lia
cannot answer, and besides a generic sense of “anxiety” she cannot say
what she is anxious about nor she can name other emotions. She reports
only a state of alertness whenever she perceives bodily arousal or
disturbing physical sensations.
The only issue she clearly exposes is the doubt about whether or not she
wants to have a child as a single woman. She is considering undergoing
In Vivo Fertilization (IVF) as a single, but she is unsure if she really
wants it and is therefore stuck. The confusion itself frightens her and
again she cannot explain why. Overall, after the first sessions the
therapist realizes she has very poor information about what Lia desires,
thinks and feels.
She is in a conflicting relationship with a man much older than her. He
lives in Venice and they have never lived together. She is unhappy about
the relationship, because she sees him as contemptuous, distant, and not
interested in making any life plans with her, though she calls it “my
partner”. She feels lonely and not entitled either to complain or to be
frightened about the idea of splitting up and again, she cannot explain
what she fears. Her social life is characterized by a few friendships in
which she tends to be compliant, and does not disclose her true feelings
and vulnerabilities. She constantly monitors others to see if they
neglect her, and after a few sessions she becomes able to say that if
she notices signs of indifference and rejection she feels very sad.
She works out of a strong sense of duty with no real passion, and has a
conflictual relationship with her boss by whom she feels underrated.
Overall she can be diagnosed as having both Generalized Anxiety Disorder
(GAD) and Dependent PD Signs of the latter are: she feels lonely, has
difficulty perceiving and valuing what she wants and feels, she is prone
to guilt and fear about abandonment and rejection. She is confused about
what she really wants and hardly pursue any goal without having asked
for approval first. She discontinued a previous psychodynamic
psychotherapy because she felt pressured to decide to try and have a
baby or not, and criticized by her therapist for lack of progress.
Case formulation
Very early, Lia had difficulties in describing what she thought and
felt. The therapist therefore had to work in order to gather information
on her mental states in order to understand patient’s functioning and
share the formulation with her. We therefore summarize here the
formulation that emerged after this preliminary work where the therapist
tried and collect the needed psychological information on which to
ground her formulation upon.
The main desire that moves Lia is to make choices she feels authentic.
However, when she tries to listen to what she feels and thinks, she is
puzzled about what she really desires. This confusion scares her and
negative arousal mounts. She fears that if she makes a choice that is
not truly hers, she will be unhappy, forced to live a life that is not
hers. She fears she will be guilty of self-inflicted suffering. She also
feels fragile and inadequate, and fears that she will make choices for
which others will criticize her and ridicule her. Finally, she fears
that her choices will make herself and others suffer and thus she feels
guilt at idea of harming others.
As a result of these ideas and emotions, Lia experiences a sense of
anaesthesia throughout her body, feels almost physically paralyzed,
criticizes herself and broods about the dangers she will face the moment
she chooses. When she finds herself brooding or feeling physically sick,
she becomes even more convinced she is too fragile.
In order to cope with these
experiences, Lia over time has learned to enact various strategies. The
main one is cognitive and behavioural avoidance; for example, she shifts
her attention to other things in order to detach from negative physical
sensations, or she avoids talking about herself to friends and family
members in order to prevent neglect or criticism; perfectionism serves
the same goal of preventing negative judgement. Moreover, in order to
cope with the idea that she will make others suffer, she does not ask
for care when she needs them and instead resorts to self-soothing. When
her desires are at odds with others’ she swiftly gives up and let others
decide. When she suffers, she swings from minimizing what is causing her
pain by telling herself: “Nothing really tragic after all” to brooding
over her own inadequacy and the dramatic consequences of her choices.
The result, as we noted, is that she becomes even more confused which in
turn scares her more. At the end of the day, she is an alien to herself
and this triggers anxiety, to the point of panic.
Lia thinks she is only “playing a role” of “daughter, sister,
employee, and best friend”. When others give appreciate her, she thinks
she is a good actor, and this boost her self-esteem but only for a short
while, as the sense of dissatisfaction and absence of desires quickly
returns.
