ARTICLES
Metacognitive Interpersonal Therapy for Treating
Persecutory Delusions in Schizophrenia
Giampaolo Salvatore, M.Sc., Luisa Buonocore, Paolo Ottavi, Raffaele Popolo, Giancarlo Dimaggio
A persecutory delusion (PD) is a person’s false belief that
others are focusing their attention on him or her with
malevolent intentions, which often results in intense
anxiety and significant disruption of daily life. PDs are
common in schizophrenia, and many patients with
schizophrenia do not respond well to current pharmaco-
logical treatments. Therefore, effective psychological treat-
ments are needed. The most well-known intervention for
PDs continues to be cognitive-behavioral therapy. It aims
to reduce patients’ stigma and then help them to question
the delusional meaning they attribute to events. The
authors hypothesized that it is possible to reinforce the
clinical approach to PDs on the basis of two important
considerations: delusions have a meaning that is con-
nected to a fundamental experiencing of the self as being
ontologically vulnerable, and PDs seem to be correlated
A persecutory delusion (PD) is a false belief that other persons
are focusing their attention on one with malevolent inten-
tions and programs. Such beliefs result in significant dis-
ruption of daily life. PDs are common in schizophrenia, and
their content may take a bizarre or highly implausible form
(1). For example, a patient with paranoid schizophrenia might
believe that her neighbors are spying on her with sophisti-
cated devices and removing her internal organs because she
does not have a boyfriend. Persistent PDs cause considerable
distress and impairment, and many patients with schizo-
phrenia who experience PDs do not respond well to current
pharmacological or psychological treatments (2). Therefore,
effective forms of psychological treatment need to be de-
veloped to accompany drug therapy.
The most well-known intervention for PDs is cognitive-
behavioral therapy (CBT) (3–5). CBT involves first working
with patients to reconstruct life events preceding the
emergence of their delusions and to analyze any aspects of
psychological vulnerability that they may have. Then, in as
cooperative an atmosphere as possible, patients (and their
families) are educated about the delusion phenomenon, with
the aim of normalizing it—for example, by explaining that
delusions can result from strong emotional stress (6). The
main purpose of this intervention is to reduce stigma and
164 psychotherapy.psychiatryonline.org
to dysfunctions in metacognition, a spectrum of mental
activities involving thinking about one’s own and others’
mental states. The authors describe the treatment with
metacognitive interpersonal therapy of a young man with
paranoid schizophrenia and pervasive PD. The four main
stages described are: regulating the therapeutic relation-
ship to avoid potential rupture; reducing the emotional
suffering caused by the PD and teaching the patient be-
havioral strategies for coping with this suffering, promot-
ing the patient’s ability to reflect on his own mind and
thereby to develop a more sophisticated metacognitive
mastery of the PD, and promoting a more nuanced under-
standing of the other’s mind.
Am J Psychother 2018; 71:164–174;
doi: 10.1176/appi.psychotherapy.20180039
then, by using logical arguments, to help patients question
their delusional meaning attributions. Other recent ap-
proaches in CBT involve focusing on factors that are thought
to play a part in maintaining delusional convictions, such
as worry mechanisms (for example, perseverative thinking
or intolerance of uncertainty [7, 8]) and cognitive biases
(for example, the “jumping to conclusions” data gathering
bias [9]).
The merit of this therapeutic approach notwithstanding,
we hypothesize that it is possible to improve the effectiveness
of psychotherapy for PDs by helping patients understand
what delusions mean in their personal experience. This
perspective is in line with the work of Chadwick (10), who
gave relevance to the personal experience of persons with
psychosis and to the meaning they ascribe to that experience.
Chadwick emphasized the role of negative self and other
schemata in determining the personal meaning of relational
events and the implantation of the idea of being threatened.
Our work looked at this question in greater detail, on the basis
of two main principles. The first is that delusions have a
meaning that is connected to the life of the individual ex-
periencing them. In our previous work (11), we proposed that
the onset of PDs in the acute phase of schizophrenia—and
their reemergence once they have been formed—may be
Am J Psychother 71:4, December 2018

correlated with a fundamental experiencing of the self as
being ontologically vulnerable, often elicited by poten-
tially stressful interpersonal situations either real or imag-
ined. This experience of the self as being vulnerable can
involve seeing oneself as being unable to both successfully
engage others and maintain intact boundaries around a sense
of oneself as differentiated from others (12). The individual
is not necessarily aware of his or her vulnerable self, which
is experienced generally in the form of anxiety, physical
weakness, or a vague threat.
The second principle regards metacognition. This refers to
a spectrum of mental activities ranging from discrete acts in
which individuals recognize specific thoughts and feelings
to more sophisticated acts in which an array of intentions,
thoughts, feelings, and links between events are combined
into larger and more complex representations. Meta-
cognition includes “mastery,” namely the ability to use
metacognitive knowledge to solve the psychologically or
emotionally challenging events and social problems occurr-
ing in daily life (13, 14). All aspects of metacognition are
impaired among persons with schizophrenia, and these
impairments are linked with greater levels of social and
vocational dysfunction (15). These problems are key to un-
derstanding how PDs arise. Patients do not understand that,
for example, in a certain situation they automatically perceive
themselves as being vulnerable and inadequate and others as
intending to subjugate them and that this is the antecedent
of psychological distress (for example, anxiety), which then
leads to the emergence of PDs. They also display low levels of
mastery. For example, they do not know how to respond to
their PD, or they tend to respond in a dysfunctional way (for
example, by attacking the other). In this perspective, a PD is
the outcome of difficulties in making sense—in the context
of interpersonal exchanges—of the antecedent of a negative
emotion and a negative self-perception connected to the
emergence of a PD.
