Complex Cases of Personality Disorders: Metacognitive Interpersonal Therapy

By Antonino Carcione and Antonio Semerari

This book proposes an integrated model of treatment for Personality Disorders (PDs) that goes beyond outdated categorical diagnoses, aiming to treat the general factors underlying the pathology of personality. The authors emphasize the development of metacognitive functions and the integration of procedures and techniques of different psychotherapies.
The book addresses the treatment of complex cases that present with multiform psychopathological features, outlining clinical interventions that focus on structures of personal meaning, metacognition and interpersonal processes.
 
In addition, this book:

• Provides an overview of pre-treatment phase procedures such as assessment interviews
• Explains the Metacognitive Interpersonal Therapy (MIT) approach and summarizes MIT clinical guidelines
• Outlines pharmacological treatment for patients with PDs
• Includes checklists and other useful resources for therapists evaluating their adherence to the treatment method

Complex Cases of Personality Disorders: Metacognitive and Interpersonal Therapy is both an insightful reexamining of the theoretical underpinnings of personality disorder treatment and a practical resource for clinicians.

• Language: English
• Publisher: Springer
• Release date: Jun 29, 2021
• ISBN: 9783030704551

Book preview

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2021

A. Carcione et al. (eds.)Complex Cases of Personality Disordershttps://doi.org/10.1007/978-3-030-70455-1_1

1. The Problem of the Diagnosis

Antonio Semerari¹  , Fabio Moroni¹  , Giuseppe Nicolò¹ and Antonino Carcione¹

(1)

III Centro di Psicoterapia Cognitiva, Rome, Italy

Antonio Semerari (Corresponding author)

Email: [e-mail]

Fabio Moroni

Email: [e-mail]

Keywords

Complex casesDiagnosisDSM-5AMDPICD-11Personality traitPersonality dimension

1.1 The Problem: A Complex Case

The first interview had barely ended, and the therapist was unable to dispel his sense of confusion with regard to the diagnosis. He began to look through his notes. Enrico is a 25-year-old university student, modest in appearance, and well spoken, who stopped taking exams over a year ago and does not attend courses. An only child, he lives with his parents and turned to the Third Center of Cognitive Psychotherapy for a rather unusual problem. Enrico faints or – he cannot say – suddenly falls asleep while others are talking to him, slumping wherever he happens to be, on a chair or sofa. For sure, he loses consciousness, and this occurs frequently, three or four times a week. For this reason, he was admitted to a prestigious neurology department in Rome. After a thorough battery of examinations, tests, and assessments, epilepsy, narcolepsy, or other organic causes were ruled out. The doctors’ verdict was: It’s a psychological problem! and they advised him to turn to the Third Center. During his hospital stay, the doctors had witnessed an episode of his passing out, and they had no qualms about excluding any possibility of simulation. They kindly sent us a video along with the EEG tracing and the measurements of muscle tone. In the very moment the video showed the patient slump, the EEG trace showed cerebral activity continuing as in a state of wakefulness (which made it possible to rule out narcolepsy), while the EMG showed a total collapse of muscle tone. Possibly a faint? the therapist wondered, meaning a dissociative defense from a situation of overwhelming threat, characterized by loss of muscle tone. Questioning the patient, however, it seemed that no thought or representation of threat preceded the blackouts. The therapist had carefully sought to investigate the emotions and representations immediately before the loss of consciousness, but he had always run up against a wall of don’t know, nothing, and don’t remember. Alexithymic and with scant metacognitive monitoring, he had jotted down in his notes. In any event, the therapist reflected, blackouts are the symptom that brought Enrico to the psychotherapy center, but Enrico presents at least two other problems, each of which would in itself warrant psychotherapeutic treatment. The first is social withdrawal. It had been immediately clear that Enrico exercised active avoidance of interpersonal relationships. In particular, situations in which he had to interact with more than one person put him ill at ease. Unfortunately, when the therapist had tried to delve more deeply into the nature of this malaise, he met the usual wall of don’t knows and vague responses. He had explicitly asked Enrico if he feared being criticized or judged badly, if he felt emotions of embarrassment and shame, but Enrico’s mental states remained basically opaque. All that the therapist was able to obtain was that Enrico, when with other people, experienced a feeling of unease vaguely describable as a sense of extraneousness and of apartness – a strange feeling, was how he put it. Then again, Enrico did not appear to suffer all that much from his social isolation. He treated it as a given, with a tone expressing resigned and moderate regret. His withdrawal from relationships had intensified with the start of university, but it appeared decidedly to be a trait. The feeling of distance and of diversity with respect to others was traced back to his years in primary school. True, there had been a romantic relationship, a story with a girl that ended badly, and a painful breaking up at the start of university, which seemed to have further upset the patient and accentuated his withdrawal. Avoidant personality disorder? or Schizoid? the therapist had entered in his notes, stressing the question marks.

