Atlas›Domain II · Behavioural & cognitive›Guide 085
Guide II-085

Cognitive-evolutionary psychotherapy

Giovanni Liotti1983Rome
A 47 · L 39 · M 1416 interventions in the Trinity explorer
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[source: …] where a claim comes from[uncertain] not confirmed in a primary source[synthesis] the writer's reconstruction

1. Introduction

Version followed: Giovanni Liotti's cognitive-evolutionary psychotherapy (psicoterapia cognitivo-evoluzionista, the Rome "relational turn" in cognitive therapy). This guide follows Farina & Liotti's 2018 account of the approach, the alliance and AIMIT work of Liotti & Monticelli (2008, 2014) and Fassone et al. (2012), Ivaldi's (2004) clinical use of the drama triangle and the dual individual-plus-group setting, and the multiple integrated treatments of Liotti, Cortina & Farina (2008). The approach is taught through the APC/SPC postgraduate schools in Rome. [source: Farina & Liotti 2018; Ivaldi 2004; Fassone et al. 2012] [uncertain: the APC/SPC training role comes from the job codebook and is not verified]

Sources and status (read first): this guide draws on these sources:

  • Farina & Liotti's 2018 review of the approach (full text) and the FrancoAngeli abstract of its companion article.
  • The abstract of the AIMIT reliability study (Fassone et al. 2012) and an AIMIT single-case study (Monticelli et al. 2018).
  • Ivaldi's 2004 clinical paper on the drama triangle (full text).
  • Cortina's 2018 account of Liotti's clinical practice and van der Hart's 2018 review (full texts).
  • The ISSTD obituary, the abstract of Liotti (2013) and the publisher description of Liotti & Monticelli (2014).

Verified: the motivational-systems theory and the five systems the AIMIT codes; the cooperative stance; the drama triangle and controlling strategies; building safety before trauma work; the dual (individual plus group) and two-therapist settings; and handling impasses through the contract.

Further reading (not drawn on): Liotti's books (Le opere della coscienza, the AIMIT manual, Sviluppi traumatici, and Teoria e clinica dell'alleanza terapeutica beyond its description) and the full texts of Liotti 2004, Liotti 2011, Liotti & Gilbert 2011 and Liotti, Cortina & Farina 2008. Claims resting only on these stay [uncertain]. The sources describe no fixed protocol, so phase boundaries and most step sequences remain [synthesis].

What it is. It is an approach to psychotherapy, not a manualised protocol. Farina & Liotti (2018) present it on three linked levels (a general psychological theory, a theory of pathogenesis and a theory of cure) and define no session plan. It grew out of Italian cognitive therapy: Guidano & Liotti (1983) proposed attachment theory as the developmental frame for cognitive therapy. It reads psychopathology and the therapy relationship through interpersonal motivational systems (IMS), which are evolved, innate social motivations. Session research codes five of them: attachment (care-seeking), caregiving, rank (dominance and submission), sexuality and peer cooperation. Older defence systems against threat sit beneath them. Attachment theory is central, especially disorganised attachment and its link to dissociation. [source: Farina & Liotti 2018; Fassone et al. 2012; ISSTD obituary 2018]

How change happens.

  • Where the problem starts: disorganised early attachment occurs when the caregiver is frightened or frightening, so the caregiver is both the source of fear and the solution to it. This leaves implicit, multiple and incompatible models of self and other. Liotti described these models with Karpman's drama-triangle roles of persecutor, rescuer and victim, all learned from attachment figures.
  • How it shows up later: when the attachment system is activated in adult distress, including toward the therapist, these implicit models are reactivated. Integration, synthesis and metacognition then break down, which produces dissociation, dysregulation and therapeutic crises.
  • What changes it: therapy moves its motivational basis away from the patient's attachment to the therapist and toward cooperation between peers. Steady, equal, attuned sharing calms the attachment and defence systems and creates the conditions for metacognition. The relationship also acts as a corrective relational experience in itself.
  • What the therapist does: monitor which motivational systems are active and repair ruptures. This is the main vehicle of change, and cognitive and trauma work rests on it.

[source: Farina & Liotti 2018; Cortina 2018; Ivaldi 2004; ISSTD obituary 2018; van der Hart 2018]

2. Framework

The sources describe no fixed session count, no manualised phases and no formal criteria for moving between phases. Farina & Liotti (2018) describe levels of theory and two treatment strategies: a cooperative relational stance, and integrated treatment across several settings. [source: Farina & Liotti 2018]

  • Format and length: usually individual and weekly. The one published AIMIT single case ran 24 weekly sessions over about eight months. [source: Monticelli et al. 2018] [uncertain: the sources do not state a typical length; severe trauma-related presentations probably need longer]
  • Combined settings: for borderline and dissociative patients, the individual setting can be combined with a group (dual setting) or with a second individual therapist (multiple integrated treatment). [source: Ivaldi 2004; Farina & Liotti 2018; Liotti, Cortina & Farina 2008]
  • Order of work: Cortina describes Liotti first helping patients feel safe, regulate emotion and feel empowered, including psychoeducation about the effects of trauma, and exploring the trauma only afterwards. [source: Cortina 2018]

The phase structure below organises this material. Its stage boundaries and transition criteria are [synthesis].