Course of treatment
Lia’s therapy took place in three phases: an initial assessment, a
second phase in which her psychological functioning was reconstructed
and shared, and a third phase focused on changing. We now take up the
aspects of her functioning previously exposed by describing the
formulation and show how the therapist worked to bring them out and then
to change them.
Assessment
Lia comes to therapy with a request to be helped understanding whether
she wants to have a child on her own or not, as she needs to choose and
find a way out from stagnation. Confusion is the major issue in the
first sessions. The therapist asks early on for specific episodes in
which Lia feels paralyzed and confused, and only after some struggle Lia
reports one recent memory. The past week she was at home on the couch,
with her mobile in her hand, and thought about calling a Spanish clinic
for IVF for an appointment, in order to start with the fertilization
process. Lia felt alarmed and paralyzed and then gave up calling. The
therapist asks Lia what she thought and felt a moment before giving up
making the call, and Lia manages to contact for a few moments the sense
of paralysis and alertness. The therapist asks what she thinks ad feels
but Lia cannot answer. As soon as she retrieves the episode, she becomes
frightened, physically stiffens, loses focus on understanding her inner
world, and again ruminates over her inadequacy.
Lia becomes more capable to report specific memories and reports several
other similar episodes, in which the difficulty in exploring her
internal experience recurs. The therapist notes: “Lia, when I ask you
to recall a moment where you felt blocked or scared, you are afraid
about what you feel, and immediately withdraw. It is like you are trying
kind of protecting yourself from knowing more about your inner
experience, is that correct?” Lia feels understood, but nevertheless
when the therapist asks why she is scared about the sensations of
trembling and tension, she patient fails to answer.
Preparatory work for exploring
cognitions
The therapist explains to Lia how she cannot understand what she thinks
and feels just on the basis of what she says. Lia is not used to think
in terms of mental states, so that her capacity to describes them is
reduced, something we refer to as poor metacognition (Semerari et al.,
2003). One first therapy goal is therefore to overcome avoidance of
physical sensations and then focus on them until Lia becomes able to
understand if they lead to specific emotions. Once this operation is
successful, a next agreed upon goal is to explore cognitions. What
thought triggered a specific emotion in a specific situation?
Lia agrees with these steps. During the first sessions the therapist
invites her to practice mindfulness; when Lia focuses on physical
sensations during meditations she will try to describe them in words,
trying to be non-judgmental. Every time Lia will be afraid of what she
experiences, the therapist will remember her to regulate her breath and
bring her attention to the contact points between her body, the chair
and the floor, as typical of mindfulness practice.
Lia recalls a Saturday afternoon when she was home alone. She did not
understand what she wanted to do and became anxious at the idea of
making the wrong decision. Lia cannot articulate her thoughts further.
T: “Close your eyes, turn back to the very moment before anxiety mounts
and recover what is passing through your mind”.
L: “… my shoulders are shaking… I’m scared”.
T: “Ok, it’s ok. Don’t run away from these sensations, stay here, what
are you thinking now that scares you?”
L: “I- I still don’t know”.
T: “Explore your body, where is anxiety?”
L: “Can’t connect it anywhere… I am not really able to
understand my mind… this is typically me… it’s bad”.
Lia is ruminating again. This is likely a sign that she had started the
task not from a position of curiosity about her inner world, but as duty
to be performed correctly. The therapist notes this shift.
T: “Lia, this is typical you are again prey of your perfectionism that
makes you worry. Are you willing to try and let this train of thoughts
fall into an imaginary waterfall instead of keep worrying?”
L: “You are right. Let me… her… it’s difficult…”
After repeated attempts, Lia is able to let self-critical thoughts fall
into the imaginal waterfall and started to explore her experience.
L: “Maybe I will go out for a walk… or… I can fix up the
house, do the laundry, I need to do them… I can invite Giulia for
an aperitivo… what is better… I am confused… can’t
tell what matters more… I can’t decide you see… there’s
something wrong in me… I’m scared”.
T: “How do you feel now”.
L: “Paralysed… empty, you see I can’t do such a small thing such
as understanding if I prefer do the laundry or going for a drink with a
friend. How can I ever do it alone?”