The therapist had experience, however, treating patients with severe social withdrawal. The first sessions were always laborious, leaving him with the sensation of having to pry the information from the patient’s mouth and with a feeling of awkwardness and fatigue in maintaining the relationship with the patient. A fatigue that risked giving way to boredom and to a desire to end the session as soon as possible. With Enrico, instead, this had not happened. Apart from the difficulties of exploring the emotive and ideative contents of the patient’s mental states, the conversation had proceeded smoothly. Of course, a diagnosis cannot be based on sensations, but the therapist did not have the impression that he found himself with a person with severe relational problems.

Enrico’s other problem, which in itself would have deserved psychotherapeutic treatment, was his obsessiveness. On this point, the patient had been less opaque. He had recounted that he was often assailed by the anguished doubt that he had not turned off the gas or closed the front door. The idea that he might be responsible, out of neglect or forgetfulness, for bringing harm to someone, especially his parents, gripped him with anxiety. But instead of giving rise to compulsions, as might have been expected, these fears engendered complex ruminations in which the patient sought to determine by logical deduction whether he had actually turned off the gas or closed the door.

The explanation he gave for this demonstrated both his acumen and his oddness. These worries, he said, had long tormented him, certainly since adolescence, and of late they had intensified. At the beginning, he had actually carried out continual checks to verify that he had not committed the feared oversights. He had realized, however, that his checks did not eliminate his doubts about forgetfulness but simply transformed them into the doubt that he had not checked well. So, he had decided to seek a line of reasoning that could give him certainty.

The second significant aspect of Enrico’s obsessiveness was its ego-syntonic nature. Paying the utmost attention to certain things was, for him, a moral obligation, pure and simple. He could not have done otherwise, nor would he have ever wanted to. Without doubt, Enrico presents an obsessive-compulsive disorder (OCD). The therapist knew that an obsessive-compulsive personality disorder (OCPD) does not necessarily correspond to an OCD. He reread some phrases that had struck him and that he had taken down almost word for word: Every day I draw up a daily plan of action. I try to set a program and stay on schedule. Even the slightest change with respect to what I had established, whether caused by me or others, makes me go haywire. No, state obsessiveness and trait obsessiveness do not always go hand in hand, the therapist thought, but this time it seemed they really did. He attempted to summarize: disorders of consciousness, alexithymia and low metacognitive monitoring, social withdrawal, state and trait obsessiveness, all seasoned with a pinch of oddness, while, in person-to-person contact, no particular difficulties are perceived. How to put this all together? What are the most important aspects of his psychopathology? Where to begin treatment?

In the Third Center, when a therapist encounters difficulty in reconstructing the interactions among the psychopathological factors of a complex case, he asks that the case be taken up in the weekly clinical meeting, in which the entire staff of the Third Center participates and only difficult cases are discussed. The latter usually fall under three headings: cases where the therapist has difficulty in completing the assessment, cases in which problems or a crisis of the therapeutic alliance is present, and cases in which techniques and procedures of proven effectiveness are not working.