Phase 0–1: Assessment and motivational case formulation (about 3–6 sessions [synthesis])

  • Goals:
    • Assess the referral and the request: who wants treatment, any external obstacles, possible sabotage, and whether the motivation is the patient's own. Also assess family and economic context and choose the setting (outpatient or residential).
    • Map symptoms, history and the motivational systems that dominate the patient's relationship episodes.
    • Assess attachment history (losses, trauma, frightened or frightening caregiving) and controlling strategies (punitive or caregiving), and screen for dissociation.
    • Agree a contract: roles, limits, setting rules, mutual commitments and goals. Decline unrealistic or "magical" requests.
    • Pace the formulation: Liotti could keep a disorganised-attachment hypothesis to himself at first and agree a narrower shared goal, so as not to activate attachment or antagonism.
    • [source: Ivaldi 2004; Cortina 2018] [ordering: synthesis]
  • Move on when there is a shared formulation or working goal that the patient recognises, explicit agreed goals, and agreed setting rules (frequency, contact between sessions, crisis plan). [synthesis]

Phase 2: Building cooperative alliance and stabilisation (open-ended; often several months for severe presentations [synthesis])

  • Goals:
    • Make cooperation the working base of the relationship. Explaining the model and your role activates it from the start. Full, informed cooperation between equals is a later achievement.
    • Limit premature activation of attachment toward the therapist.
    • Recognise and repair ruptures.
    • Build safety, emotion regulation and a sense of empowerment, with psychoeducation about trauma.
    • Contain dangerous behaviour and dissociative collapse with containing interventions.
    • In severe cases, set up and coordinate a second setting (a group or a second therapist).
    • [source: Ivaldi 2004; Cortina 2018; van der Hart 2018; Farina & Liotti 2018]
  • Move on when:
    • the patient can usually notice and name shifts in the relationship;
    • ruptures are repaired within the session or the next one;
    • dissociation in session is manageable;
    • self-harm and crisis behaviour are contained.
    • [synthesis]

Phase 3: Work on internal working models and traumatic memory

  • Goals:
    • Link present relational patterns to attachment history and to implicit relational knowledge, not only to explicit beliefs.
    • Build metacognition about multiple, contradictory self–other representations, such as the drama-triangle roles.
    • Explore traumatic and unresolved memories.
    • Integrate dissociated states.
    • [source: ISSTD obituary 2018; Cortina 2018; Farina & Liotti 2018]
    • Work within the window of tolerance. [synthesis: this wording is not from the sources]
  • Move on when there is:
    • a more coherent autobiographical narrative;
    • fewer drama-triangle enactments in and out of therapy;
    • more flexible use of the motivational systems (cooperation, appropriate care-seeking and caregiving, non-destructive competition).
    • [synthesis]

Phase 4: Consolidation and ending

  • Goals: generalise the new relational patterns. Work through the ending as an attachment separation, since loss re-activates the attachment system. Taper or coordinate the end of any parallel treatments.
  • Criteria: patient-led sense of sufficiency, and stability across a planned tapering period [synthesis].

3. Guiding principles

Sources are given for each principle below. The one-line practical meanings are [synthesis].

  • Motivation comes before cognition. Practical meaning: before you interpret what a patient believes, ask which motivational system is active: seeking care, caring for someone, competing, cooperating, seducing or defending. [source: Farina & Liotti 2018; Fassone et al. 2012]
  • The relationship is a specific therapeutic tool. Farina & Liotti call it a corrective relational experience in itself, and necessary with difficult patients. Practical meaning: give the here-and-now relationship equal or greater weight than content work. [source: Farina & Liotti 2018]
  • Peer cooperation is the working base of the alliance. Practical meaning: frame the work as two equals looking together at the patient's experience, with explicit shared goals. Keep up "la costante condivisione paritetica" (constant sharing on an equal footing). [source: Farina & Liotti 2018; ISSTD obituary 2018]
  • Cooperation supports metacognition, and attachment overload and rank undermine it. Practical meaning: when reflective capacity collapses, restore cooperation before you push for insight. [source: Farina & Liotti 2018; Monticelli et al. 2018; Prunetti et al. 2008 as reported by Cortina 2018]
  • Avoid activating the patient's attachment to you too early. With traumatised patients, an empathic focus on painful feelings can activate attachment, while task-focused, cooperative comments often support mentalizing better. Practical meaning: offer steady, non-intrusive availability. Don't over-rescue, which feeds the rescuer–victim roles, and don't withdraw, which feeds abandonment. [source: Cortina 2018; van der Hart 2018 quoting Cortina & Liotti 2014]
  • Motivational systems pull each other. Practical meaning: the patient's active system tends to pull the matching one in you, for example rank pulls rank and attachment pulls caregiving. Notice the pull and choose your response. Therapists can end up colluding with a patient's dysfunctional interpersonal schemas. [source: Farina & Liotti 2018] [the wording about pulls: synthesis]
  • Read countertransference as your own motivational activation. Practical meaning: name to yourself which system your emotion signals (irritation suggests rank, an urge to protect suggests caregiving, attraction suggests sexuality, fear suggests defence). Know which drama-triangle role you tend to take. [source: Ivaldi 2004] [emotion-to-system mapping: synthesis]
  • Ruptures and impasses are shifts out of cooperation. Practical meaning: treat each one as information about which system took over and whether you colluded. Repair it by re-establishing shared goals. [source: Farina & Liotti 2018]
  • Stay outside the drama triangle. Practical meaning: don't accept the rescuer role. Respond from a position from which you and the patient can observe the triangle and talk about it. [source: Ivaldi 2004]
  • Dissociation is a failure of integration rooted in disorganised attachment. Practical meaning: expect sudden state shifts, gaps and contradictions. Build safety and stability before trauma work. [source: Farina & Liotti 2018; Cortina 2018]
  • Controlling strategies are protections, not resistance. Practical meaning: treat a patient's dominating (punitive) or caretaking behaviour toward you as a learned way to keep attachment disorganisation at bay. Expect both strategies in the same patient. [source: Cortina 2018; van der Hart 2018]
  • Spread the attachment load in severe cases. Practical meaning: with borderline or dissociative patients, consider a group setting or a second, coordinated therapist, so that one dyad doesn't carry the whole load. [source: Ivaldi 2004; Farina & Liotti 2018; ISSTD obituary 2018]
  • Be transparent, and treat the contract as common ground. Practical meaning: explain the model, the process and your role, which activates cooperation. In conflicts, return to the agreed contract as neutral ground. [source: Ivaldi 2004]
  • The therapist is fallible. Practical meaning: acknowledge your own part in ruptures openly. Doing so calms rank competition and models cooperation. [synthesis, consistent with Farina & Liotti's citation of Safran & Muran]

