Interpersonal Reconstructive Therapy: Promoting Change in Nonresponders (Book Review)
Author: Benjamin, Lorna Smith
Publisher: New York: Guilford Press, 2003
Reviewed By: Annie Lee Jones, Winter 2004, pp. 51-54
Maurice Green (1964) quotes Clara Thompson on Sullivanian therapy: “There are two current misconceptions about the relation of Sullivan’s methods and ideas to psychoanalysis. One group claims that what Sullivan taught is not psychoanalysis; the other group, in complete contradiction, insists that Sullivan says the same things as Freud but in different words. To clarify the first assumption requires a definition of psychoanalysis. If the term is to be used only for therapy, which subscribes without question to all of Freud’s hypotheses, then it is true that what Sullivan taught is not psychoanalysis. If by psychoanalysis one means recognition of unconscious motivation, the influence of repression and resistance on the personality and the existence of transference, then Sullivan’s thinking fulfills all requirements for being considered psychoanalysis. He himself was not concerned with this point and preferred to call his therapeutic approach intensive psychotherapy. I have already indicated the points at which his technique parallels current psychoanalytic method, and I can only say if Sullivan’ s methods are not psychoanalytic, then all character analysis methods are not psychoanalytic” (p. 88).
In her book, Lorna Smith Benjamin states that interpersonal theory is the guiding theoretical frame for her exposition on an evidence-based approach to the treatment of chronic and resistant cases of Axis II diagnoses, with a particular focus on personality disorders. At the outset, let me say that, as made clear by the above quote from Clara Thompson, to be psychoanalytic and to propose a method of treatment for the mental disorders that are not classifiable as neurotic, it is appropriate to rely on interpersonal theory to frame one’s thinking. It is my position that unconscious processes and interpersonal relationships can be examined in the dyad with the direct inquiry into social connections, both conscious and unconscious, and that behavior directed towards the self or others is evidential material to be used in psychoanalytic work.
In classical interpersonal theorist style (Sullivan, 1962), Benjamin uses case histories developed from the detailed inquiry as a requirement for treatment formulation. Additionally, her understanding of the use of the “talking cure” as an avenue for behavior change in severe psychiatric conditions is reminiscent of what Sullivan (1962) said about treating schizophrenics: “Impervious barriers generally keep one from establishing rudimentary interpersonal relations with the unfavorable patient of insidious onset. This is probably a direct result to be expected from consideration of the environmental personal situation in which the personalities had their development” (p. 239).
Why Benjamin saw the need to include evolutionary theory is not clear, other than to lend credence to the position that her approach to therapy is rooted in established principals of learning (see pp. 8-10). Her purpose seems to be to design a treatment strategy that meets standards of testability and reliability. From the introduction and overview of her approach, Benjamin thrusts IRT into the current debate around empirically validated treatments (see Levant, 2003, pp. 4-16).
These are the apparent theoretical underpinnings of Benjamin’s key concepts as outlined in the book. First, there is the Developmental Learning and Loving theory (DLL), which supports the Structural Analysis of Social Behavior (SASB). SASB is based on the systematic analysis of the social and interpersonal ramifications of the copying process that maintains the fantasies that are derivatives of the Important Persons and their Internalized Representations (IPIRs). Benjamin hypothesizes that attachments to these early fantasies related to important internalized objects result in a type of self-destructive love that drives the patient to repetitions, which become destructive and psychically damaging.
What makes this population of patients particularly resistant to treatments-as-usual is the strength of these early attachments that are linked via copying to over-learned behavioral patterns. According to Benjamin: “In the IRT case formulation and treatment method, problem patterns are linked to learning with important early loved ones via one or more of the three copy processes: (1.) Be like him or her; (2) Act as if he or she is still there and in control; and (3) Treat yourself as he or she treated you” (p. vii).
The author refers to her work as “empirically informed attachment theory” (p. 63) and goes on to define her own theoretical perspective. She states that her Developmental Learning and Loving (DLL) theory is “A specifically detailed version of attachment theory. DLL theory centers on Bowlby’s concept of internal working models and calls them Important Persons and their Internalized Representations (IPIRs). DLL theory increases the specificity of Bowlby’s concept by describing internal working models more precisely in terms of the SASB model, and by specifying connections between IPIRs and problem patterns via copy processes and predictive principles of the SASB model” (pp. 67-68).
She then presents a detailed procedural manual for implementing Structural Analysis of Social Behavior, which is a method for objectifying social perceptions, and internalized representations to create a therapeutic environment to foster change.
Benjamin calls her approach to treatment of the difficult, resistant, and refractory patient, Interpersonal Reconstructive Therapy (referred to throughout the book as IRT). She states: “The fundamental idea of IRT is that treatment-refractory patients are responding to internalizations of important persons more than they are to persons in their present-day real world. IRT addresses their relationship with those internalizations. After old expectations and hopes in relation to the internalizations are given up, usual and customary treatment procedures (e.g., medications, cognitive-behavioral or psychodynamic therapy) have a better chance to work” (p. vi-vii).