The discussion was rather concise. Obsessiveness and social withdrawal, with a dose of oddness, it might be a case of Asperger’s Disorder, someone observed. The therapist felt this could be ruled out. The impression was too different and, in the anamnesis, social relations, though complicated, did not seem so severely compromised.

The relationship between obsessiveness, dissociation, and social withdrawal was examined. It could not be assumed that there was a direct relationship. Withdrawal possibly constituted an independent personality framework which, however, might exacerbate obsessiveness and dissociation, depriving Enrico of the stimuli of, and engagement with, external reality.

The discussion began to formulate hypotheses about the relationships among the various elements. One hypothesis underscored the primacy of dissociation. According to this view, first as a child and then as a young boy, Enrico had been frightened and confused by relationships and had progressively withdrawn from them, developing his obsessiveness in the attempt to deal with the fantasies of threat typical of a patient with a dissociative disorder. But Enrico did not recall particular traumatic events in his life. It was necessary, however, to explore subtler traumatic situations, such as interaction with a disturbed parent, traumatizing and frightening not because the parent was aggressive, but because the parent, too, was frightened.

Another hypothesis placed obsessiveness at the root. Trait obsessiveness, manifesting itself precociously, could have made Enrico feel different from others, unable to share interests and values with his peers – hence his progressive social withdrawal. Subsequently, his solitary activities as an obsessive may have fostered the dissociative phenomena.

Concluding the discussion, the supervisor remarked that there were not sufficient elements to establish a hierarchy among the different psychopathological components. All the different hypotheses should be explored. However, from the point of view of treatment, it was possible to formulate a preliminary program subject to revision on the basis of updated assessment. The formulated program took account of the various obstacles to treatment. Withdrawal and obsessiveness were, for the time being, too ego-syntonic to be dealt with first. In this case, the obstacle would have been the lack of a therapeutic alliance: certainly, too great an obstacle to be tackled head-on. Enrico had come to the Third Center to treat his fainting spells. On the goal of reducing his blackouts, the alliance would be easy.

The greatest obstacle to treating this symptom was scant metacognitive monitoring, which rendered obscure what was happening in the patient’s mind in the moments preceding his faints. Appeal to his sense of responsibility, the supervisor had advised the therapist. Explain the self-observation homework assignments to him. Explain to him that this is his indispensable contribution to the success of therapy. Remind him to jot down any image or thought that comes to his mind as soon as he notices even the slightest diminution of muscle tone. Add psychoeducation on emotions, if necessary. During sessions, comment on every detail that emerges. Keep in mind that all this, beyond giving us information, could solve the problem. If he becomes able to consciously observe what is happening in his mind at the moments of consciousness disorders, the consciousness disorders should disappear (Table 1.1).

Table 1.1

Enrico’s psychopathological problems

1.2 The Problem of the Diagnosis: The Crisis of Current Nosography

Why begin a manual with such a complex case? Should not a manual deal with patients whose diagnosis and pathology are well defined, permitting a detailed and reproducible description of the therapeutic intervention?

The fact is that Enrico’s complexity is no exception. On the contrary, patients with a single, well-defined diagnosis are an exception. Among the patients treated at the Third Center, those who satisfy the criteria for the diagnosis of a single personality disorder constitute a minority of around 35%. Some 37% have at least two diagnoses, 16% satisfy the criteria for three personality disorders, and 12% have more than three diagnoses. Furthermore, the data of our sample are in line with those reported in the literature (Zimmerman, Rothschild, & Chelminski, 2005). We find similar percentages when we consider the comorbidities between personality disorders and symptomatic disorders (Axis I of the DSM up to IV-TR; APA, 2000). These percentages are too widespread to be attributable to error or to inadequate diagnostic criteria. They challenge the very idea of a psychiatric nosography based on separate, clearly demarcated categories. As far as personality disorders (PDs) are concerned, the problem of comorbidity and co-occurrence has dominated the nosographic debate in recent years, to such an extent that anyone who has followed the debate cannot escape a sense of weariness at the idea of still having to deal with it. Yet, it is necessary to discuss the problem, for it is still found, alive and unsolved, in a multitude of real cases like that of Enrico.