4. Intervention inventory

Cognitive-evolutionary therapy has no separate catalogue of named techniques. Its interventions are relational procedures described across the writings of Liotti and his colleagues, plus the cognitive and trauma-informed methods it absorbs. Each entry below marks what is documented in the sources with [source: …] and this guide's own operationalisation with [synthesis]. Claims that rest only on books not drawn on stay [uncertain]. All example language is illustrative, not quoted from the authors.

4.1 Motivational case formulation

  • Purpose / when: at intake and whenever therapy stalls. It builds a map of which interpersonal motivational systems organise the patient's problem episodes. [source: Farina & Liotti 2018; Fassone et al. 2012] [uncertain: Liotti 2001/2005]
  • Steps:
    1. Collect 3–5 concrete recent relationship episodes: who was involved, what happened, and what the patient felt, wanted and did.
    2. For each episode, code the dominant system: attachment (seeking closeness or protection), caregiving, rank (dominance or submission, shame or pride), sexual, peer cooperation, or defence (fight, flight, freeze, collapse).
    3. Note the emotion typical of each system. Fear and loneliness go with attachment; shame, humiliation or anger with rank; guilt or compassion with caregiving.
    4. Look for repeating sequences, for example an attachment need, then fear of rejection, then a switch to rank control.
    5. Gather attachment history: losses, trauma, frightened or frightening caregivers, and role reversal with parents.
    6. Write a short formulation that links past attachment experiences, current motivational patterns and symptoms.
    7. Share it in plain words, at a pace the relationship can bear. Liotti sometimes kept a disorganised-attachment hypothesis to himself early on and agreed a narrower practical goal instead. [source: Cortina 2018]
    • [steps 1–6: synthesis]
  • Example language (illustrative): "When your partner was late, it sounds like the first thing you felt was fear of being left. Then, very fast, you were angry and in charge. Does that sequence feel familiar?"
  • Watch for / working when: the patient recognises the pattern in new episodes without your help. Be wary of a formulation the patient agrees with only to please you, because that agreement is itself caregiving or submission.

4.2 Moment-to-moment monitoring of motivational systems in session (AIMIT-informed listening)

  • Purpose / when: throughout every session. It detects which system is active in the patient's speech and in the exchange.
    • What the AIMIT is: the Assessing Interpersonal Motivations in Transcripts, a research coding method. Trained raters code the patient's units of transcribed dialogue (an utterance plus the other person's reply) for verbal indicators of five systems: attachment, caregiving, rank, sexuality and peer cooperation. They keep relationships narrated from outside therapy separate from those enacted in the session, and they code transitions between systems.
    • Why it matters clinically: Farina & Liotti present monitoring of motivational systems as a way to track the quality of the alliance and to spot impasses and ruptures in real time.
    • How clinicians use it: clinicians in this school use the AIMIT categories to train their listening. It is not a scale to administer in session.
    • [source: Fassone et al. 2012; Monticelli et al. 2018; Farina & Liotti 2018] [uncertain: the exact indicator list in the AIMIT manual (Liotti & Monticelli 2008) is not verified]
  • Steps:
    1. Listen for markers of each system:
      • attachment: requests for help, comfort or reassurance;
      • caregiving: offers of help, concern for others or for you;
      • rank: comparison, judgement, challenge, shame, submission or self-devaluation;
      • sexual: seduction or an erotic tone;
      • cooperation: shared goals, "we", negotiation, joint curiosity.
    2. Note when the system shifts, especially away from cooperation. Note also whether the episode is narrated or happening between you now.
    3. After the session, review two or three moments when the system shifted and what came just before each. Recording sessions, with consent, helps.
    • [steps: synthesis]
  • Example language (illustrative): usually silent. If voiced: "I notice that in the last few minutes we moved from exploring this together to you asking me to tell you whether you did the right thing."
  • Watch for: over-coding, that is, labelling every sentence. Use the coding to guide your next move, not to lecture.

4.3 Therapist self-monitoring of own motivational activation

  • Purpose / when: continuously, and especially when you feel a strong pull such as irritation, an urge to rescue, boredom, attraction or fear. It stops you enacting the complementary role. Farina & Liotti note that therapists can collude with the patient's dysfunctional interpersonal cycles. Ivaldi advises knowing your own preferred drama-triangle role, so you can notice it before it is activated. [source: Farina & Liotti 2018; Ivaldi 2004]
  • Steps:
    1. Notice your emotion and your urge to act.
    2. Identify the system it belongs to:
      • wanting to win or prove a point suggests rank;
      • wanting to soothe or fix suggests caregiving;
      • wanting to withdraw or protect yourself suggests defence;
      • attraction suggests sexuality.
    3. Ask which drama-triangle role you are being pulled into, and which role you tend to slip into anyway.
    4. Ask what in the patient's behaviour invited it.
    5. Choose a response that offers cooperation rather than the complementary role.
    6. Take the pattern to supervision.
    • [steps: synthesis]
  • Example language (illustrative, internal): "I'm getting drawn into proving I'm competent. That's rank. Step back and get curious with them."
  • Watch for / working when: escalating exchanges become rarer, and you can name your pull before acting on it.