In this article, we describe the stages in the treatment of a
young man at the onset of paranoid schizophrenia and with
a pervasive PD. The patient was treated with metacognitive
interpersonal therapy (MIT) (16, 17) adapted for psychosis
(18, 19), which aims at progressively fostering metacogni-
tion until patients are able to understand what kind of in-
terpersonal events or ideas about interpersonal interactions
trigger their PDs and what delusions mean in their personal
experience. Because the PD was too pervasive and the pa-
tient’s metacognitive capacity too low in the very first ses-
sions, the therapist regulated the therapeutic relationship to
avoid any potential ruptures and to promote the best re-
lational atmosphere achievable in the sessions and tried to
reduce the emotional suffering caused by the PD and to teach
the patient behavioral strategies for coping with this suffer-
ing while simultaneously promoting an improvement in the
patient’s ability to reflect on his own mind. At the second
stage, when it was possible to elicit the autobiographical
episodes during which the PD emerged, the therapist tried to
reduce the symptoms by promoting a further improvement
Am J Psychother 71:4, December 2018
SALVATORE ET AL.
in the patient’s ability to reflect on his own mind, using a
precise intervention hierarchy (18, 19) that aimed at stimula-
ting identification of problematic feelings and understanding
the link between interpersonal activating events, problematic
feelings, and the onset of the PD; making more complex
psychological links between problematic interpersonal
schemata and the PD; and promoting a more sophisticated
metacognitive mastery of the PD. At the third stage, the
therapist promoted a more nuanced understanding of the
other’s mind so that the patient’s reading of others’ inten-
tions would be less exclusively driven by the expectation—
typical of the schema—that others will be dominant and
ill intentioned.
MIT BASIC PRINCIPLES
MIT was originally designed for personality disorders (16, 17)
and then adapted for the treatment of psychosis (19), in line
with the principles established by Lysaker and colleagues (20,
21). Its main goal is to progressively promote metacognition
and awareness of problematic forms of subjective experience
and of the schemata driving social behavior. Once this is
achieved and patients are better able to think about mental
states, a therapist should help them question their rigid and
maladaptive ideas about the self and others and find new
meanings in order to fulfill previously suppressed wishes that
they thought beyond their reach. With both personality
disorders and schizophrenia, MIT uses step-by-step proce-
dures to stimulate metacognitive skills throughout therapy
(19, 20, 22); however, with patients who have schizophrenia,
the therapist often has to begin by promoting the functioning
of the most basic levels of metacognition. For example, if a
patient is not able to recognize that the thoughts in his head
are his own (rather than thinking that the thoughts are in-
troduced into his mind by an outside entity), the therapist
needs to first carry out some minimal interventions aimed
principally at "restoring" the patient’s agency over his own
thoughts. Moreover, for persons with schizophrenia, the
therapist should know that the patient’s level of meta-
cognitive functioning fluctuates over time, from session to
session and at different moments in the same session.
Eliciting specific narrative episodes is a method MIT uses
to further improve metacognition (22). A narrative episode—
namely, the detailed account of a personally relevant event—is
the most fertile soil for collecting examples with which to
explore patients’ subjective experience, problematic emotions,
meaning-making style, and biased interpretations of the
self’s and others’ ideas and intentions. Such episodes bear
information about what a patient thinks and feels while
engaging in an intersubjective transaction and also about
what self-image the patient has and how the patient relates to
others and metacognitively represents their minds (22, 23).
Therapists should tactfully divert patients from narratives
that are abstract and intellectualized.
Finally, MIT considers regulating the therapeutic re-
lationship and working to prevent and repair alliance
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MIT FOR TREATING PERSECUTORY DELUSIONS IN SCHIZOPHRENIA
ruptures; this is essential throughout the course of treatment,
because any intervention, no matter how technically correct,
risks failing if carried out at a moment of relationship rupture
(24). A fundamental part in regulating the relationship is
played by maintaining a constantly validating attitude (17, 18,
25). Validating consists in constantly expressing empathetic
understanding, acceptance, and support and in transmitting
the following idea: “I can manage to grasp what you’re telling
me (or what you’re doing), I can see the reasons, motivations,
and emotions causing it, even if it’s questionable for your
well-being or counterproductive.”
MIT for psychosis bears many similarities with meta-
cognitive reflection and insight therapy (MERIT) (14, 26),
because they both draw on similar practice elements (for
example, attention to the patient’s agenda, exploration of
narrative episodes, and interventions to promote both self-
reflectivity and metacognitive mastery) for progressively
promoting metacognition in a context of tactful regulation
of the therapy relationship (22). The key difference is that
unlike MERIT, MIT assumes that persons with significant
psychopathology attribute meaning to events according to a
series of maladaptive interpersonal schemas and that a major
task of therapy is making them aware of such schemas while
promoting different and more flexible interpretations of
personal events. A second difference is that whereas MERIT
has been developed to be theoretically integrative and
technically eclectic, MIT is integrative and adopts more
specifically techniques drawn from CBT for treating symp-
toms of psychosis in its procedures.
CASE ILLUSTRATION
At the start of therapy, Oscar was a 22-year-old Caucasian
male from a small town in southern Italy. His maternal
grandmother was diagnosed as having schizophrenia at about
age 30. He is an only child. From his infancy, his parents, who
were socially retiring and anxious, had been very protective of
his independence and of his relations with his peers, which
contributed to his gradual social isolation. Oscar has been
“shy” since childhood, avoided social relationships, and felt
different from others and an outcast. He had never had a
girlfriend. He had not developed any hobbies or interests
beyond his school work, in which he had done well until half
way through his final year at high school, when he began to
experience prodromal symptoms of psychosis. He began to
frequently play truant and spent a lot of time shut in his room.
He managed to get his diploma with help from his teachers.
His relatives gave little importance to this behavior and
allowed Oscar to spend years totally socially isolated.