1.2.1 The Two Classifications of Personality Disorders in DSM-5: Advantages and Limitations

The current DSM-5 (APA, 2013) has given us a twofold nosography of PDs, neither of which fully convinces the experts of the sector. The official nosography has remained identical to that of DSM-IV-TR (APA, 2000), in which a personality disorder is defined as an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment. PDs have been subdivided since DSM-III into ten diagnostic categories, which in turn are grouped into three clusters: cluster A (eccentric and odd), comprising schizoid, schizotypal, and paranoid disorder; cluster B (dramatic), comprising borderline, histrionic, narcissistic, and antisocial disorder; and cluster C (anxious), comprising dependent, avoidant, and obsessive-compulsive disorder. An official nosography that has outlived itself, considering the critiques and findings that in recent years have demolished its two cardinal points, namely, the stability and demarcation of the diagnostic categories.

Although a PD is, by definition, a stable pattern, stability does not appear to be an attribute of the categorical diagnoses. Patients who receive a diagnosis do not stay within the diagnostic category but fluctuate during their lifetime, entering and leaving one or more categories (Fossati et al., 2000). What do appear to be stable are some basic maladaptive traits that underlie these fluctuations (for a discussion, see Clark, 2005, 2007).

An even more serious problem for the credibility of the official nosography is its inability to delimit the diagnostic categories. As we mentioned, some 60% of patients with a PD receive a diagnosis of at least one other PD, and similar percentages of comorbidity are recorded with symptomatic disorders (Clark, 2007). Now, since personality is single by definition, the idea that an individual can simultaneously have two or more disordered personalities is, at the very least, bizarre.

Precisely the difficulty of defining the boundaries of the categories led to the proposal of a classification based on dimensional concepts. According to this approach, the different facets of personality disorders can be described empirically on the basis of a hierarchically organized structure of dimensional traits. Thus, in Section III of DSM-5, we find an alternative model for PD diagnosis, consisting of a hybrid system, both categorical and dimensional. The inclusion of this diagnostic model has, in some respects, created a nosographic anomaly: a manual with two different systems of classification, both legitimately usable but both with an uncertain future.

Nevertheless, this model contains some important innovations. Perhaps the most important is Criterion A, which contains both a redefinition of the concept of personality disorder and a formulation of the general severity of the functioning of personality. Harking back to a proposal put forward by Livesley (2003), a personality disorder is defined as a disorder of the functions of the self and of interpersonal relations. The disorders of the self are divided into identity and self-direction disorders, while those of interpersonal relations include lack of empathy and difficulty in establishing intimate relationships. On these elements, the clinician must determine a level of severity on a Likert scale from 0 (no impairment) to 4 (extreme impairment) (Tables 1.2 and 1.3).

Table 1.2

Self in DSM-5 (APA, 2013)

Table 1.3

Interpersonal relationships (DSM-5 APA, 2013)

No doubt, the definition based on personality functions captures the essence of a personality disorder better than the stable pattern of the traditional classification. Furthermore, the DSM-IV categorical diagnosis, transferred into DSM-5, does not, in and of itself, provide any indication of severity, permitting cases with totally different levels of social functioning and subjective distress to fit into the same category.

While the new general definition of personality disorder may find an easy consensus, the aspect of the proposal that stirred the greatest opposition was the second criterion, Criterion B, which in the authors’ intentions was meant to mark the transition to a dimensional nosography. Under this criterion, the specific pathology of personality is described by means of a set of traits organized in five broad domains: negative affectivity, detachment, antagonism, disinhibition, and psychoticism. Each domain, in turn, is composed of several facets, for a total of 25. Thus, under the alternative model, a PD should be diagnosed, first, according to the degree of functional alteration of personality in the self and in interpersonal relations (Criterion A) and, subsequently, along the dimensions of the 5 major traits and 25 facets (Criterion B).

After these major criteria come those that define the pervasive and stable character of PDs (Criteria C and D) and the criteria for excluding a PD when there are other explanations of the pathology (Criteria E, F, and G).