4.4 Fostering peer cooperation (the cooperative alliance)

  • Purpose / when: from the first session onward, and after every rupture. It activates the cooperative system so that defence, attachment overload and rank calm down and reflective work becomes possible. [source: Farina & Liotti 2018; Ivaldi 2004; Cortina 2018]
  • Steps:
    1. Explain the model, how therapy will proceed and what your role is. Ivaldi notes that this activates the cooperative system from the start.
    2. Make goals explicit and choose them together. With patients whose attachment is easily triggered, a narrower practical goal may work better than an ambitious one. In Liotti's case of "Sara", the shared goal was managing her conflicts with her parents and husband rather than exploring trauma.
    3. Treat the patient's account and symptoms as real, and engage the patient as an equal.
    4. When attachment is easily triggered, prefer task-focused, collaborative comments to intense empathic statements. In a pilot study, borderline patients mentalized better after neutral, task-focused comments (Prunetti et al. 2008).
    5. Look at the problem together as a shared object, and ask for the patient's view of what helps. Share decisions about the setting.
    6. Expect early cooperation to be compliant or therapist-directed. Full, informed cooperation between equals comes later.
    • [source: Ivaldi 2004; Cortina 2018] [ordering: synthesis]
  • Example language (illustrative): "Let's look at this together, as if we were both studying it. You know it from the inside and I can offer an outside view. What do you notice first?"
  • Watch for / working when: the patient brings material on their own initiative, disagrees with you safely, uses "we", and makes more reflective statements in session. A patient who only complies (submission) is not yet cooperating.

4.5 Regulating attachment activation toward the therapist

  • Purpose / when: when the patient seeks comfort, contact, reassurance or extra sessions, or shows fear of abandonment. This is common around breaks and endings.
    • Liotti (2013) describes a phobia of attachment and a phobia of losing attachment, which often coexist in the same traumatised patient. This explains contradictory approach–avoid behaviour toward the therapist.
    • The aim is to limit premature activation of attachment toward the therapist without rejecting the patient's care-seeking.
    • [source: Liotti 2013 (abstract); van der Hart 2018 quoting Cortina & Liotti 2014; Ivaldi 2004]
  • Steps:
    1. Validate the need as legitimate.
    2. Offer predictable, bounded availability with rules agreed in advance, such as when and how to contact you. Ivaldi notes that the therapist may temporarily act as an attachment figure whose secure responses can correct insecure models.
    3. Avoid over-rescuing: crossing the setting, excessive reassurance, or a caregiving stance that exhausts you. Avoid cold distancing too.
    4. Once the immediate need is met, move to cooperative reflection on what happened.
    5. Prepare breaks in advance: dates, cover arrangements and a transitional plan.
    • [source: Ivaldi 2004; van der Hart 2018] [steps: synthesis]
  • Example language (illustrative): "It makes sense that you want more contact when things are this hard. Here's what I can reliably offer. Then let's look together at what makes the gap between sessions so frightening."
  • Watch for: sudden switches to anger, numbing or confusion after closeness, which signal disorganised activation. If they appear, move to 4.8 and 4.11.

4.6 Recognising and working with controlling strategies

  • Purpose / when: use this when the patient shows one of two consistent patterns:
    • controlling-punitive: dominates, criticises or punishes the therapist, a power struggle drawing on the rank system;
    • controlling-caregiving: looks after the therapist, a role reversal.
    • These strategies, described from Main & Cassidy (1988) onward, develop by school age. They compensate for disorganisation in the child–parent relationship, and the same patient often shows both. [source: Cortina 2018; van der Hart 2018 citing Liotti 2011 and 2016]
  • Steps:
    1. Recognise the pattern across several sessions.
    2. Don't dominate back, and don't accept the caretaking.
    3. Gently name the pattern as protective rather than as a fault.
    4. Explore when it started and what it guards against.
    5. Expect that softening the strategy may bring out attachment distress or dissociation, and pace the work accordingly.
    6. If a caretaking patient suddenly turns angry, or the reverse, don't be thrown and don't placate. Explore the movement between the two positions with the patient. [source: van der Hart 2018 citing Steele et al. 2017]
    • [steps 1–5: synthesis]
  • Example language (illustrative): "I've noticed you often check whether I'm tired or OK before you talk about yourself. I wonder if looking after others has been a way to stay safe for a long time."
  • Watch for: distress may rise briefly as the strategy loosens, which is expected. If naming the pattern brings shame, slow down and normalise it.

4.7 Recognising and not enacting the drama triangle

  • Purpose / when: with disorganised or traumatised patients who switch between seeing you, or themselves, as persecutor, rescuer and victim.
    • Liotti used Karpman's (1968) drama triangle to describe the multiple, incompatible self–other models learned from disorganising attachment figures. These models are re-enacted when attachment is activated.
    • Ivaldi (2004) turned the triangle from a way of describing into a therapeutic tool.
    • A typical double message is an open request for help alongside an implicit message that you cannot help.
    • [source: Ivaldi 2004; Cortina 2018] [uncertain: Liotti's 1999 and 2004 originals]
  • Steps:
    1. Track which role the patient puts you in and which role they take.
    2. Notice the pull to fit the role. The rescuer role is the usual way in, so know your own preferred role.
    3. Respond from outside the triangle, from a position where you can both observe it and talk about it.
    4. When the patient can reflect, explain the triangle as a shared tool for observing the shifting roles. Ivaldi treats the explanation itself as therapeutic.
    5. Link the roles to early caregiving relationships.
    6. In a dual setting, use the group and the other therapist to observe the roles from a third position.
    • [source: Ivaldi 2004] [step order: synthesis]
  • Example language (illustrative): "Last week I felt like the one who would save you, and today I seem to be the one hurting you. Could we look at how quickly those roles change, without either of us having to be the villain?"
  • Watch for:
    • Naming the pattern too early can feel like an accusation, which is persecution. Name it only once cooperation has been restored. [synthesis]
    • Ivaldi observes that stalls and dropouts arise mainly when the therapist has entered the triangle. [source: Ivaldi 2004]