After more discussion she chooses to go helping her mother shopping.
Paradoxically, resorting to her usual caregiving behaviour calms her
down and grants her a renewed sense of self-efficacy. This pattern
reappears over and over again across many episodes. The therapist
realizes that until Lia is in this negative state, Lia’s capacity to
know herself will hardly improve. Actually, negative emotions and
thoughts tend to diminish human capacity for reflection on psychological
states (Fonagy et al., 2002; Semerari et al., 2003) so the therapist
tries a different strategy, which is typical of MIT (Dimaggio et al.,
2015; 2020). She tries to elicit a positive state first, passing through
the body channel, and then see if Lia becomes more able to describe her
inner world without neither judgment nor anxiety.
First, the therapist explores in which areas of the body Lia perceives
that she is free from the feeling of bewilderment, confusion, and fear.
Then she asks Lia to refocus on her foot and the point of contact
between her body, the chair and the floor. Lia realizes now she feels a
sense of slight presence and stability and worrying is gone. She notes
that the positive states are related to the pressure the body exerts on
the contact points, “It’s a feeling of being here”. The therapist asks
if these feelings are associated with specific thoughts, but Lia remains
unable to identify them and turns to self-criticism. Another moment of
mindfulness helps Lia detach from negative thoughts.
T: “Now use your hands to squeeze the muscles in her arms and
legs… how does that feel?”.
L: “Present… it’s fine… stable… I feel it not
just… it’s all over the body now”.
In the following weeks Lia reports several brief moments of positive
experiences, both in her mind and in her body, alternating with negative
states. Now Lia responds better to attempts at calming down in session
thanks to body oriented work. Once she enters the session feeling lost
the therapist invites her to touch her warm, soft scarf and observe her
feelings until she calms down. In another moments she says: “I feel
like vapor” and the therapist suggests to visualize herself as a tree,
with a powerful trunk and strong roots starting at her feet and going
down to the centre of the earth, until she regains a sense of solidity.
Session after session, Lia becomes familiar with the feelings of
solidity, stability, presence, and she says: “I feel whole for the
first time”. One day at work, Lia is startled by a shoulder tremor
whose reason she cannot tell. She realizes she is frightened though, and
brings her attention to the areas of her body that are in contact with
the world. Then she spontaneously clasps her arms with her hands and
recovers the sense of solidity she now knows well, until fear of
physical sensations recedes. She now considers ungrounded. Lia is now
aware she considers these sensations as signs of her weakness, which
implies risking criticism, but no longer firmly believes that weakness
is a negative trait.
Understanding the roots of self-criticism.
At this point the therapist shares with Lia the need to begin
reconstructing how much this way of feeling and acting characterizes her
beyond the choice of whether or not to have a child on her own. The
therapeutic task is to collect repeated episodes over the next few weeks
and see if this pattern repeats. Lia accepts the task and is already
sure that feeling wrong is something she has always experienced. The
newly collected episodes confirm how Lia relies on self-criticism as an
automatism.
During a Sunday lunch she is sitting at the table with her mother,
sister, and brother, talking about the pregnancy of her sister’s friend.
Lia has not yet told her mother and sister about her idea of having a
pregnancy on her own for fear of criticism. During this episode Lia
feared they would abandon if they knew, so she will remain alone and,
fragile as she is, unable to take care of herself. Lia also realizes
that she feels guilty about making her relative suffer while she ruins
her own life. She becomes aware she have the same ideas and emotions
with her partner, friends, and at work.
For example, she is on the phone with her partner and feels like wanting
to tell him that she has gathered information about the clinic in Spain
for in vitro fertilization. She fears he will abandon her, and she will
remain alone, so she does not tell him anything. At this point Lia is
more able to report the cognitive antecedents of her emotions and
behaviours. The decision-making paralysis stems from the idea she is
fragile and inadequate which makes her give up with any autonomous plan
out of fear of criticism and abandonment.
Time is ripe to try to help her Lia form a more benevolent perspective.
