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Origami Flapping Birds

"Marco" - a case study

Edits and additional comments by
Kresta Dalrymple, LMFT

This is an edited version of the case study for ease of reading and length. Parts included have been faithfully copied from the original text. To read the whole case study go to : Full Case Study

Comments in green are by Kresta to illustrate how concepts of "Internal Family Systems"  aka "parts work" are similar in approach, and how it is not necessarily the modality that helps, but the topics and depth of the processing within the therapy that ultimately gets lasting results. If you are not already familiar with IFS, please take a moment to read the blog post on "Internal Family Systems" first.

Metacognitive Interpersonal Therapy for Misophonia: A Single-Case Study by Natalini E, Fioretti A, Eibenstein R, Eibenstein A (2024)

Presenting Problem:

     Marco is a 25-year-old man with symptoms of misophonia since the age of 10. In the early years, however, certain sounds were rarely perceived as threatening and they did not create great discomfort.

     The problems with misophonia became stronger after high school, at the age of 18, when he spent more time at home, went to university, and started his first job. During university, which he did not complete, he had difficulties with his roommate’s breathing, which he felt was too heavy. While studying, he was annoyed by the music he heard coming from his earphones.

     During his first job, working and living at home with the same people, the trigger sounds were those related to swallowing and chewing, the same ones he was currently complaining of in his family. The difficulties with sounds were less with friends or strangers. Marco used earphones. Initially, the volume was low, then increased to the point where he could no longer hear the family’s conversations at the table. When he got up from the table, his anger was so intense that he often vented it by slamming doors or kicking objects.

     Marco presented over-control and rigidity that were also visible in his posture. His life was characterized by self-imposed habits and rules. He set the alarm clock early every day even if he had no commitments, his diet was very controlled by excluding certain foods (e.g., carbohydrates because they make him drowsy), and he had significant difficulty with spending money. There is little space for spontaneous desire and no awareness of the difference between what he wanted and what was right to do or what he had to do. The tendency to perfectionism is a coping strategy that emerges from the narratives and the fear of making mistakes and of not doing everything as it should be, which hampers the paths he takes. Faced with the possibility of a difficulty, he generally tended towards avoidance.

As previously reported, Marco has often changed study or work paths. He worked in a company in the administration office and sometimes helped his father in one of the family businesses. He joined a group of close friends and has never had an intimate relationship.

     Marco came to the Tinnitus Center in Rome, in July 2021, having previously tried two other therapeutic paths for the problem.

Course of Treatment:

     In the first year, Marco’s therapy was carried out in person on a weekly basis. There was a break of about 6 months requested by the patient himself who was abroad for work reasons. Subsequently, therapy was resumed in online mode. Currently, sessions are held every fortnight. The treatment was carried out by a psychotherapist with MIT training and work experience of about 10 years, 8 of which in hearing disorders.

Shared Formulation of Functioning: (language from study underlined, followed by IFS translations of shared concepts in green)

     As indicated by MIT, the first part of the treatment focused on the construction of a shared formulation of the patient’s functioning. In the first meetings, exercises of exploration and observation of the internal state were assigned to improve narrative and self-reflective skills (getting to know your system by turning towards inner experience with curiosity and compassion). Marco was asked to remove the earphones at trigger moments related to misophonia to check which thoughts, emotions, physical sensations, and action tendencies he was experiencing (“trailheads” to parts needing attention). Attentional techniques to be used in case of excessive discomfort were described and explained. Marco was already familiar with mindfulness, and this helped the process. In addition, he was given descriptive emotion cards to help the patient name his feelings.

 

     The first part of the treatment was used to collect narrative episodes, i.e., detailed autobiographical memories that are well located in time and space (exploring parts—their ages, jobs, burdens, and where in time and space they are stuck). The focus was then placed on the details of these episodes to search for feelings, ideas, and motivations for actions (“contracting” to focus on getting to know one particular part or parts around a particular symptom or issue). The observation and narration of the episodes led to the identification of several interesting points (interviewing a” firefighter” part). Anger (the firefighter), typical of misophonia, emerged because Marco felt forced by others not only to witness unpleasant sounds but because others ate unhealthy food. This last observation was related to the feeling of disgust, of a moral kind, which also emerged in another observation. Marco felt more misophonia-related distress towards people who did not help tidy up the table and whom he judged to be rude, with no respect for others (positive intention of part- to protect from disrespectful people as disrespect means persons may not respect boundaries, personhood, needs, or physical life/wellbeing).

     The exercises also helped to identify problems within the family. At the table, quarrels and discontent were the order of the day, and Marco suffered especially due to his mother, who was described as complaining and discontented. His mother often refused to eat with them when she was angry and this aroused feelings of anger and guilt (polarized parts) in Marco. In the past, there was aggressive behavior when the parents argued, with the father breaking objects and the mother damaging her own person as a demonstrative act of her suffering (examples of the threats to boundaries, personhood and physical life/wellbeing that were not being respected by parents).