4.8 Rupture recognition and repair through metacommunication

  • Purpose / when: at two kinds of rupture:
    • withdrawal ruptures: going silent, agreeing superficially, changing topic, cancelling;
    • confrontation ruptures: attack, complaint, devaluing.
    • Farina & Liotti present real-time monitoring of motivational systems as a way to catch impasses and ruptures early. That includes the patient leaving cooperation by starting a problematic interpersonal cycle, and the therapist colluding with that cycle. They cite Safran & Muran on negotiating the alliance.
    • Liotti & Monticelli (2014) make building the alliance from the first sessions, and repairing it after crises, the core clinical task.
    • [source: Farina & Liotti 2018; Liotti & Monticelli 2014 (publisher description)]
  • Steps:
    1. Notice the marker.
    2. Identify the system that has taken over: rank, attachment or defence.
    3. Step back from the complementary response.
    4. Metacommunicate: describe what is happening between you now, tentatively and from your own side.
    5. Acknowledge your own part where there is one.
    6. Explore the patient's experience of the moment.
    7. Renegotiate tasks or goals and return to cooperation. Where a contract exists, use it as common ground. [source: Ivaldi 2004]
    8. Later, link the episode to the formulation.
    • [steps: synthesis, following Safran & Muran's sequence]
  • Example language (illustrative): "I think something I said a moment ago landed badly. I may have sounded like I was judging you. Can we look at what happened just now?"
  • Watch for / working when: the patient returns to engaged dialogue that isn't merely compliant, and later refers back to the repaired moment. A string of unrepaired ruptures means you should review the case in supervision.

4.9 Declining rank competition

  • Purpose / when: when the patient challenges your competence, argues to win, devalues therapy, or slips into shamed submission. It keeps the rank system from taking over the relationship, because a contest for dominance shuts down reflection.
    • [source: Farina & Liotti 2018 (rank as an interpersonal motivational system); Cortina 2018 (the power-based controlling strategy, and Liotti's work on a patient's competitive battles with authority figures)]
    • [uncertain: the AIMIT manual and Liotti & Monticelli 2014]
    • [steps: synthesis]
  • Steps:
    1. Don't defend your status or argue the point.
    2. Acknowledge whatever is valid in the criticism.
    3. Turn the disagreement into a shared question.
    4. With submissive or shamed patients, avoid an expert stance and ask for their judgement.
    5. Watch for shame, the core emotion of losing in rank, and name it gently.
  • Example language (illustrative): "You may be right that this isn't working well enough yet. Rather than me defending it, let's work out together what would make it more useful."
  • Watch for: your own urge to prove yourself (see 4.3). Success shows when hostility softens into curiosity.

4.10 Fostering metacognition within cooperation

  • Purpose / when: once cooperation is established. It builds the ability to recognise mental states in oneself and others and to integrate contradictory views of self and other.
    • Farina & Liotti argue that cooperation supports empathy and metacognition.
    • In an AIMIT single case, cooperative activation correlated with metacognitive scores. The finding is correlational only.
    • This links to the metacognitive work of the same Rome group, later Metacognitive Interpersonal Therapy.
    • [source: Farina & Liotti 2018; Monticelli et al. 2018] [uncertain: Liotti & Gilbert 2011]
  • Steps:
    1. Pick a specific episode.
    2. Slow it down to identify the patient's emotions, wishes and thoughts.
    3. Invite hypotheses about the other person's mind.
    4. Contrast the different self-images the patient holds in different states.
    5. Ask the patient to notice which motivational system was active and how it shaped what they perceived.
    6. If reflective capacity collapses, go back to restoring cooperation (4.4) before continuing.
    • [steps: synthesis]
  • Example language (illustrative): "In that moment, what did you want from her? And what do you guess she was afraid of?"
  • Watch for: intellectual answers with no emotion, or sudden confusion or blankness, which may be dissociation (4.11).

4.11 Working with dissociative shifts in session

  • Purpose / when: when the patient blanks out, becomes confused, loses time, changes state abruptly or shows freeze or collapse, often as attachment material comes up.
    • Farina & Liotti understand dissociation as a Janetian loss of integration of higher mental functions, linked to disorganised attachment and trauma. It is set off when implicit attachment-related memories are reactivated.
    • [source: Farina & Liotti 2018; Cortina 2018]
    • [steps: synthesis drawing on standard phase-oriented trauma practice; the sources give no in-session protocol for dissociation]
  • Steps:
    1. Notice the shift: glazed eyes, a flat voice, losing the thread, a change of posture.
    2. Lower the intensity. Stop exploring the content and speak calmly and simply.
    3. Orient the patient to the present: the room, the date, your shared task, their feet on the floor.
    4. Re-establish cooperative contact by asking what they notice and what would help.
    5. Once the patient is stable, reflect together on what set off the shift.
    6. Adjust the pace of memory work.
    7. Agree a plan for dissociation between sessions.
  • Example language (illustrative): "It looks like you went somewhere far away just now. You're here with me in the room. Can you tell me one thing you can see? We'll come back to that topic only when you're ready."
  • Watch for: repeated dissociation means trauma processing is premature, so go back to stabilisation. If indicated, screen with a validated dissociation measure. Name the instrument, but don't reproduce its items.