She now wonders why she so firmly beliefs she is so weak, but cannot
find any answer. The therapist, consistent with MIT procedures (Dimaggio
et al., 2015; 2020), invites her to retrieve older memories in which
something happened that shaped her idea of being lonely, fragile, and
wrong. Initially, no memories come to mind, she just tells her life was
“painful”. Lia is the second of three children and reports that while
her sister had her father’s attention and her brother her mother’s, she
felt invisible, treated with indifference and coldness, as if she did
not exist. In spite of awareness of a pattern, no specific memories
appear. The therapist hypothesizes that access to past episodes may be
facilitated by increasing negative arousal. When Lia explores the past,
she experience no affect, a likely sign that she is protecting herself
from something painful. Therefore, if arousal increases, associations
with episodes in which she experienced similar affects may emerge. The
therapist first let Lia focus on a recent episode where a friend
criticised her. Once Lia feels anxious and ashamed the therapist asks
for past memories. A memory appears. She is 5 years old and is in the
living room. The light is dim, on one side her mother is talking to her
brother, on the other side her father is playing with her sister. She
first approaches her mother then her father but no one listens to her.
She shows them her doll, but no look at her. Suddenly something happens.
L: “I feel lost, the living room is so big and I am so small. I’m
scared. I am in the middle of the room and there is no one for me. I am
in a faraway land, everything is empty, I am afraid”.
T: “What are you afraid of right now, Lia? What could happen?”.
L: “I can disappear. I’m not there. No one is looking at me… and
then I see my father getting up and going to work in his office…
I’m even sadder, there is no connection, I only sense his presence from
the light that filters through the crack under the door… I don’t know
how to say it… It’s like that light is the only connection to my
father”.
T: “And how do you feel now?”
L: “Completely alone and lost”.
Once the imagination is over, despite the painful quality of the memory,
Lia feels calmer: “It’s as if something has lit up in my mind…. I
know now why I still feel alone and lost. It’s my story”.
Other memory appears: she was 8 and found herself writing her name
everywhere, on furniture, on glass, on walls. After being repeatedly
scolded, she began to write her name under the soles of her shoes and
slippers. When the therapist asked her what thoughts or emotions
motivated this behaviour, Lia could not answer. Between the age of 10
and 18, when she asked her father for permission to play basketball, and
later drums, to go paragliding, he always told a rigid: “Because it is
just no”.
The patient and therapist share how, as a result of all these
experiences, Lia progressively inhibits access to her own desires and
emotions. She enters relationships guided by the expectation that others
will discard her thoughts and desires as they are immersed in their own
worlds. Lia now understands how perfectionism was an attempt to be
appreciated, not for who she was, but at least for what she did. She
also remembers her mother felt frequently bad and she learnt to care for
her as the only way to gain proximity.
At 16, her father leaves home. Lia experiences this moment as a
liberation, but after a few months he fell ill, disabled, and returned
home. She perceived family expectations she took care of him and she
complied. She wanted to run away, but at the idea of refusing to take
care of him she felt mean and guilty and, as the ultimate consequence,
abandoned and alone. She took care of her father for a year and a half
and, when she turned 18, chose to leave the family home to live and work
in Berlin. The therapist tries to explore what allowed Lia to move away
from home, as this seems like a healthy behaviour, but Lia has no
answer. She remembers she felt good in Berlin but appears distant now
and her expression is flat. While she was abroad, her father died, but
she remained in Berlin. She was conflicted about coming back home to see
him alive one last time, but she chose to stay abroad motivated by the
idea that, after all, there had never been any relationship with that
father.
After about a year, her mother begins to express concern about Lia’s
work, calling her in tears at night to be reassured about how her day
had gone and begging her to move back to Italy by changing jobs. After a
few years her mother falls ill and the doctor tells Lia that her mother
should not be subjected to stress, and Lia, overwhelmed by guilt,
returns to Italy and starts her current job.
At this moment in therapy, the therapist and Lia are aware of how Lia’s
history has shaped the way she thinks and feels: deeply lonely,
vulnerable, wrong and also unable to bring her own projects to life.