Benjamin reports a step by step approach that she views as being testable, effective, and reliable with a broad spectrum of difficult to treat cases. She holds that patients with severe resistant interpersonal and intrapsychic problems can be brought to the position where change is possible. With this method, which requires strict adherence to the originating case formulation, Benjamin holds that the therapist can use scripted text and formulary restatements of early love attachments gone wrong in order to direct the patient into new and health promoting manners of relating to early love objects so that change is possible. This recognizes the importance of early life experience and also utilizes the force of long established belief systems to effect change.
The method is designed for the therapist to move from one point to the next as predetermined from initial case history. Case formulations are constructed from interviews and tied to a specific diagnostic category. Then unique and specific events of the patient’s life are plugged into the IRT formulary approach, which is detailed in the book. A developmental learning and loving theory is proposed that captures the unique and clinically viable aspects of each patient’s case history. Benjamin positions her approach as a reliable and valid method of psychodynamic based behavior therapy, which would meet current demands for evidence-based treatments of mental illness, although she admits that significant research on her proposed methodology is yet to be done (p. ix). In the current private practice environment where managed care companies are exerting constricting pressure on practitioners to use brief interventions that they feel are justified based on their “compendium of the best available evidence to guide clinical practice in specific mental health problems” (UnitedHealth Foundation, p. ix, 2002), Benjamin’s book is an example of the direction managed care companies would support, where the evidence that the recommended technical changes are based on is not scientific even with an N = 1 research paradigm, and is not based on research representative of the broad spectrum of subjects that comprise the nonresponder population. Levant (2003, pp. 4-16) discusses the impact of this type of empirically supported therapy on psychoanalytic practice in general, and basically found that it is common practice to produce evidence-based treatment approaches that in fact do not meet current criteria, even though the technique is held out to be scientifically grounded.
Benjamin refers to research that could be done on her treatment manual and ends the book with descriptions of feedback from training sites where the protocol is used effectively. Benjamin also describes future plans to test IRT scientifically to see if her anecdotal findings are reproducible in different settings with a variety of subjects. Benjamin’s plan is to provide hospital-based and outpatient clinic-based practitioners with a procedure that will result in positive outcome in the treatment of DSM-IV Axis I and Axis II patients who have not been cured with traditional methods. Benjamin states that the term nonresponders “can apply to disorders, individuals, populations and more” (p. 3).
She defines her target group as people who have a history of minimal responsiveness. She also states: “This book pursues in depth the question of how to work with psychosocial factors (including but not limited to Axis II complications) to improve results with nonresponders or patients with treatment-refractory disorders. The method, called Interpersonal Reconstructive Therapy (IRT), is primarily psychosocial, but does recommend medications for specific situations. IRT does not offer any new treatment techniques per se, such as a new drug or a new way of relating to patients. Rather, IRT offers a way of thinking about patients that helps clinicians more effectively choose interventions from the array of possibilities available within any and all frequently used methods of intervention, called treatments as usual (TAU). The Therapy, divided into five steps or stages, draws techniques from TAU according to highly specific algorithms (flow charts)” (p. 2).
In her introductory chapter, Benjamin compares psychotropic drug research with psychotherapy and concludes, “In contrast to the literature on psychopharmacological treatments, problematic side effects of psychotherapy have been largely ignored” (p. 7). She quotes from a paper by Lambert and Bergin (1994) and concludes that because most empirically supported therapies do not factor in those subjects that are either dropped from the research or who deteriorate, then there is a need for a more standardized approach to treatment selection that can be universally applied, eventually resulting in replicable research that would improve the overall care of difficult-to-treat patients in both hospital based and outpatient based treatment settings.
It is this population of psychiatric patients that is the focus of Benjamin’s work. Her thesis is that treatment modalities can be more effectively applied to nonresponder type patients if a systematic procedure is applied to the interpersonal and social history obtained from the patients using her method. Benjamin further proposes a theory of development and interpersonal relating that explains her view of how intrapsychic structures are held on to by resistant patients. She holds that her method called the Structural Analysis of Social Behavior is a “perspective on the structure of interpersonal and intrapsychic patterns helps the clinician function at a higher level of expertise” (p. 122). In the book, she details the three dimensions that underlie all versions of the SASB treatment plan. They are conceptualized as components of interpersonal space: Focus, Affiliation, and Interdependence. Figures, diagrams, and methods of coding are presented from her previous works (pp. 122-138). The basic premises that underlie her system are based on the codification of object relational concepts, and Sullivan's concepts regarding the introjections of early experiences with others.
The book presents five steps that are considered essential to effective implementation of the procedure. Formulary tables, charts and graphs are presented to guide the clinician through each step. The actions of the clinician during each step of the procedure are linked to the material provided in the book. Of particular note is her use of the traditional medical model for treatment, and recommendation that the work should be guided by the “time-tested medical algorithm, SOAP (S, subjective report of the patient; O, objective relevant data; A, analysis [from the DLL perspective]; and P, plans that were and will be implemented) (p. 112).