4.12 Linking present patterns to attachment history (working models)

  • Purpose / when: in Phase 3, once cooperation holds. It reconstructs how early relationships shaped current motivational patterns and the self–other models behind them. It targets implicit relational knowledge, not only explicit irrational beliefs, and continues the developmental side of Guidano & Liotti (1983). [source: ISSTD obituary 2018; Farina & Liotti 2018]
  • Steps:
    1. Start from a current episode and its motivational sequence.
    2. Ask when the patient first felt that way, or who used to respond to them like that.
    3. Explore the early scene concretely while staying within the window of tolerance.
    4. Identify the model of self and other that formed there.
    5. Contrast that model with present relationships, including the relationship with you.
    6. Build a coherent narrative over time.
    • [steps: synthesis]
  • Example language (illustrative): "That expectation that people will turn on you as soon as you need them: where did you first learn it?"
  • Watch for: flooding or dissociation (see 4.11). If insight brings no change in how the patient relates, return to here-and-now relational work.

4.13 Trauma memory work within a phase-oriented frame

  • Purpose / when: unresolved trauma or loss, after stabilisation.
    • As Cortina describes Liotti's practice, the patient first learns to feel safe, regulate emotion and feel empowered, with psychoeducation about trauma's effects on brain and body. Only then is the trauma explored. [source: Cortina 2018] [uncertain: Liotti & Farina 2011]
    • Practitioners in this lineage pair it with various processing methods, for example EMDR or sensorimotor approaches. These are not specified here and are not Liotti's own technique. [synthesis]
  • Steps (exposure safety):
    1. Confirm stability: no active crisis, manageable dissociation, a reliable alliance, and coping skills in place.
    2. Get explicit informed consent. Explain the purpose, the expected temporary distress and the right to stop at any time, and agree a stop signal.
    3. Work in small, titrated pieces, alternating with grounding.
    4. Keep checking cooperative contact.
    5. Close each session with stabilisation and plan aftercare for the time between sessions.
    6. Pause, or don't start, if any of these are present: acute suicidality, uncontrolled self-harm or substance use, ongoing abuse, severe uncontrolled dissociation, or a ruptured alliance.
    • [synthesis]
  • Example language (illustrative): "We'll approach this memory a little at a time. You're in charge of the pace. If you raise your hand, we stop and come back to the room."
  • Watch for: rising dissociation, self-harm urges after sessions, and worsening nightmares. If these appear, slow down or go back to Phase 2.

4.14 Multiple integrated treatments (combined setting)

  • Purpose / when: severe borderline, dissociative or complex-trauma presentations where one therapist–patient pair cannot hold the attachment intensity. The sources describe two forms:
    • Dual setting: individual plus group therapy. It spreads affect across several figures and gives the patient a real third party (see 4.16).
    • Multiple integrated treatment: two therapists see the patient in separate, coordinated settings, so one can act as a stabilising figure when the relationship with the other is disrupted.
    • Aims: to modulate the activation of disorganised attachment memories while protecting the alliance, to protect the therapists, and to support metacognition.
    • [source: Farina & Liotti 2018; Ivaldi 2004; Cortina 2018; Liotti, Cortina & Farina 2008 (citation only); Liotti, Farina & Rainone 2005 (book) [uncertain]]
  • Steps:
    1. Agree the settings and roles at the start, with the patient's consent. Make sure the patient understands the distinct boundaries and goals of each setting.
    2. Stay in constant contact with the other therapist, and let the patient know you do.
    3. Keep the relationship between therapists open and collaborative, with a shared formulation and regular meetings.
    4. Agree who handles crises and medication.
    5. Expect splitting, with one clinician idealised and another devalued. Read it as the drama triangle spread across settings, and coordinate replies so that no one enacts rescuer or persecutor.
    6. Taper in a coordinated way.
    • [source: Farina & Liotti 2018 for steps 1–3] [steps 4–6: synthesis]
  • Example language (illustrative, to the patient): "You'll work with me individually and with the group led by my colleague. We'll talk to each other regularly, with your agreement, so we're all working on the same goals."
  • Watch for: conflict between clinicians that mirrors the patient's internal models. Bring it to the team meeting rather than acting on it.

4.15 Therapeutic contract, setting and planned endings

  • Purpose / when: at the start, and again around breaks, crises and termination. A clear, jointly agreed contract supports cooperation and gives both of you neutral ground ("zona franca") to return to during conflict. [source: Ivaldi 2004]
  • Steps:
    1. Define competences, limits, setting rules (frequency, fees, cancellation, contact between sessions), mutual commitments and goals.
    2. Decline unrealistic or magical requests. Make treatment conditional on the commitments it requires, for example detoxification alongside therapy.
    3. Agree a crisis plan, such as phoning before acting on an urge, as in Ivaldi's case example.
    4. When the contract is tested, return to it as a cooperative negotiation rather than as enforcement.
    5. Announce breaks and endings well in advance, and explore the attachment reactions they bring.
    • [source: Ivaldi 2004 for steps 1–4] [step 5: synthesis]
  • Example language (illustrative): "Let's agree together how we handle contact between sessions, so neither of us has to guess."
  • Watch for: repeated testing of the setting. Treat it as information about motivational patterns, not only as a rule violation.