Identifying resources and capacities
An important stage of psychotherapy for PD is to help patients become
aware of their healthy aspects, strength and resources (Dimaggio et al.,
2020). Despite her suffering, Lia experienced moments when she allowed
herself to follow her own desires. We have already noted, for example,
the moment when she decided to work abroad and the moment when she
managed not to return home while her father was dying. Against the
background of these positive memories, the new goal is help Lia focus on
her desires during the day and try to act consistently, instead of
letting herself get stuck in a guilt and passivity. Lia agrees, although
she thinks it will be very difficult “because moving is scary for me, I
feel out of balance”.
Lia needs not only to remember that a part of her is able to choose
according to her own desires, but also to re-experience that part. The
therapist therefore invites her to recall in imagination an episode in
which she was driven by something she felt deeply own and authentic, and
to focus on the emotions and sensations she felt during recall. Lia
remembers one time when she told a colleague about her weekend. She did
it so spontaneously and fluently that she is amazed. Lia experiences
again stability, presence and “feeling whole”. The therapist asks Lia
to experience solidity and fullness in the body, “holding them together
with the rhythm of the breath”, imagining that the area she experiences
as solid and stable expands throughout the body with each breath. Lia
feels progressively stronger and her mood turns positive, she perceives
her body as eager to move.
Functioning reconstruction phase
With the information gathered so far, the therapist summarizes Lia’s
functioning as follows:
T: “Lia, from what we have reconstructed I understand that you have a
desire to grasp what you want and make choices accordingly, doing what
really interests and pleases you”.
L: “Yes that’s right”.
T: “When you try to choose according to what you want, however, you
feel inadequate and unable to grasp what you do wants. You think you are
fragile, inadequate, lonely and guilty in relation to another who is
absent, distracted or preoccupied. Do you agree so far?”
L: “Yes, I anticipate that people will not take in what I want and in
any case I feel unable to stand up for my choices”.
T: “All of this causes confusion, fear and shame, and you are afraid of
those states and you try to keep them at bay. You also become
perfectionism, you comply with others, you avoid social exposure, you
avoid choosing and let the other choose…”
L (laughing): “I’m a mess”
T (laughing): “Exactly!”
T: “But we also know there are moments you feel secure, feel active,
solid, stable and full, and we can build on that, agree?”.
After this shared formulation, in an very good therapeutic atmosphere,
the new goal is help Lia regain a sense of agency and pursue her own
authentic desires. The first task is try and during the day when she is
again prey to negative ideas and feelings about herself, and not
recognize there are just the same old thoughts and nothing more than
that. Then Lia will try and note when she feels desires and positive
emotions and stay in touch with them instead of letting them disappear,
covered by fear and self-criticism. Lia still needs support in session,
as the task is difficult. Let see how the therapist helps her let
suffering lose control of her mind.
T: “Feel your body now you are seated. It occupies a limited space and
it has a weight, you are not vapor. Notice the boundaries of your body,
it is three-dimensional. Within your three-dimensional body notice where
fragility is located.”
L: “I feel a sense of emptiness in my stomach”.
T: “Notice the boundaries of this feeling, as if it were an object that
is in your stomach. Now perceive the space occupied by this object, much
smaller, along with the space occupied by the whole three-dimensional
body”.
L: “The sensation in the stomach becomes smaller”.
This new somatically anchored experience, together with the perception
of herself as safe, stable and “full”, becomes the basis on which to
build subsequent therapeutic actions aimed at promoting change.
Behavioural change phase
Behavioural experiments are now crucial. They agree Lia will try and act
to her wishes, even if worry and anxiety mount. If they do, Lia will try
and retrieve the positive states she has experiences during her sessions
and use them to calm down first, and try again later. During a work
meeting Lia tries to have her say on a document she feels is wrong. The
boss disagrees, criticizes Lia and discards her opinion. Lia realizes
she suddenly feels vulnerable, wrong and scared.
L: “I was in a fog when he ignored me, I felt confused, lost. But it
was only for a while. Then I recovered the memory of when in session I
felt that a large part of me felt firm and secure. It was as if the fog
in my mind had cleared…. I was anxious but I also felt strong … I
didn’t feel helpless, I felt in control… I said to myself, Lia, this
is your story, it’s you alone in the living room at home”.