In addition, specific combinations of alterations in functions and maladaptive traits delineate specific diagnostic categories. Six categories of the traditional classification are retained: antisocial, avoidant, borderline, narcissistic, obsessive-compulsive, and schizotypal PD. However, since the diagnosis is made first of all on the basis of dysfunctions and traits, and since there is ample scope for diagnosing a PD outside of these categories, it would not be mean-spirited to suspect that this hybrid presence was a transitory expedient devised by the DSM-5 taskforce in order to avoid unduly disorienting clinicians accustomed to the categorical diagnoses until the community became habituated to the new procedures, when it would then be possible to move over to a consistently dimensional system. And the problem has not been solved with the latest version of the International Classification of Diseases (ICD-11), it likewise a source of criticisms and discussions.

Ultimately, therefore, with the two diagnostic models existing side by side in the same manual, the choice of which model to use is left to clinicians (Tables 1.4 and 1.5

Table 1.4

Personality disorders in DSM-5

).

Table 1.5

DSM-5 alternative model for the diagnosis of personality disorders (section III- APA, 2013)

The criticisms essentially revolve around the idea that the alternative model cannot be used in daily clinical practice (Shedler et al., 2010). This critique has been framed in various ways, but we shall dwell on three arguments: (a) the excessive descriptive complexity in reaching a clear diagnosis, (b) the overly abstract nature of the dimensions and traits, and (c) the absence of a clear indication of treatment deriving from the diagnostic assessment.

For example, if a PID-5 assessment is administered to a patient with a diagnosis of borderline personality disorder, we would be able to highlight the traits that do not help us in the diagnosis but which might have a bearing on treatment, such as emotional lability, distractibility, and hostility. While DSM-IV obliged us to make a black-or-white choice, the new proposal set out in DSM-5 risks forcing us to produce a mere list of traits. That an antisocial patient is manipulative, deceitful, non-empathetic, and hostile is a truth acknowledged by all, but how these traits interact to produce some typical manifestations of that disorder cannot be deduced either from DSM-IV or from DSM-5. For that matter, the tools of assessment do not have scales of control for validity but are self-compiled by the patient. They are unusable in clinical practice for the less aware and more manipulative patients, such as those with antisocial disorder. Lastly, as will be explained and clarified below, it is not easy to establish when a personality trait takes on the status of a disorder. To be more explicit, we are required to treat patients in whom the disorder causes clinically significant malaise, but this is not the same as saying that the traits present or observed in a given patient are pathological in and of themselves. The problem, precisely, is the result of putting the statistical approach before the clinical approach, so that what is statistically significant has become clinically significant and not the reverse.

1.2.2 The Excessive Complication of the Diagnosis

The first argument goes more or less as follows: clinicians are accustomed to observing the constellation of symptoms and to framing, accordingly, categorical diagnoses for use in formulating treatment as a convenient vehicle of communication among colleagues. Compared with this culture, the procedures of the alternative model, with the assessment of self and relational dysfunctions and subsequent evaluation of the facets, are too long and complex and difficult to communicate. If one sought to impose them, most likely they would remain a dead letter; they simply would not be used, and diagnoses would be made hurriedly in the blink of an eye. What is more, this would entail an even more serious risk: that of seeing personality disorders vanish from the cultural horizon of psychiatrists and clinical psychologists. There are some grounds for these observations, but if one were convinced of the validity of the contents of the alternative model, the proper course would be to fight this attitude openly rather than to forgo a valid nosography. To be sure, it would be desirable to have available such clear diagnoses that merely uttering their names would convey significant clinical information, but what is one to do when reality does not correspond to desire? Try to transmit the clinical information concerning Enrico’s case with a simple diagnostic label and you will find that significant aspects will be lost immediately. Rapidity of diagnosis and simplicity of communication are ideals to be pursued, but not to the point of sacrificing accuracy and informational content.