4.16 Using the group in a dual (individual plus group) setting

  • Purpose / when: with borderline and dissociative patients whose individual relationship is overloaded or keeps falling into the drama triangle.
    • The group offers a real third party and spreads attachment affect across several people.
    • Patients can check their readings of others against their peers' readings (consensual validation).
    • [source: Ivaldi 2004, drawing on Yalom 1995 and Berne 1968]
  • Steps:
    1. Explain the dual setting and why it is used. Ivaldi treats the explanation itself as therapeutic, because it builds a sense of mastery.
    2. In the group, let members compare their readings of, and gut feelings about, one another and the therapists.
    3. When you are not directly involved in an exchange, act as an auxiliary "terzo occhio" (third eye) that names the roles being played.
    4. Invite the patient to bring group episodes into individual sessions and work through them there.
    5. Expect to revisit the same dynamics many times before the patient fully grasps them.
    • [source: Ivaldi 2004] [step order: synthesis]
  • Example language (illustrative): "You said you felt the group turned on you when you asked for help. Shall we look at it here together: who seemed to play which part, and which part did you find yourself in?"
  • Watch for: the group becoming a new stage for the triangle, with one member rescued and another scapegoated. Coordinate with any co-therapist and bring the issue back to the shared contract. [synthesis]

5. Handling problems

The motivational reading of each problem follows the framework as documented in the sources [source: Farina & Liotti 2018; Ivaldi 2004; Cortina 2018; van der Hart 2018]. The concrete responses are largely [synthesis]. Items with a source tag are documented in that source.

  • Stuck client (circular sessions, no change).
    • Check which drama-triangle role you have taken. Ivaldi observes that stalls and interruptions arise mainly when the therapist has entered the triangle. [source: Ivaldi 2004]
    • Use motivational monitoring to catch the impasse before dropout. [source: Farina & Liotti 2018]
    • Ask which system dominates the stuck sessions. Often it is quiet compliance (submission, or caregiving toward you) passing as cooperation. Name it, renegotiate goals together and bring in a fresh, specific episode.
    • Check whether you are over-caregiving and doing the work for the patient. Revisit the formulation in supervision. [synthesis]
  • "Resistance" (opposition, arguing, discounting).
    • Read it as rank activation or a power-based controlling strategy, not as a lack of motivation. [source: Cortina 2018]
    • Decline the contest (4.9), acknowledge whatever is valid, and make the disagreement a shared question.
    • Explore what being helped by you would mean to the patient, for example losing status or exposing need. [synthesis]
  • Overwhelm or dissociation.
    • Stop content work, ground the patient and re-establish contact (4.11). Return to building safety and regulation before trauma work. [source: Cortina 2018]
    • Consider spreading the attachment load across a second setting (4.14, 4.16). [source: Farina & Liotti 2018; Ivaldi 2004]
    • Agree an early-warning signal for overwhelm. [synthesis]
  • Non-adherence (missed sessions, tasks not done).
    • Ask without blame. Look for motivational meanings: avoiding attachment closeness, a rank protest, or caregiving obligations elsewhere.
    • Simplify tasks and set them jointly.
    • If attendance is chronically erratic, return to the agreed contract (4.15) as neutral ground and renegotiate it cooperatively. [source: Ivaldi 2004 for the contract] [synthesis]
  • Ruptures.
    • Use the repair sequence (4.8). After a severe rupture, consider a session that reviews the relationship itself.
    • If ruptures recur in a fixed pattern, map them onto the drama triangle (4.7).
    • [source: Farina & Liotti 2018; Liotti & Monticelli 2014; Safran & Muran 2000 as cited by Farina & Liotti] [synthesis for the review session]
  • Idealisation followed by devaluation (rescuer turning into persecutor).
    • Expect swings between idealising and devaluing in disorganised attachment. Don't accept the rescuer role at the start. [source: Ivaldi 2004]
    • Name your limits early and gently, so the later disappointment is smaller and can be talked about. [synthesis]
  • Sudden switch between caretaking and anger.
    • Don't be thrown and don't placate. Explore the movement between the two positions with the patient. [source: van der Hart 2018 citing Steele et al. 2017]
  • Erotic or sexual activation in the relationship.
    • Read it as the sexual system standing in for attachment or rank.
    • Hold the boundary clearly and without shaming, explore the need behind it, and get supervision. Never act on it. [synthesis]
  • Role reversal (the patient looks after you).
    • Decline the care warmly and name the pattern as protective (4.6). Expect attachment distress as it loosens. [source: Cortina 2018; van der Hart 2018]
  • Splitting between settings or clinicians.
    • Read it as the patient's incompatible models spread across clinicians.
    • Keep therapists in constant, open contact, agree a consistent response, and avoid taking sides. [source: Farina & Liotti 2018; Cortina 2018] [synthesis]
  • Suicidal crisis or self-harm (not specifically addressed in the sources beyond agreeing in the contract to phone before acting [source: Ivaldi 2004]).
    • Follow current standard risk assessment: ask directly about ideation, intent, plans, history, protective factors and access to means.
    • Write a collaborative safety plan with lethal-means counselling (safe storage or removal of means, involving trusted others).
    • Step up care, including crisis or psychiatric services, as indicated.
    • Frame the safety plan as a joint, cooperative task. Watch that the crisis doesn't push you into the rescuer role, and coordinate with any co-therapist. [synthesis]
  • Breaks and endings provoking crisis.
    • Announce them early, arrange cover, explore the attachment reactions, and consider tapering sessions gradually. [synthesis]
  • Therapist burnout or strong countertransference.
    • Van der Hart warns that a caregiving model of therapy leads therapists to overextend and become exhausted. [source: van der Hart 2018]
    • Use regular supervision or intervision focused on the motivational systems being activated in you. In severe cases, don't work alone (4.14). [synthesis]
  • Mismatch with the patient's goals (they want brief symptom relief only).
    • Agree a narrower practical goal, as Liotti did with "Sara", while keeping the cooperative stance. [source: Cortina 2018]
    • Don't impose long-term relational therapy. Refer to a protocol-based treatment if that fits better. [synthesis]

Sources

Sources:

Further reading (not drawn on) [uncertain]:

Books and papers cited, by author, year and title. Entries not drawn on are marked [uncertain].