When he was 22, his parents found him a job in a firm
through a relative in a big city, who provided him with ac-
commodation. After one week of work, Oscar started think-
ing that some of his colleagues were making fun of him. Over
the following days, Oscar became convinced that the firm’s
“secret agents” were after him and were leaving him signals
(for example, a purple towel in the toilet of a café near where
166 psychotherapy.psychiatryonline.org
he lived), which were intended to tell him that they wanted
him dead. His delusional ideas totally restricted his freedom
of action. At this stage, Oscar’s symptoms included bizarre
behavior and a serious sleep disorder. For example, he would
cover his head with a saucepan to prevent the secret agents
from monitoring his mind with “radiation”; although not
often, he also experienced insulting auditory hallucinations,
enough for a diagnosis of a first episode of psychosis. He was
taken to therapy by his parents. The therapist, one of the
authors (GS), prescribed olanzapine, sodium valproate, and
lorazepam, which improved Oscar’s sleep quality and di-
minished his bizarre behavior and hallucinations but did not
eradicate his delusional beliefs.
Oscar met criteria for schizophrenia (27) and had no in-
sight about his illness. Oscar had poor metacognitive skills.
This dysfunction in metacognitive capacity was assessed
by using the Metacognition Assessment Scale–Adapted
(MAS-A) (13, 28). The MAS-A contains four scales that reflect
various forms of metacognitive activity: self-reflectivity, the
comprehension of one’s own mental states; understanding
the mind of the other, the ability to comprehend other in-
dividuals’ mental states; decentration, the ability to see a
world in which others have independent motivations; and
mastery, the ability to use knowledge of one’s mental states to
respond to social and psychological problems. The MAS-A
assessment of Oscar’s self-reflectivity at the beginning of his
psychotherapy showed that he was able to identify his anxiety
and tendency to ruminate over negative thoughts, such as,
“There’s no escape; the secret agents are coming to kill me,”
consequent to his PD. However, the assessment also showed
that he was entirely unable to detect the thoughts and per-
ceptions of himself and others that triggered the anxiety and
rumination. Similarly, he managed to recognize the anxiety
he felt in social interactions at work but was not able to
recognize the situational and cognitive variables generating
his anxiety. In regard to understanding the mind of the other,
Oscar displayed a poor ability to grasp others’ emotions and
thoughts, because he attributed them, even if in a sophisti-
cated manner, without any decentration—that is, in social
interactions, Oscar was convinced that he was the center or
cause of others’ behavior. A cordial expression by a colleague
would be interpreted as dissimulating malicious intentions.
Finally, Oscar displayed a mastery dysfunction; in response to
his PD and to social situations that caused him emotional
distress, his only solution was to avoid social interaction.
Oscar’s psychotherapy in a private outpatient clinic was
conducted under routine conditions and lasted for almost two
years; follow-up (one session every two months) is ongoing.
Sessions were weekly and, at the client’s request, lasted 30 to
40 minutes. The psychotherapy was conducted in line with
MIT principles, adapted to schizophrenia, which we describe
below.
Regulation of the Therapeutic Relationship
In his first session Oscar appeared very reserved toward the
therapist and wary because he feared that he would be
Am J Psychother 71:4, December 2018

considered “crazy” by the therapist. Because he had no in-
sight into his own illness, he could not understand why his
parents had taken him to a psychiatrist or why there was an
urgent need for drug therapy. To positively regulate the re-
lationship, the therapist was guided by three principles:
maintaining a constantly validating attitude; achieving as
much attunement as possible with the patient’s agenda (29)—
that is with the overriding need that the patient brings to the
relationship with the therapist at the start of a session; and
establishing a cooperative atmosphere by working with the
patient to put together a representation of the psychological
problem that is acceptable to him and by making the first goal
that of agreement on a drug therapy.
In regard to the first point, when the therapist was faced
with Oscar’s prolonged silence and lowered gaze at the start
of the first session, the therapist grasped that the patient was
scared and in need of emotional soothing and reassurance.
The therapist knew that patients with schizophrenia are
often so marginalized and stigmatized that care is needed to
not only avoid taking charge of their delusions but also to
ensure that the patient is not just “going along with” the more
powerful other (the therapist). Finally, the therapist di-
agnosed that Oscar had problems understanding others’
minds and thus tried first to evaluate this with regard to his
(the therapist’s) own mind and then to reduce the impact of
any difficulty of this sort. “I believe I can see how it’s very
difficult for you to keep up this interview with me,” the
therapist said. “After all, it wasn’t your choice, and in your
shoes, I too wouldn’t be very willing to be with a stranger I
imagined was there in order to analyze me.”
Oscar replied with a slight smile, which encouraged the
therapist to go on. “I can see how difficult it can be for you to
open up with me,” he said. These empathetic validation in-
terventions helped Oscar loosen up and openly reveal to the
therapist his belief that if he told the therapist the things that
were happening to him, the therapist would consider him
“crazy” and give him drugs to take. At this point the therapist
openly revealed his point of view and the rationale for his
procedures by saying, “I don’t think you’re crazy at all, Oscar.
Generally, ‘crazy’ is a word with not much meaning to me. My
attention is entirely concentrated on what is agitating you. I
can feel you are afraid of speaking about what makes you
suffer because you fear you’ll be considered ‘crazy,’ but
precisely not speaking about it could be making you suffer
even more. What can I do to make you realize you have no
reason for worrying about what I think?” Oscar seemed
calmer and told that he felt persecuted by the secret agents
who were in contact with the management of the firm where
he worked.
Oscar needed drug therapy, but if the therapist had im-
posed it while using the bizarreness of the delusional beliefs
as the reason, he would have confirmed Oscar’s fear about
being considered “crazy” and would have undermined Os-
car’s trust in the therapist and the relationship. Consequently,
the therapist said, “Oscar, I listened very carefully to your
story. I noticed that while you were telling it, you were ever
Am J Psychother 71:4, December 2018
SALVATORE ET AL.
more agitated and that the expression on your face was tense
and distressed. I reckon that what I saw was a reflection of
what you live through constantly. You showed me yet more
clearly how much all this, even when you just think back on
it, literally takes over your mind.”