1.2.3 Which Dimension to Consider? Personality Traits

If the first argument is weak, the second most certainly is not: the traits that ought to describe the fundamental aspects of personality are too general to be of practical use in clinical work. This theory, let us add, was born in the academic rather than the clinical sphere and has mainly been tested in that sphere (Shedler et al., 2010).

The clinician is interested primarily in the subjective experience of the patient. He wants to know what his patient concretely imagines, thinks, and feels; what are his purposes and his behaviors; how he sees himself and his relationships; and how all this practically affects his daily life. What information do we get from knowing, for example, that the patient has a high level of negative affectivity? For the clinician who comes across a study conducted with one of the main dimensional scales, research results that are usually summed up in a limited number – between three and five – general traits may well seem abstract. Proponents of the dimensional approach respond that these instruments have a hierarchical structure and that the general traits are composed of clinically interesting facets. If we consider, for example, the self-rating diagnostic tool inserted in DSM-5 to identify traits and facets, the Personality Inventory for DSM-5 (PID-5), we find that the facets, in turn, are constructed with the responses to questions that coincide largely with those that clinicians ask. The structure of the elements of lower order can therefore be used to trace detailed and clinically significant profiles of individual patients. The work to bridge the gap between clinical practice and dimensional concepts is feasible and could yield useful results. However, the very fact that the need is felt for a translation of the dimensions into clinical terms shows how far the problem is from solution.

1.3 From Diagnosis to Treatment

The preceding observations lead us to the most critical point of the alternative model and to the crux of this book: the difficulty of determining the treatment design based on diagnoses.

Given the way it is structured, the alternative model seems to lead not so much to a diagnosis as to a careful assessment of the individual case. While this is praiseworthy in many respects, it presents the problem of the indications of treatment. A diagnosis should identify a group of patients homogeneous enough to respond in a similar way to the same indications of treatment, while an overly complex diagnostic structure risks being unserviceable for this purpose. In reality, Clarkin and Huprich (2011) held a strong hand in stating that the latter model leaves the clinician without therapeutic indications.

There is a highly practical aspect that has remained largely implicit in this discussion. The attempt to shift to a decidedly dimensional classification came just as treatments of proven efficacy were being developed for the most closely studied diagnostic category, borderline personality disorder. Consequently, the doubt took hold among the experts that it was not worth giving up the categories just when the most widely discussed and studied of them began to be successfully treated. It is no coincidence that ICD-11, which eliminated the categories, leaving only a general diagnosis of PD, nonetheless envisages specifying whether the borderline subtype is present. Yet, even for borderline personality disorder (BPD) itself, we have the paradox that if, on the one hand, there is evidence that it constitutes a consistent, single diagnostic entity (Clarkin, Hull, & Hurt, 1993; Clifton & Pilkonis, 2007; Fossati et al., 2000; Sanislow, Grilo, & McGlashan, 2000), on the other hand, its frequent comorbidity with other PDs creates different subclasses of patients who display specific symptoms and problems and require a diversified structure of treatments (Critchfield, Clarkin, Levy, & Kernberg, 2008). Since the number of co-diagnoses with other personality disorders and specific functional factors, such as the capacity to recognize and regulate emotions (McMain et al., 2013), influences the outcome of the efficacious treatments, there is a widespread need to adapt the treatment of BPD to the specific and differing psychopathological configurations that this disorder presents.

This closes the circle, bringing us back to the initial problem that we sought to illustrate with the case of Enrico: how to structure effective treatments in the face of superimposed diagnoses and the consequent heterogeneousness of the psychopathology? We shall see how this problem can become an opportunity to better understand the nature of personality pathology. Now, before showing the positive side of the coin, we must introduce the pivotal concept of our work: metacognition (Table 1.6).

Table 1.6

Criticisms of DSM-5

1.4 The Diagnosis of Enrico

To allow readers to reflect on the comparison between the two diagnostic systems, we conclude the chapter with the diagnosis of Enrico according to the two models (Table 1.7).

