Concrete thinking, an extraordinarily difficult condition to treat, has been psychoanalytically theorized to result from failures of symbolization-problems forming, linking, or fathoming the meaning of symbols-and/or failures of differentiation, resulting in difficulties distinguishing symbols from the thing being symbolized, fantasy from reality, self from other. Though difficulties symbolizing and differentiating are clearly evident in patients whose thinking is concrete, these may be a manifestation of concrete thinking rather than a root cause. Childhood thinking is characteristically concrete, and a persistence of such thinking into adulthood can be adequately explained as a failure to develop a more sophisticated theory of mind. Given that patients who exhibit such thinking tend to respond poorly to classic psychoanalytic interpretations, alternative technical approaches have been proposed. One such approach, "metacognitive" in nature, draws on a mode of thought used by gifted individuals that helps them "think outside the box" by dispensing with a typical pattern-recognition search so that novel meanings might be discovered. Metacognition, thoughts about one's thoughts and thought processes, facilitates symbolic thinking by creating sufficient distance from one's thoughts to allow the consideration of alternative meanings.