Oscar answered, “It’s true. But do you believe in these
things I told you?” This is a very delicate moment in the
regulation of the relationship—the moment when the patient
asks the therapist to “take sides” about the patient’s de-
lusional contents. The therapist’s reply was an example of the
second of the interventions listed above and was based on the
principle that we define as “being nonjudgmental about
the delusions and diversion in the direction of a shared thera-
peutic goal.” “Listen Oscar,” the therapist replied. “I’ll clearly
explain my position on this question, and I’ll be happy to go
back to it every time you want. I can imagine how important it
can be for you to feel that your therapist agrees with you on
what you feel to be threatening in your life at this moment, but
both on account of my turn of mind and because of my role as a
therapist who needs to help you to understand your mental
states, it’s not obvious to me that I should be concentrating on
whether it’s true or not that the firm’s secret agents have got
it in for you that much. What interests and strikes me most
are two things. The first is that, as I said, this thinking about
the secret agents takes up your mind very, very often.”
When Oscar nodded sadly, the therapist continued, “In
technical terms you have what’s called ‘ruminative thoughts.’
It happens to all of us when we are very worried. We can’t
manage to think about anything else, and the more we think
about it, the more we get worried. The insistence of these
thoughts at many different moments in your day causes you
a state of profound agitation, as we can see even now. You
told me that thinking constantly about those secret agents
stops you sleeping almost completely. If I put myself in your
shoes, I could imagine I’d feel I was under the sway of these
thoughts, a bit powerless, vulnerable, and also worn out by
having to experience this fear so very often.”
When he saw Oscar’s positive reaction, the therapist
concluded, “I’d like to help you immediately with this. Could
we consider a drug therapy to help you to reduce the in-
vasiveness of these thoughts and get back to sleeping
enough?” Oscar accepted, and on this basis, a drug therapy
was agreed upon.
PD Interventions: First Stage
Medications helped Oscar sleep better and reduced his
bizarre behavior and hallucinations, but they did not have
any significant effect on his delusional beliefs, which were
reactivated especially when he went out. As a result, social
withdrawal persisted. Thanks to the positive regulation of
the therapy relationship, at this initial stage in his therapy
Oscar still worried about the threats by the secret agents but
was more open with the therapist and asked him less fre-
quently whether he believed that these threats really
existed. Oscar was making urgent pleas for help and re-
assurance from the therapist. During the second session, for
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MIT FOR TREATING PERSECUTORY DELUSIONS IN SCHIZOPHRENIA
example, he said with a pained expression, “The firm’s
secret agents have got some very sophisticated ways of
spying on me. The films you see at the cinema . . . all true.
They haven’t invented anything. The devices you see in
James Bond films . . . they’re now closing in on me.”
Moreover, because his intense negative arousal and low
level of self-reflectivity seemed to prevent him from fo-
cusing on any specific activating situation, at this stage
Oscar was incapable of reporting specific narrative epi-
sodes during which the PD emerged. Only once, in one of
the first sessions, did he manage to relate that a car parked
near the clinic was linked to the secret agents, but he
was incapable of performing an articulated reconstruc-
tion of the scene and the thought links and emotions pre-
ceding his delusional perception. He was capable only of
reporting the emotional distress caused by the persecu-
tory idea, which made him seek refuge by shutting him-
self at home. With this scenario, the therapist took the
following series of measures: empathetically soothing
the patient’s emotional suffering regarding the delusional
ideas, promoting behavioral mastery, and promoting self-
reflectivity.
Empathetically soothing and normalizing. Faced with Oscar’s
dramatic pleas for help, the therapist bore in mind that such
a vulnerable and scared patient tends to pay attention first
and foremost to the nonverbal signals (intonation, prosody,
posture, facial expressions, and proxemics) from the thera-
pist’s inner disposition and that the degree to which this
disposition is regulated will have the greatest weight in
regulating a patient’s emotional reactions in session (30).
Accordingly, the therapist regulated his own sense of urgency
with respect to the patient’s agitation. First, he listened to
Oscar and avoided interrupting him. When Oscar stopped
speaking, he modulated his nonverbal behavior by, for example,
maintaining a calm vocal tone and tried to sooth him. “Oscar, I
can see very clearly from the expression on your face how
much you are suffering when you feel threatened and encircled
by the secret agents. Don’t worry because I’m going to make
every effort and use all my professional skills to help you.”
Promoting behavioral mastery. This intervention calmed Os-
car sufficiently to let the therapist promote a reattribution
of meaning with regard to his emotional suffering. At this
point, the therapist invites the patient to consider the emo-
tional suffering triggered by the emergence of the delusional
ideas as a problem that the patient has the power to act upon,
as in the following session excerpt:
T: You get very scared and very tired when you think a lot
about the secret agents and you see yourself under the sway
of this thought. Let’s try thinking another way about this
secret agents problem. Something that frightens you a lot, so
that you think about it very frequently, and for this reason it
makes you still more frightened.
O: It becomes a fixed idea.
168 psychotherapy.psychiatryonline.org
T: This is very understandable. It happens to everyone. To me
too. It has happened many times to me that I’ve got very
agitated about a worry that kept going through my head. In
these cases, we miss the most important question, that is that
we think we have no other choice but to undergo this state of
mind. We can’t wait for the suffering to disappear, but we
imagine we can’t do anything to alleviate it. But that’s not true.
We can act upon our suffering. At least to alleviate it. The first
thing to do in this regard is change your attitude toward the
ideas about the secret agents and the suffering they cause.
What would happen if we were to consider these ideas just an
ordinary source of stress and to concentrate on trying to
reduce this stress? The best thing to do is try to talk about them
with someone close to us or to distract ourselves, or—why
not?—both things.
In such a situation, a therapist can take the next step and,
while still adopting a validating attitude, negotiate strategies
for behaviorally mastering the emotional suffering resulting
from the delusional thought. At this stage, we prefer two types
of strategy: first, those based on a resort to the therapist fig-
ure to seek reassurance and solace, and second and simulta-
neously, behavioral strategies based on activities potentially
effective at distracting the mind as much as possible from the
suffering caused by the delusional thought. The therapist said
to Oscar, “Let’s establish together how to tackle this worry.