Benjamin holds that effective treatment begins with the DSM-Based Case Assessment (Table 2.1, p. 35), which is a requirement to create the Developmental Learning and Loving (DLL) Case formulation. It is this theory that “directs the Interpersonal Reconstructive Therapy (IRT) case formulation method, which seeks to organize the presenting symptoms in relation to common psychosocial causal factors. The definition of “casual factors” in DLL theory is wide-ranging; several other variables, such as heredity, traits, states, situations, and free will, are considered to be among contributing causal factors” (p. 32). Benjamin uses case histories to demonstrate her points at each step of the tutorial in how to construct an effective case formulation that can lead to effective treatment choices.
In chapter four, Benjamin provides the research design for her work. She states “Structural Analysis of Social Behavior (SASB) is a technology that objectively measures perceived interpersonal and intrapsychic relations. The methods therefore make Developmental Learning and Loving (DLL) and Interpersonal Reconstructive Therapy (IRT) concepts amenable to research confirmation or refutation. The SASB model can also function as a lens through which the clinician sees patterns more clearly and connects them more precisely. These skills enhance case formulation, therapy process, and outcome (p.120). This dense and highly concentrated chapter puts forth coding methods, training tools for using related questionnaires, and references the potential research uses of her technique. Diagrams are also presented to show how information obtained during the structured interviews can be charted and diagramed to develop a formulary for decision-making.
Benjamin states, “Every intervention in Interpersonal Reconstructive Therapy (IRT) attempts to invoke a maximal number of elements of the core algorithm.” She continues: “The core algorithm specifies that each intervention offers and facilitates (1) accurate empathy; (2) maximal support for the Growth Collaborator (Green), and minimal support for the Regressive Loyalist (Red); (3) a focus on key aspects of the case formulation; (4) articulation of detail about input, response, and impact on the self for any given interpersonal episode in terms of affect, behavior, and cognition (the ABCs); and (6) implementation of one or more of the five steps from the therapy learning hierarchy” (p. 72).
The 6th item above refers to the five steps of effective therapy change which are (1) Collaboration; (2) Learning about patterns, where from and what for; (3) Blocking maladaptive patterns; (4) Enabling the will to change; and (5) Learning new patterns. (Figure 3.1, p. 88). Adherence to the SASB model in the five steps of IRT is designed to lead to internal and external changes in the resistant patient. The above steps are designed to identify internal attachments that sustain the illness.
Benjamin’s DLL proposes two types of internalized objects that must be connected to repetitive ideations in the patient in order to begin the collaborative process towards behavior change. She calls these the Regressive Loyalist (Red), and the Growth Collaborator (Green). “The Regressive Loyalist is identified by following the trail from problem behaviors through copy processes back to early important caregivers (the IPIRs).” The growth collaborator (Green) has a more technical function in IRT model. Benjamin says, “The Green name is appropriate if the interpersonal and intrapsychic habits connect to normative therapy goal behavior.” (p. 76-77). These concepts along with scripted text for speeches to be delivered to the patient at differing stages of the IRT process are the methodology that Benjamin recommends as the way to meet demands for what she calls empirically based treatment strategies.
It is at this point I wish to raise questions regarding what Benjamin calls empirically based treatment. In the last chapters of the book she describes how IRT increases the effectiveness of traditional treatment methods such as behavior therapy, and psychodynamic methods. Benjamin also states that the key to treatment of difficult, nonresponder patient populations is her empirically based formula. Benjamin holds that testimonials are not usually considered valid measures of treatment effectiveness, but that the consistency of the types of features she observed in the testimonies from ex-patients obtained in training settings is a valid measure of treatment effectiveness (p. 341). This may be true but proves problematic given the overall thrust of the book towards empirical validation. The absence of a clear chapter on any available data using classic randomized clinical trails to test IRT as an effective tool in reducing mental health risk factors in the nonresponder population is problematic. Why risk adding the rigidity and inflexibility of the SASB model to the clinician’s treatment strategy without the evidence of valid and reliable benefits. Even though clinicians have long relied on the use of the case study method as a valid and reliable assessment tool for treatment formulation, Benjamin does not support her claims to justify the use of the IRT technique as an effective methodology to reduce suicide risk, promote behavior change in Axis II diagnoses, or to reliably eliminate the self destructive behavior of non hospitalized character disorders. Using Benjamin’s criteria as established early on in the book, it appears that a portion of a quotation reported by Levant (2003) applies: “Slavish attention to ‘the manual’ assures empathic failure and poor outcome for many patients” (p. 5).
Green, Maurice R., (1964). Interpersonal psychoanalysis: The selected papers of Clara M. Thompson. New York: Basic Books, Inc.
Levant, Ronald F., (2003). The Empirically-Validated Treatments Movement: A Practitioner Perspective. Psychologist-Psychoanalyst, 23, 4, 4-16.
Sullivan, Harry Stack, (1962). Schizophrenia as a human process. New York: W. W. Norton & Company Inc.
UnitedHealth Foundation, (2002). Clinical evidence--mental health, reprint from Clinical Evidence, Issue 7. Tavistock Square, London: BMJ Publishing Group.
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