On a bodily level, Marco’s physical sensations were characterized by stomach tension and muscular rigidity (exiled parts showing up in the body) that could result in aggressive behavior that Marco later regretted (firefighter part trying to protect the parts showing up in the body). Marco began with the therapist to see how misophonia was the only way to express anger because, from his point of view (the point of view from one of his manager/protectors) his complaints were correct and the others were in the wrong.

     After analyzing the misophonia episodes, he was asked to bring back other episodes related to the emotion of anger in therapy to see what interpersonal patterns might be activated (following the trailhead of anger- getting to know that part).  The investigation was not easy because, outside of misophonia, for the reasons described above, it was difficult for Marco to tell himself that he was feeling that emotion (protector part strategy to avoid feeling emotions of exiled anger part).

     It was possible to identify moments of strong stress related to his father’s requests for help at work (example of a trailhead). Marco did not want often to help him but did so because he would otherwise feel selfish (example of a polarization of two parts- one wanting to say “no” the other acting on burden of belief that saying “no” is selfish). The feeling of guilt also came back when his mother showed signs of impatience or sadness (another trailhead).

A healthy desire to live alone emerged (sign of growing Self Energy) during the interviews. The family owned a house that was sometimes used by the father because it was closer to work and because of his bad relationship with his wife. Some meetings were dedicated to the possibility of using this house, but Marco found it very difficult to ask—he felt he did not deserve this possibility (trailhead to burden of belief of an exile “I don’t deserve…”). During the session, the therapist led Marco to evoke autobiographical memories related to the current situation in order to show the patient the existence of recurrences in the way of relating.

T (therapist): Does this belief that you don’t deserve things remind you of something from the

past? Where could you have heard it? (following the trailhead)

P (patient): When I was a child, I never had fashionable clothes and I was very ashamed (burden of exile). My mother wouldn’t buy them for me not to spend money (legacy burden of frugality or poverty). I was angry (protector trying to not feel shame) but then I stopped asking (manager exiling anger because it didn’t help get needs met and made connection to mother worsen). . . I don’t know then at some point it felt right (anger is successfully exiled by manager with burden of shame to keep it exiled). Once, however, I had asked for a game and she bought it for me. . . I wanted it so much, I was happy, but then my mother. . .

(he turns dark)

T: What’s happening? I can see sadness on your face. . .

P: Yes. . . I remember that I saw her suffering. . . it wasn’t a gesture made in joy, I felt

that it was wrong, that the shopping was damaging the family, that I was a bad child. . .

instead I had to be a good child, I didn’t have to cause problems (parts carrying burdens of “my needs are wrong, spending money is damaging, I’m a bad child to have needs, to be good I can’t have needs—then I won’t cause the problem of making my mom or family suffer”)

T: And how did you feel towards your mother?

P: I felt guilty. Both she and dad always said they stayed together for us children and did things for us. I felt. . . I don’t know. . . ungrateful, if I only thought of myself. It’s dawning on me that my mother also used to complain a lot when she had to take me to football school, she made me feel it was weighing on me. . . (parts sharing moments in time when belief of “I’m ungrateful and selfish” were taken in)

     The information obtained through the narrative episodes and autobiographical memories allowed the reconstruction of interpersonal schemas (“burdens” of belief parts carry). The desire for autonomy was hindered by the perception of himself as selfish and ungrateful if he took care of his own needs (burden of belief), and he felt guilt for this (emotion signaling burden of “I did something wrong”). The perception of the other was of a person who could be hurt by his desires or needs (burden of an exile “having desires or needs is dangerous or harmful to others”). In this case he felt the relationship threatened (disconnection from caregiver as life threatening to younger parts). Sometimes, however, the feeling of anger was present when he perceived the other as controlling and domineering (anger as protector part). In this case, Marco felt that the other wanted to subjugate him, and his self-image as a person capable and deserving of autonomy (presence of Self energy) was activated. In this case the healthy part emerged (Self energy), as it is called in MIT. Perceiving the other as dominant also activated the motivational schema of social rank (form of legacy burden). This emerged to counter the self-image (of the healthy belief of being capable and deserving of autonomy), not only as inferior because of submissiveness, but also inadequate and incapable (burdens of belief carried by exiles getting over-ridden by the legacy burdens carried by other parts). High morality and the need to follow certain rules were used in order to perceive oneself as better than others and wiser (common manager strategy). The dysfunctional coping strategies related to the schemas were perfectionism (Burden carried by one or many parts), the use of high morality (strategy of manager part), and avoidance (another kind of manager strategy, depending on the method used, could be a “firefighter”).