When it becomes insistent and makes you agitated, you could
try and remember my words. Perhaps this won’t be enough to
calm you down, so then you might try calling me to discuss it, a
bit as if we were in a session, just as we did today. Today it
worked. By talking about it, you calmed down a bit. I reckon it
could work on the phone too. If you can’t get through to me,
you can send me a text or an e-mail and wait for me to call you
back. In the meantime, you could try distracting yourself by
doing something you like. To find what is most likely to work
we need to think a bit together.”
Oscar agreed. At this stage in his therapy, Oscar called the
therapist several times when he was in the grip of the de-
lusions, and the therapist adopted the very same position
toward the problem that we have just described. Oscar
managed to calm down, at least partially, by talking with the
therapist. At this stage, a therapist should expect the frequent
emergence of negative emotions to make the patient forget
what has been discussed in session and the patient to repeat
the delusional contents in the form of a frightening factual
event, a reality causing dismay and fear. In other words, very
often at this stage in his therapy, Oscar asked the therapist for
help because he was threatened by the secret agents and not
because his worrying about the secret agents had become too
unrelenting. In these cases, the therapist did nothing other
than repeat the series of operations we have just described: he
pointed out that the pervasiveness of these contents was
causing suffering, helped Oscar to identify this suffering, and
validated it—to then reach agreement with Oscar on how to
handle it. At a more advanced stage, after noticing that Oscar
relied on him at moments of emotional distress, the therapist
attempted to expand Oscar’s set of regulation strategies:
“Should you not manage to get me, you could try calming
Am J Psychother 71:4, December 2018

down another way, with, for example, physical activity, like
gymnastics or walking or else something you usually like
doing, like listening to music. They’re things we all do ha-
bitually to divert our attention from some negative state of
mind that’s tormenting us, and they usually work even if
they require a bit of effort at the beginning.”
Constantly promoting patient’s self-reflectivity. While
promoting Oscar’s behavioral mastery skills at the times
when he was not suffering from the PD, the therapist also
worked continuously at stimulating his self-reflectivity
at the level he was capable of. More specifically, Oscar
showed the basic capacity to recognize that the thoughts in
his head were his own, so the therapist tried to stimulate
the more complex ability to identify and label his own
thoughts and emotions in the here and now of a session.
For example, he often asked what Oscar thought and felt
after each intervention. In this context, he helped Oscar label
the thoughts and the emotional suffering emerging over a
session. In one session, Oscar was silent and looked sad.
The therapist asked him what he thought, and Oscar
answered:
O: I was thinking my life is falling to pieces, and I’m never
going to have any friends or a new job.
T: From your expression, one can see how much this thought
makes you sad, I’m really sorry.
O: [nodding] I’m often sad because of these matters.
T: I can understand that thinking this way makes you so sad,
but listen, I don’t expect to convince you now about what
I’m saying, but I’m certain that when we have such
negative thoughts about the future it is natural to expe-
rience a profound sadness, and this same sadness ends up
stoking these thoughts in a vicious circle. The effort we
need to try and make at moments like these is to say to
ourselves that we’re experiencing a mental state, made up
precisely of thoughts, images, emotions, and physical
sensations. And a mental state is not a mirror of reality. It
has nothing to do with any reliable forecast of the future, with
how many friends you’ll really find and with the job that you’ll
do. A mental state is rather similar to a room with one door to
go in and another to go out. What happens is that, when we
enter this room, we stay there for a bit but then we go out.
That’s how the mind works. Once we’ve entered a mental
state, whatever it is, even the most distressing, we’re destined
to get out of it.
O: [smiling] I don’t know… I hope so.
A therapist’s aim in this case is first of all to validate the
patient’s emotional suffering and promote a represen-
tation of the former that is welcoming, accepting, sup-
portive, and able to soothe and then stimulate the patient’s
ability to see his or her own mental representations
and emotions, and the links between the two, together
with the ability to differentiate these representations from
reality—namely, to perceive that they are hypothetical and
fallible.
Am J Psychother 71:4, December 2018
SALVATORE ET AL.
PD Interventions: Second Stage
The key features in the second stage of Oscar’s PD treatment
were as follows: eliciting a narrative episode in which a PD
emerges; in the context of this episode, promoting Oscar’s
understanding of the link between his emotional suffer-
ing and the PD; promoting awareness that disturbed in-
terpersonal schemas lead to the emergence of the symptom;
and promoting high-level mastery strategies for PDs, based
on his use of this psychological knowledge.
Eliciting a narrative episode in which a PD emerges. The key
feature of this therapy stage is that the therapist should
continue to stimulate self-reflectivity by working on any
narratives emerging. On the basis of a narrative episode, the
therapist can invite the patient to find a link between his or
her subjective suffering elicited by interpersonal situations
and the emergence of the PD. When a patient reports even
an insufficiently well-organized narrative scene, in which a
symptom got activated, the therapist should first help the
patient pinpoint details of the scene to retrace more pre-
cisely the activating interpersonal event and then promote
awareness of the patient’s emotional reactions to the event.
During the fourth month of Oscar’s therapy, the therapist
tactfully discussed with him the importance of working on
narrative episodes to better understand his emotions. Even if
initially with some difficulty, Oscar managed to recall a scene
that took place about two days earlier: “I was at the super-
market. . . . We picked up a trolley and went in but . . . at a
certain point we saw this big guy. Then we started to do the
shopping and to put things in the trolley, and that’s when I
really started to tremble. . . . That’s when it became clear that
he was there like all the others to make me pay for it. Because
these people I was working for were real experts of the
human mind. They were totally crazy and during the short
period I worked for them I could see everything they were
capable of doing to me.”
Promoting the patient’s understanding of the link between
emotional suffering and the PD. The next step consisted in
stimulating Oscar’s awareness that the interpersonal events
described in his narrative scenes were accompanied by a
painful emotional arousal and biased way of reasoning,
contributing to the appearance of his persecutory ideas, as
can be seen in the following intervention:
T: I can see how much it still now scares you just to recall those
moments. I can imagine your fear. However, it’s important for
us to go back over those moments. I was struck by one thing in
your story. I found you insisted a lot about the fact that this
person was big. As if it was an image that stayed particularly
impressed in your mind. Does the fact that this guy was very
big have anything to do with your fear being so strong?