Table 1.7

The diagnosis of Enrico

References

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Clark, L. A. (2007). Assessment and diagnosis of personality disorder: Perennial issues and an emerging reconceptualization. Annual Review of Psychology, 58, 227–258. https://​doi.​org/​10.​1146/​annurev.​psych.​57.​102904.​190200CrossrefPubMed

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Livesley, W. J. (2003). Practical management of personality disorder. New York: Guilford Press.

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Shedler, J., Beck, A., Fonagy, P., Gabbard, G. O., Gunderson, J., Kernberg, O., et al. (2010). Personality disorders in DSM-5. American Journal of Psychiatry, 167(9), 1026–1028. https://​doi.​org/​10.​1176/​appi.​ajp.​2010.​10050746Crossref

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© The Author(s), under exclusive license to Springer Nature Switzerland AG 2021

A. Carcione et al. (eds.)Complex Cases of Personality Disordershttps://doi.org/10.1007/978-3-030-70455-1_2

2. Knowing the Mind

Antonino Carcione¹  , Livia Colle¹, ² and Antonio Semerari¹

(1)

III Centro di Psicoterapia Cognitiva, Rome, Italy

(2)

Department of Psychology, University of Turin, Turin, Italy

Antonino Carcione

Email: [e-mail]

Keywords

MetacognitionMentalizationTheory of mindMonitoringDifferentiationIntegrationDecentrationMastery

2.1 Meta-Representation

As long as scientific psychology was behaviorist, it could not concern itself with how human beings developed a knowledge of their own minds. Behaviorists had enthusiastically signed on to the central methodological principle of logical neopositivism. This tenet decreed that a scientific theory must be constructed in a language whose propositions are verifiable through direct observation or logical proof. Every other affirmation was considered meaningless. In psychology, this meant that theories that referred to something unobservable, such as representations, had to be excluded from scientific discourse. If it was not possible to talk scientifically about representations and thoughts, it was beyond imagination that one could talk about thoughts on thoughts, or rather meta-representations. It took a revolution, the cognitive revolution , to give dignity to the everyday experience in which behavior is driven by representations that we call goals and desires and is regulated by other representations that we call beliefs. Cognitivists, however, in their enthusiasm for the triumphant revolution and their fascination with the intelligence of machines neglected, for a while, the fact that human beings, in addition to producing representations, also reflect on them, just as they reflect on the representations that they attribute to others. These reflections on thoughts, as well as mental states in themselves, have an enormous importance in determining our behavior and our social lives.

To tell the truth, this problem, despite its importance, was left to simmer on a sort of back burner in the fields of developmental psychology and the psychology of learning. Initially, it was developmental psychology that signaled the importance of knowing how to observe and come to know one’s own mental processes, a capacity that Flavell defined as the capacity to think about thoughts or also metacognition (Flavell, 1979). From these initial observations, developmental psychologists concentrated on studying, seriously and modestly, how metacognition influenced learning, by asking, for example, How does what children know at various ages about how their memory works influence their learning? This brought them very close to the heart of a more general problem: In what ways do our attempts to know our mental contents and processes actually structure our minds themselves, in a way that makes us typically humans?

Paradoxically, the importance of the problem was highlighted by a question posed by primatologists. In 1978, Premack and Woodruff, after describing the exploits of a most intelligent chimpanzee, posed a question to the scientific community, which became the title of an article they wrote: Does the chimpanzee have a theory of mind? This pioneering work posed the question of what allowed primates to have a complex and articulated social life, more like that of human beings than that of their other fellow mammals. Chimpanzees live in groups according to a very complex hierarchical social organization. They hunt in groups, communicate with each other with a rich repertory of gestures and actions, and develop privileged and more intimate relationships with some conspecifics with whom they engage in various purely social activities. The intention of Premack and Woodruff, therefore, was to understand whether these complex social skills of primates were based on a cognitive capacity, a way of thinking, which enabled them to interpret and predict behavior, thanks to the attribution of mental states. In other words, if they could formulate, in their internal language, an analysis and a prediction of behavior based on the attribution of intentions, desires, and emotions, along these lines: "Male Beta would like to go to