Change Promoting:

     At the change promoting stage, clients are helped to take a critical distance from their schemas (unblend from parts so “Self” can be present) to build new ways of thinking and feeling in order to implement more adaptive behaviors (unburden parts to make room for new ways of being/acting). A first step towards differentiation, that is, taking a critical distance from one’s schemas, was obtained with the use of mindfulness and guided imagination to remind Marco how some doubts about the present comes from thoughts anchored in the past (turning inwards and unblending from parts to learn about them--age, job, where they are in time, and burdens each carries). His belief that he did not deserve to live in his father’s house was linked to past episodes in which he perceived himself as selfish and ungrateful (burdens carried by parts). Validating his desire for independence on several occasions lead to an explicit request to his father to move. Fortunately, the request was accepted by his parents with little resistance and Marco lived alone for a few months. His relationship with his parents changed enormously as did his misophonia, which was no longer present or of mild intensity when he returned for family lunches. He felt that his desire for autonomy could be satisfied, and he saw his parents again with more pleasure and when he wanted to (when parts get what they need by Self honoring boundaries, protectors can relax). At the same time, not only in family but also in friendship relationships, we worked on the recognition of his own needs and the ability to put limits on the demands of others (Self-lead healthy boundary setting). In carrying out these exercises, Marco realized that it was not easy for him to identify his own desires because he was conflicted by the need to be ‘good’ (burden carried by exile). By sharing how he functioned, he noticed that misophonia was often triggered when his friends ate food that he desired but considered unhealthy and denied himself in order to emerge as the wiser and more righteous one. Understanding this mechanism made it possible to read the presence of the sounds in a different way, realizing that the sense of constriction was often linked to his internal mechanism (client noticing parts involved in relational dynamics contributing to misophonia response).

Two similar episodes that happened a few days apart were interesting.

P: On Monday I went to the cinema with a guy I just met, I ate what I wanted before going in, he was nice, he even drove without letting me take the car. He was complaining about some people eating in the hall. I was surprised because I had no misophonia! I wondered why and realized that I was happy and satisfied with the day, I had done what I wanted (parts got what they needed, system is happy).

T: Well I’m glad! When your needs are met and you know you have chosen, you are more quiet.

P: Yes exactly, as we said. In fact, listen. . . on Saturday, when I went back to the cinema, I noticed that I was annoyed by some girls who were eating chips. . . so I asked myself how I felt and what was happening to me. . . before going to the cinema I had been persuaded by friends to get a sandwich that I didn’t like and I hadn’t taken the chips. I was hungry

and those girls were eating what I wanted but was denying myself for the reasons we know. After doing this I felt better and was able to concentrate on the film. However, I couldn’t bring myself to buy the chips. . . partly because of the unhealthy food issue, partly because I still think eating at the cinema is rude. . . (laughs).

     Another important step was to realize that it was not his responsibility to meet his parents’ needs in order to see them happy and consequently have a better self-perception. Marco was able to tell himself that ‘mum is always dissatisfied and fighting with the world, I realized that it is not my problem and that I am not the cause of this. The same for my father, I see him sad but he is the one who decided for this life, he cannot take it out on us sons’ (updating parts and removing burdens of being responsible for parents inner experiences). Working on interpersonal cycles with exposure exercises, Marco realized how his tendency to complacency and submission contributed to their activation. By eliminating these tendencies, e.g., with his father for work requests, he realized that when he was able to say ‘no’, he did not feel annoyed by the sounds his father made (ability to set healthy boundary- no misophonia). By working on these dynamics, Marco realized that misophonia did not arise when he perceived that his demands were taken into account, accepted, and listened to (parts getting needs met, system is calm).

     The improvements on misophonia are remarkable, but the work with Marco is not finished. The awareness of his functioning has paved the way for new therapeutic goals. Work is now focusing on the final stages of MIT treatment with the construction of a new self-narrative and the promotion of advanced mastery strategies, consisting of knowing how to voluntarily use learned psychological knowledge to cope with emotional distress, manage interpersonal conflicts, realize one’s own desires, and cooperate appropriately with others.

     Marco went back to live with his parents after returning from his work experience abroad. He no longer had angry outbursts and did not wear earphones at the dinner table. He recognized moments of stress and duress and shifted his attention to his internal dynamics or different stimuli. Misophonia, in the presence of friends and acquaintances,

was absent. He understood and increasingly saw that constricting situations were due to active interpersonal patterns. He has increased his ability to stop and identify his needs in order to give them a voice in his relationship with others (more presence of "Self energy" and speaking up for needs of parts).

     Therapy continued to solidify a different self-image as some work failures, such as the one abroad, and increased his sense of inadequacy and confusion about his life goals. He had mood swings at times, but he generally maintained an optimistic outlook; he paid more attention to his appearance by working out at the gym, and he dedicated himself to

finding new job opportunities. As soon as economically possible, he will move back to living alone.

 

Conclusions:

     We think that emotional regulation and attention shifting techniques are useful for the treatment of misophonia but not sufficient. More specific work on managing relationships with others and thus on interpersonal patterns is necessary to diminish or eliminate symptoms. On this basis, we believe that MIT can be an effective therapy for the treatment of misophonia because, in addition to working on interpersonal schemas and continuous modulation and attention in the therapeutic relationship, it adds experiential techniques useful for managing arousal in the presence of misophonic stimuli.

Note from Editor

"This case study illustrates the connections to past traumatic relational experiences and how they can affect our interpersonal relationships in the present, personal belief systems, and ultimately contributes to Misophonia triggers. This is why I believe that the answer to Misophonia is not in any one therapeutic approach. It is in the content of the processing that is done within the therapy relationship, and the willingness to turn towards the misophonia, get curious about what is has to teach us, and follow the trailheads...."  Kresta Dalrymple, LMFT

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