O: Yes . . . I think so
T: Can you manage to focus on what in the fact that this guy
was big frightened you so? Did you imagine that something
in particular might occur between you and this person?
psychotherapy.psychiatryonline.org 169
MIT FOR TREATING PERSECUTORY DELUSIONS IN SCHIZOPHRENIA
O: I can’t really tell you, I’m sorry.
If a patient struggles to perceive the links between his
cognitive and emotional variables, the therapist can suggest
some hypotheses, especially based on what the therapist can
infer by identifying with the patient and on anything that can
be universally shared in the mental states that take shape in a
certain situation:
T: Don’t worry. It can happen that in these situations we can’t
manage to halt the images and thoughts making us frightened.
One of the reasons one can experience fear when faced with a
big person, even if we don’t know them and they haven’t done
anything to us, is that we instinctively imagine a physical
encounter with them and feel ourselves to be weaker. What
do you say?
O: I reckon that’s exactly how it is. I felt precisely weak . . . in
danger.
The therapist’s next intervention had a three-stage
structure: reformulating the activating interpersonal
event-belief-emotion sequence and asking the patient for
his feedback, validating the patient’s emotional experience,
and stimulating the patient to see the link between the
sequence as identified and the emerging of his delusional
ideas. A request for feedback on what has been recon-
structed is important for the therapeutic relationship, be-
cause it transmits to the patient that the therapist’s purpose
is not to coerce the patient into some arbitrary theorizing but
to help the patient make contact with the causes of suffering
and that this purpose is achievable only with the help of the
patient:
T: So, Oscar, I’ll try and summarize and you correct me any
time I’m wrong. At the supermarket you bump into this guy
and his physical appearance, the fact he was big, makes you
feel weak precisely in a physical sense, with regards to the idea
of being physically threatened, and for this reason you feel this
intense fear. Can you see yourself in what I’m saying?
O: Yes, I do!
T: I can see very well how you felt. As I was telling you, it’s
a really age-old mechanism, connected to our instinct for
survival. In some of us it’s particularly strong. It happens to me
too every so often. We’ll keep on working on it.
O: [smiling] Okay, thank you.
Promoting awareness that disturbed interpersonal schemas
lead to the emergence of the symptom. The next step, once the
therapist had stimulated an increase in Oscar’s self-reflective
skills, was to get him to relate other narrative episodes in
which the tendency to ascribe persecutory intentions to
another may have emerged in the presence of similar
emotional suffering and a negative self-perception. The
therapist’s aim was for Oscar to practice—every time he
was prepared to do it—identifying in session the general
connection between the emotional suffering elicited by
interpersonal situations and the emergence of his PD, as in
the following excerpt:
170 psychotherapy.psychiatryonline.org
O: There was this guy who came to repair the boiler. He
was big . . . was wearing this trendy blouson jacket and had a
tattoo. . . . It made me feel tense to see him in our home. That
time too I felt in danger.
T: There you are, Oscar, we’re perhaps on the right track. . . .
So, we have the man at the supermarket first, then the boiler
guy. . . . I reckon—but don’t hesitate to tell me if it doesn’t
tally—that these situations have one thing in common: that
you meet people who are physically big and rough looking,
and it’s as if you felt a bit vulnerable. And at this point you
automatically get the idea that the other has threatening
intentions toward you. However, what I find most important
is precisely this sensation, really primitive.
O: Of survival. . . . In fact, my sensation in these cases is
precisely that I’m at the mercy of someone stronger.
T: We can call it the vulnerable part that there is inside each
of us. In this episode, you told me how it came out forcefully.
We just have to learn how to tackle it.
At this stage, the therapist helped Oscar to recall a further
set of less recent episodes in which a similar schema arose. In
one session at this stage, Oscar recalled a prototypical epi-
sode originating from when he was about nine, when he
was suddenly threatened and then hit at the bus stop by
a physically very big bully. Once he got home, he sought
comfort from his father, a big, rough man, who replied by
shrieking at him and angrily showing him his fists, “You
deserved it, because you’re a weakling!” After reminding
Oscar of the first episode described above and other similar
ones, the therapist helped him—with the assistance of a di-
agram on the blackboard—to reconstruct a general in-
terpersonal schema. “Oscar, I’ve thought a lot about all the
episodes we’ve reconstructed, where you had this paralyzing
fear while feeling vulnerable and weak. And I was very struck
by that scene at nine years old where you got attacked by that
bully much bigger than you and then sought comfort from
your father, who reacted just as aggressively. It seems that all
these experiences are telling us something important. It’s
as if, when he had the desire to be comprehended for his
vulnerability—that vulnerability we all experience, that’s
part of us—Oscar learned to expect a very different response
from what he would have wanted. A response that’s violent
and humiliating rather than understanding and comforting.
As if the other me told me, ‘How disgusting that you’re
vulnerable!’, instead of consoling, reassuring, and letting me
know that a person can be valid even if, like everyone, he
sometimes feels weak and letting me know that being afraid
of being attacked is normal and does not at all mean being
unworthy. What do you think?”
Oscar agreed. Now that he was certain Oscar had un-
derstood the diagram and agreed with it, the therapist helped
him to grasp that the PD seemed to arise especially when this
schema got activated: “There you are, then! As happens to all
of us when we have experiences like that, that leave a bit of a
mark on us, a sort of inner rule has got established in you.
When you experience that sensation of vulnerability anybody
Am J Psychother 71:4, December 2018

could experience when faced with people that give us the
impression of being strong or aggressive, or even simply very
sure of themselves, it’s a bit as if one felt one was nine again
and found oneself with that bully. You feel very vulnerable,
but at the same time you’re very scared by that vulnerability,
because you’ve never been able to confide in someone who
would reassure you and say, ‘Don’t worry, nothing’s going to
happen, it’s happened that I too have felt like that. It’s a
sensation experienced even by people who are very big,
physically strong and apparently very sure of themselves.’”