Lia then accesses feelings of well-being: she feels in control of the
situation and feels solidity in her legs. In the next weeks Lia finds
easier to access the state of solidity and security, even under stress.
She feels the urge to tell some friends and her partner about her plans
to have a child and “feel in my body the decision to tell them”. They
role-play the scene until she feels able to doing it effectively. Lia
returns home with the homework of trying and tell her partner first and
her friends later she wants to undergo IVF.
The next session Lia reports she did and her partner got angry in
response: he does not want to be involved. He then scolded and scorned
her, accusing her of being a fool. Yet Lia remained stable, she did not
feel stupid, and is able to tells her friends about her project. They
supported her idea and she did not feel judged.
By the end of these behavioural experiments, she is more aware that her
idea of being inadequate and fragile is a result of her learning
experiences, but it is not necessarily true and she can also see herself
as safe and right. After two months she separates from her partner by
letting him go when he moves away and beginning to feel, along with the
initial loneliness and sense of loss, a newfound possibility of acting
and feeling solidity and presence despite the other’s loneliness and
distance. An initial sense of strength begins to emerge, made up of
awareness of bodily boundaries, solidity in the legs and deep breathing.
L: “I feel like a straight line inside, a beam of light that is warm
and solid and goes from the throat to the belly and I feel that I am
there”. Lia reports that for the first time in her life she thought of
herself in terms of “me” instead of “the couple” and “if my
partner…” and she begins to take care of herself by trying to follow
her desires and making room for positive emotions. She starts taking
care of the house, cooking with care, going out more with friends. She
finds that she really enjoys meeting new people, becomes talkative with
friends and new acquaintances, and focuses less on signs of criticism.
Within about three months she discovers that these new feelings, bodily
sensations, and habits are becoming automatic, a kind of new Lia now
driving her choices.
When Lia faces alone moments of vulnerability the therapist considers
that Lia needs to figure out some other character than can take care of
her and asks her if she can retrieve some memories where someone, maybe
some friend, cared for her and she sensed it. For the first time in
therapy Lia remembers her grandmother: she was the only one who loved
and understood her during her childhood and adolescence. They recall her
presence during a guided imagery focused on a childhood memory.
As often happens in patients with dependent and other PD, the imagined
presence of a positive other is unstable. Lia does not feel her
grandmother is really there for her and feel scared like at treatment
beginning. After the usual moment of somatic regulation, the therapist
asks Lia if she can picture in her mind a “compassionate” figure in
front of her, one that is very large and solid and at the same time
welcoming and validating. This time Lia manages to portray it and feel
its stable presence. It has some feature of her grandmother, but some
aspects of Lia herself. This time she succeeds bringing back this
character in the living room when she was 5. The character hugs the girl
who was sad and silent, until she burst into tears and reciprocate the
hug. Lia now feels warmth throughout her body: “it is like a ball of
light in the centre of my body that makes me feel stable”.
Behavioural homework can now continue: Lia joins a hiking group. During
the first meeting she is able to talk openly about herself, telling
about her job and the work she was doing abroad. Lia now realizes that
she likes her job: she holds a relevant position with a role in managing
humanitarian corridors in war zones. For the first time she says to the
therapist she perfectly speaks four languages and that she feels
passionate about those missions. Lia describes herself as capable,
effective, able to make responsible decisions, and thinks she is able to
deal with the risks and consequences of her work, such as going into war
zones even if others will worry for her.
Behavioral tasks can now continue: Lia joins a group of walkers. During
the first meeting she is able to talk openly about herself, telling
about her job and the work she was doing abroad. Lia realizes that she
liked her old job: she holds an important position with a role in
managing humanitarian corridors in war zones. For the first time she
tells the therapist that she speaks four languages perfectly and feels
passionate about these missions. Lia describes herself as capable,
effective, able to make responsible decisions, and thinks she is able to
deal with the risks and consequences of her job, such as going to war
zones even if others worry about her.