  • Berne, E. (1968). Principles of Group Treatment. Oxford University Press. (As cited by Ivaldi 2004.)
  • Cortina, M. (2018). A tribute to Giovanni Liotti: gentle soul, first rate thinker, scholar and clinician. Cognitivismo clinico, 15(2), 118–131.
  • Cortina, M., & Liotti, G. (2014). An evolutionary outlook on motivation: implications for the clinical dialogue. Psychoanalytic Inquiry, 34, 864–899. (Cited via Cortina 2018 and van der Hart 2018.)
  • Farina, B., & Liotti, G. (2018). La svolta relazionale in psicoterapia cognitiva: origini e prospettive della psicoterapia cognitivo-evoluzionista. Cognitivismo clinico, 15(1), 6–21; also Quaderni di Psicoterapia Cognitiva, 42, 11–34.
  • Fassone, G., Valcella, F., Pallini, S., Scarcella, F., Tombolini, L., Ivaldi, A., Prunetti, E., Manaresi, F., & Liotti, G. (2012). Assessment of Interpersonal Motivation in Transcripts (AIMIT): an inter- and intra-rater reliability study of a new method of detection of interpersonal motivational systems in psychotherapy. Clinical Psychology & Psychotherapy, 19, 224–234.
  • Guidano, V. F., & Liotti, G. (1983). Cognitive Processes and Emotional Disorders. Guilford. (Confirmed via the ISSTD obituary.)
  • Ivaldi, A. (2004). Il triangolo drammatico: da strumento descrittivo a strumento terapeutico. Cognitivismo clinico, 1(2), 108–123.
  • Ivaldi, A. (Ed.) (2016). Treating Dissociative and Personality Disorders: A Motivational Systems Approach to Theory and Treatment. Routledge. [uncertain]
  • Karpman, S. B. (1968). Fairy tales and script drama analysis. Transactional Analysis Bulletin, 7, 39–43. (As cited by Ivaldi 2004.)
  • Liotti, G. (2001; 2nd ed. 2005). Le opere della coscienza: psicopatologia e psicoterapia nella prospettiva cognitivo-evoluzionista. Raffaello Cortina. [uncertain]
  • Liotti, G. (2004). Trauma, dissociation and disorganized attachment: three strands of a single braid. Psychotherapy: Theory, Research, Practice, Training, 41, 472–486. (Citation confirmed via Cortina 2018.)
  • Liotti, G. (2011). Attachment disorganization and the controlling strategies. Journal of Psychotherapy Integration, 21, 232–252. [uncertain: cited via van der Hart 2018]
  • Liotti, G. (2013). Phobias of attachment-related inner states in the psychotherapy of adult survivors of childhood complex trauma. Journal of Clinical Psychology, 69(11), 1136–1147.
  • Liotti, G., Cortina, M., & Farina, B. (2008). Attachment theory and multiple integrated treatments of borderline patients. Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry, 36, 295–315. (Citation confirmed via PEP-Web.)
  • Liotti, G., & Farina, B. (2011). Sviluppi traumatici: eziopatogenesi, clinica e terapia della dimensione dissociativa. Raffaello Cortina. [uncertain]
  • Liotti, G., Farina, B., & Rainone, A. (2005). Due terapeuti per un paziente. Laterza. [uncertain: cited as in press by Ivaldi 2004; publication not confirmed]
  • Liotti, G., & Gilbert, P. (2011). Mentalizing, motivation, and social mentalities: theoretical considerations and implications for psychotherapy. Psychology and Psychotherapy, 84, 9–25. [uncertain: cited via Cortina 2018 with a garbled volume]
  • Liotti, G., & Monticelli, F. (Eds.) (2008). I sistemi motivazionali nel dialogo clinico: il manuale AIMIT. Raffaello Cortina. [uncertain]
  • Liotti, G., & Monticelli, F. (Eds.) (2014). Teoria e clinica dell'alleanza terapeutica: una prospettiva cognitivo-evoluzionista. Raffaello Cortina. (Book description; the publisher name is [uncertain].)
  • Monticelli, F., Imperatori, C., Carcione, A., Pedone, R., & Farina, B. (2018). Cooperation in psychotherapy increases metacognitive abilities: a single-case study. Rivista di Psichiatria, 53(6), 336–340.
  • Prunetti, E., et al. (2008). Attachment disorganization and borderline patients' metacognitive responses to therapists' expressed understanding of their states of mind. Psychotherapy Research, 18, 28–36. (As cited by Cortina 2018.)
  • Safran, J. D., & Muran, J. C. (2000). Negotiating the Therapeutic Alliance: A Relational Treatment Guide. Guilford. (Cited by Farina & Liotti 2018 for negotiating the alliance.)
  • van der Hart, O. (2018). Understanding trauma-generated dissociation and disorganised attachment: Giovanni Liotti's lasting contributions. Attachment: New Directions in Psychotherapy and Relational Psychoanalysis, 12, 101–109.
  • Yalom, I. D. (1995). The Theory and Practice of Group Psychotherapy. Basic Books. (As cited by Ivaldi 2004.)
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