Oscar fully identified himself in this reconstruction and
thanked the therapist. The therapist added that the next step
in the therapy would be "becoming ever better at observing
Oscar in situations in which the schema would get activated."
The second part of this intervention is explaining from a
normalizing standpoint the link between a schema and the
contingent activation of delusional symptoms. While con-
tinuing to use a diagram on the blackboard to illustrate what
he was saying, the therapist told Oscar, “There’s something
else very important we’ve learned together. When they feel
vulnerable and consequently frightened, it happens with all
human beings that they get this sensation of being threatened.
Before we were saying that if we are faced with a man who’s
very big and strong, a mechanism can get activated that leads
us to feel vulnerable and potential victims. But something else
important that occurs is that while we feel like that and get
this sort of unease or anxiety, we are automatically, through
a really age-old mechanism, led to feel a bit threatened by
this person. We can also become wary. In reality, what’s
happening is merely the consequence of the sensation of
vulnerability. In practice feeling vulnerable leads us auto-
matically to think that the other is going to attack us. Could
this have perhaps happened several times to you, for example
at the supermarket or with the plumber—that is, when you
met someone very big and well set?”
Even if a patient gives positive feedback to this type of
intervention, carried out tactfully and with a validating at-
titude, the patient is very likely to feel that his coping
strategy—in this case based on diffidence and the hyper-
activation of vigilance toward a potential outside danger—is
being blocked. Feeling that his coping strategy is threatened
could in turn lead a patient to use it to shield himself and to
entrench himself behind it. In other words, accepting a
therapist’s suggestion of grasping the subjective origins of
suffering involves accepting the risk of lowering one’s guard
toward an outside world that is perhaps not as dangerous as
one thought until now; however, lowering one’s guard can
reactivate vulnerability, and with it negative arousal, re-
triggering the coping strategy.
Oscar at this point answered, “You’re right, I agree. I
hadn’t ever seen it like that . . . and for sure that’s what
happens to me. . . . However, the other time, in the super-
market those guys really had it in for me. There’s no doubt.”
Then the therapist said, “I understand, Oscar. My aim was not
to make you change your ideas about those guys at the super-
market. I was just keen to get you to know a practically
Am J Psychother 71:4, December 2018
SALVATORE ET AL.
universal mechanism in which there’s a close link between
feeling weak and feeling automatically that the person, vis-à-
vis whom we feel weak, is hostile. Sometimes it can happen
that we meet someone who really is hostile, but it’s never-
theless extremely important to know this mechanism in
which the other seems a priori hostile to us almost every time
that this sensation of vulnerability, that we managed to focus
on together, emerges from deep inside us. Perceiving this
mechanism in ourselves makes it possible for us to continue to
be watchful toward outside threats—let’s say to not lower our
guard but to learn better to distinguish when these threats
are real as compared with when they originate from within
ourselves, from our feeling vulnerable.” Oscar relaxed and
agreed with the therapist. Yet again, the therapist did not try
to refute the delusional perception of the other’s malicious
intentions but only to offer the patient a new evaluation
perspective, more centered on his subjectivity.
Promoting higher-level mastery strategies. The therapist
should now promote the patient’s use of this high-level
psychological knowledge to achieve a more sophisticated
mastery of PDs. To facilitate recalling the schema recon-
structed in the session, the therapist left Oscar a copy of the
schema diagram and a brief memo saying, “Oscar, remember
that when you feel threatened, it’s most probably also because
you are feeling very vulnerable, and that it happens to all of us
to feel very threatened when we feel physically vulnerable.”
The therapist and Oscar agreed that when Oscar’s sensation
of being threatened returned, he should choose which
mastery strategy to use from among those already used (for
example, calling the therapist), trying to recall the work done
together in the session (for example, by rereading the notes
from the therapist), or performing some pleasurable activity,
such as going to the gym. On various occasions, Oscar
recounted that by using such a strategy, he had managed to
switch his attention from his PDs, and the voices disappeared.
Advanced Treatment Stages
After 23 months of psychotherapy, Oscar has a good outcome
in regard to the PD and is now starting to see the therapist
only once every two months. With Oscar, the therapist used
the analysis of new narrative episodes to make him aware that
his ego-dystonic perception of vulnerability was a recurring
one. Thanks to their discussion of the schema, Oscar had
managed to identify his perception of vulnerability as at least
partly connected to his perception of an outside threat and to
understand that this image had taken shape gradually on the
basis of negative experiences. For Oscar, his vulnerable self
had taken a pervasive hold and his differentiation (that is, of
reality from representation) was thus not stable. However,
with the therapist’s assistance, Oscar began to understand
that each time a situation gave him a sensation of physical
vulnerability, he tended to feel threatened. Therefore, the
therapist is currently working on encouraging Oscar’s
exposure to situations that could be a source of well-being
for him and on the reinforcement in these situations of
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MIT FOR TREATING PERSECUTORY DELUSIONS IN SCHIZOPHRENIA
Oscar’s metacognitive ability to understand others’ minds
and decenter in a more sophisticated fashion. For example,
in one session during the 20th month of therapy, the
therapist proposed an exercise of the imagination focused
on reading the mind of another who had looked and smiled
at him:
T: Try closing your eyes and going back to the scene. Are you
doing that?
O: Yes.
T: If you can, home in on the image of that person looking at
you and smiling. Can you see him?
O: Yes, I’ve got him in my mind.
T: Very good, Oscar. Now try and imagine what’s going
through the mind of this gentleman while he’s smiling.
However, while doing it try not to think that this gentleman,
the tobacconist, has Oscar in front of him. That is, imagine just
the personal reasons that might be pushing this gentleman to
smile. Try to put yourself completely in his shoes while you’ve
got the picture of his smiling face in your mind. Am I managing
to make myself clear?
