Interpersonal problems stem mostly from predictions arising from earlier formative relational experience. For example, neglect during childhood leads us to predict that others will neglect us when we have emotional needs. Patients expect that some of their innermost wishes will remain unmet by the others. This is an idea at the core of the large majority of psychotherapeutic orientations. Just as an example, Cognitive Analytic Therapy (CAT, Ryle & Kerr, 2020), Schema Therapy (Young et al., 2003), Transference Focused Therapy (Clarkin et al., 1999) and my own model, Metacognitive Interpersonal Therapy (MIT, Dimaggio et al., 2015; 2020) share this view.

Such wishes are relevant as they have been evolutionarily selected, and failing to meet them meant to our ancestors risking starvation, physical integrity, failing to mate and, ultimately death (Liotti & Gilbert, 2011). Examples of those wishes are: the need to be cared for when in pain, i.e. attachment (Bowlby, 1969/1982); social rank, which grants order of access to limited resources (Gilbert & Irons, 2005); exploration and autonomy, which are activated when the individuals need to find new resources such as food, lands, and refuges when necessary; caregiving, aimed at protecting the breed; sexuality, in its more complex form which is more than mere mating, and refers to forming stable bonds filled with intimacy; and group belonging, which increases the odds of being protected from predators and outgroups and to reach shared goals the individual would be unable to meet if left alone.

Due to a mixture of temperament, developmental history and cultural influences, individuals develop predictions of how others will react when they try to fulfil their wishes. A couple of examples may help. In the domain of attachment the individual can predict that ‘If I ask for care the other will be unavailable’. As a consequence, she forms a core self-concept such as ‘I am unlovable’. In the domain of social rank the prediction can sound like: ‘If I seek appreciation the other will scorn me and ridicule me’, which leads the individual to harbour the idea that ‘I am inferior and unworthy’. In the domain of exploration a typical negative prediction sounds like: ‘If I try to learn something, I will need resources that the other will not provide me with’, which leaves the individual with a core concept of ‘I am powerless and stuck’.

Due to those predictions, individuals tend to experience suffering and act in order to protect themselves from the psychological pain arising from both the negative view of themselves they endorse and the reactions from the others they fear. A person with a core self-concept such as ‘I am unworthy’ will be more prone to experience shame and sadness and as a consequence to become perfectionistic, to avoid social exposure and will be keen to adopt maladaptive coping strategies such as alcohol or drug abuse in order to soothe a pain he is unable to soothe in other ways.

What is the target of psychotherapy in the light of such ideas? I maintain here that three ingredients are necessary:

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1. changing perspective. If individuals suffer from their predictions, they need to try and view themselves and the world from a different angle. Psychotherapy therefore is about helping individuals to form or bring to light alternative predictions about the fate of their own wishes.

2. in order to change perspective hope is needed. It does not mean thinking unrealistically that others will be always there for us, praise us and sustain our efforts. It is about having an underlying, albeit minimal, idea that we are not doomed to fail and that others will respond as we wish.

3. in order to change perspective and sustain hope, committed action is necessary. There is no point thinking that personality disorder-type problems will change only because we have developed a new and more adaptive set of ideas. They will not truly change the way they see themselves, the others and the world only by talking with their therapist if, once home, they sit on the sofa, ruminate about past relational problems, worry about the future or dwell on their anger about having been mistreated. Change comes to life out of sustained behavioural efforts to alter one’s set of ideas held for a lifetime, and discover how alternative views are possible.

I will now describe how clinicians can implement these elements with a (fictionalised) case history, so to give a sense of their pragmatic application.