O: I think so. I think I’m managing to do it.
T: The tobacconist smiling. Just think about the tobacconist
smiling like he smiled at you in that scene, but now you’re not
there. Concentrate.
O: Yes.
T: What’s passing through the tobacconist’s mind while he’s
smiling?
O: That he’s fine. That he’s happy.
T: At this moment do you find him a threatening, dangerous,
and bad person?
O: No, no. . . . He’s a man a bit on in years, about 60. I’m
imagining him smiling to his customers.
T: Perfect. While he’s smiling to his customers, what does he
think of them?
O: Well, yes. . . . He’s grateful in a certain sense because they
buy things from him.
T: Very good. Now try and imagine you’re before him. You’re
meeting him again as happened when you bumped into him in
the street, and he has that same smile, that expression we’ve
imagined up to now. How do you feel while you’re before him
now?
O: Calm.
T: Is it possible that in this scene this man about 60, the
tobacconist, is happy to see you and has no evil intentions?
O: Yes, I think so.
T: You can open your eyes if you want. . . . You see, this exercise
was very interesting because it showed us that by imagining
the tobacconist with that same smile, but without him being
before you, you imagined him as being kindly. Then you
thought you were again with that smile before you and your
172 psychotherapy.psychiatryonline.org
reaction changed. You no longer felt vulnerable and didn’t see
him as being threatening as in the episode. You felt calm and
unperturbed in the presence of another who’s smiling at you
cordially. This is an example of how your sensation of what
others’ intentions towards you are often risks being not very
objective, as if it was driven by your mental state at that
moment, whereas to grasp others’ real intentions we perhaps
need to move out of our shoes and put ourselves a bit in theirs.
What do you think?
P: [reflecting] I really think so.
CONCLUSIONS
We have described the treatment of a PD in a young man
meeting the criteria for schizophrenia and treated with MIT.
We have described how in the first stage of the treatment,
when the PD was very pervasive, arousal very high, and
metacognitive skills very low, the therapist adopted a vali-
dating and soothing attitude to stimulate the patient’s be-
havioral coping with the delusional beliefs. MIT does not try
to challenge delusional beliefs, because this requires high-
level self-reflection skills, which are very unlikely to be
present in patients with psychosis, especially at moments of
emotional turmoil. With the support of a validating atmo-
sphere, the goal is for a patient to change his or her idea of not
being able to cope with symptom-related suffering. It should
be suggested that the patient adopt a set of strategies (meta-
cognitive mastery) for coping with suffering until he or she
develops a sense of agency over the symptoms and of self-
efficacy. These emerging feelings will then reinforce the
patient’s ability to take action to solve his psychological
problems.
We then showed that at a more advanced stage in the
treatment, the therapist helped the patient to consider the
persecutory ideas as an expression of his emotional reactions
generated by activating interpersonal situations in which he
felt vulnerable. On this basis, the therapist promoted a de-
gree of self-reflection to the extent that the patient could
understand the social triggers that, together with his self-
schemas, ignited his delusions. This created the conditions
for the patient to adopt a critical distance from the schema
and use this new psychological knowledge to achieve an
advanced metacognitive mastery of his PD.
We do not try to help a patient grasp that a representation
“is not true” but rather to help the patient glimpse—with
a massive resort to empathetic validation and normal-
ization—the underlying universal agreement about the rep-
resentation, namely, that it “is not more true for the patient
than it is for the rest of the human race.” In other words, we
aim to help the patient grasp how much, for example, we all
possess a core of vulnerability. On this basis, a therapist
should encourage a patient to look at this image, when it
emerges in life situations, with a cognizant and accepting eye
and should help the patient modulate it, together with the
emotional suffering and the symptoms that it tends to trigger.
Am J Psychother 71:4, December 2018

Repeatedly experiencing empathetic validation and nor-
malization in the therapy session will clash dialectically
with periods when the negative self-image and the schema
triggering the delusions get activated. A therapist should not
feel defeated by such negative fluctuations, which are
normal.
Here we have described a two-phase sequence for the sake
of clarity, but in everyday clinical practice, a therapist is more
likely to move back and forth between the two phases until a
problem is solved. Patients’ metacognitive abilities tend to
fluctuate over time (18, 21), often in the same session, and the
therapist has to adjust his or her action to the patient’s current
skill level. For example, at one moment, the patient might
understand that the activation of an interpersonal schema is
the antecedent of the emergence of the delusions. The patient
may start questioning his or her own schema. But moments
later, when thinking about a distressing episode, the patient
may lose this ability and again complain about a threat. In
such cases, the therapist must go back, for as long as needed,
to interventions belonging to the first phase.
Several important limitations need to be pointed out. The
first concerns the generalizability of the good therapy out-
come. For example, the effectiveness of the interventions may
not have depended exclusively on their technical correctness
but on other variables—for example, the therapist’s personal
characteristics, such as his self-confidence; the fact that the
patient’s illness was at its onset; and the patient’s good level of
neurocognitive functioning. Consequently, further research
is needed on single-case studies to verify the effectiveness of
the procedures described when treating patients with PDs, a
longer history of illness, chronic symptoms and co-occurring
negative ones, and a different neurocognitive profile. Nev-
ertheless, psychotherapy using MIT seems to be effective in
stimulating metacognitive skills and reducing PDs, and even
if it does not have a definitive impact on self-beliefs, it can
stimulate a patient to see that PDs are generated by internal
attributions.
AUTHOR AND ARTICLE INFORMATION
Center for Metacognitive Interpersonal Therapy, Rome (Salvatore, Buonocore,
Ottavi, Popolo, Dimaggio); Humanitas, School of Psychotherapy, Rome
(Salvatore, Popolo); Istituto A. T. Beck, School of Cognitive Behavioral
Therapy, Rome (Ottavi, Dimaggio).
Send correspondence to Mr. Salvatore (giampaolosalvatore@virgilio.it).
The authors report no financial relationships with commercial interests.
Published online November 21, 2018.
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