Theoretical Components Of The Model

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The theoretical components of the IRT model are summarized in terms of the underlying theory of psychopathology and the theory of change.

Theory of Psychopathology

Interpersonal reconstructive therapy draws heavily on Bowlby's (1969, 1977) observations on the role of attachment in human development. His perspective is clinically compelling and has received broad support in many research contexts (Cassidy & Shaver, 1999). Applications of attachment theory in IRT concentrate on two of Bowlby's propositions. First, basic security is most affected by reliable proximity to the caregiver and by what Harlow and Harlow (1967) called "contact comfort." Second, experiences with caregivers shape children's internal working models of self and others. The case formulation method in IRT requires that presenting problems be linked to internal working models and that internal working

This chapter derives from and summarizes portions of L. S. Benjamin (2003). Interpersonal Reconstructive Therapy: Promoting Change in Nonresponders. New York: Guilford Press.

models be connected to relationships with specific loved ones. The IRT treatment method seeks to transform those internal working models in a way that allows the patient to become free to behave in new, more desirable ways.

Interpersonal reconstructive therapy theory operationalizes the definition of internal working models and provides specific methods to link them to presenting problems. In its most formal form, the case formulation method uses Structural Analysis of Social Behavior (SASB; Benjamin, 1979) to define and link key figures to presenting problems (Benjamin, 2003, chapters 2, 4, and appendix 4). Links involve one or more of three copy processes:

2. Act as if he or she is still there and in control.

3. Treat yourself as he or she treated you.

The three copy processes have these respective names: identification, recapitulation, and introjection. Using the SASB model and an early version of IRT procedures, Benjamin (1996) proposed that each of the symptoms of the DSM-IV personality disorders can be accounted for by specific copy processes usually found in their respective prototypic interpersonal histories. For example, if a child lives with a parent who unrealistically adores and serves him or her, the child is likely to develop a "pervasive pattern of grandiosity, a need for admiration, and lack of empathy," as is characteristic of Narcissistic Personality Disorder defined in the DSM-IV (American Psychiatric Association [APA], 1994).

Copying exists in normal as well as disordered individuals. The SASB model defines normal in terms of behaviors that are friendly and that show moderate degrees of enmeshment (one person is in control and the other submits) and differentiation (one person emancipates and the other separates). Pathological behavior includes characteristic positions that are hostile and/or that are extremely enmeshed or differentiated. A normal person can be hostile or extreme, too, but only in appropriate time-limited contexts. By contrast, a disordered person is characteristically hostile or occupies positions of extreme enmeshment or differentiation regardless of context. For example, consider the characteristic positions of personality-disordered individuals. Paranoid and antisocial patients are characteristically hostile. Schizoid and avoidant persons show extreme differentiation. Borderline, histrionic, dependent, and obsessive-compulsive individuals too often can be described as extremely enmeshed. Passive-aggressive and narcissistic persons are likely to alternate between the extremes of enmeshment and differentiation.

A core assumption in IRT is that copy processes are maintained by the wish that the internal working models, called important persons and their internalized representations (IPIRs), will forgive, forget, apologize, wake up, make restitution, relent—or otherwise make it possible for there to be rapprochement and blissful reunion. The usually unconscious plan in relation to the internalizations is that by providing living testimony to the IPIR's rules and values, the IPIR will become more loving, affirming, and nurturing. For example, the child who identifies with the parent is saying, "See, I am just like you. I agree with your views and apply them to myself. I love you so much. Please love me." The child who recapitulates the patterns he or she showed with the parent "says" to the internalization, "I love you so much, I agree to maintain the rules and values we always had. I hope I am doing it well enough to receive more and better love from you."

Range of Psychopathology and Personality Disorders within Scope of Treatment 153

Children who treat themselves as the parent or other caregiver treated them engage in similar emotional logic.

These often unconscious wishes to be affirmed by, to achieve psychic proximity to the IPIRs, is called the gift of love (GOL). This may seem to be a strange interpretation for cases that engage in endless destruction of self and others. How can hostile and self-destructive patterns be based on love? Unfortunately, the conceptual problem is not whether, but why this is so. Copy process connections to relationships with attachment figures usually become apparent when IRT procedures for case formulation are followed. Even when the relationship to an IPIR seems dominated by pain, patients acknowledge copy process and the gift of love with remarks such as: "I thought I hated him, but I see that I am just like him. That really upsets me. But, you know, he is my father. I do love him."

In IRT, pathological patterns that are driven by wishes to have proximity to and the love of IPIRs are named the regressive loyalist or the Red. Therapy goal behaviors, which are the normative patterns of friendliness and moderate enmesh-ment or differentiation, are called the growth collaborator or the Green. A conflict between the Red and the Green is always present. For the nonresponder population, the Red part is disproportionately large. The goal of IRT therapy is to reduce the magnitude of the Red and enhance the Green to the point where the patient is comfortable relating to self and others in normal ways.

An IRT case formulation must be developed in collaboration with and confirmed by the patient, else it is incomplete. Because the case formulation is so central to the choice of interventions, it is vital to revise and update it if warranted by the continuing therapy narrative. Often, changes in the case formulation involve the addition of IPIRs, such as a big brother or a grandmother, to the original formulation.

Theory of Change

Because the patient's relationship with the internalization sustains the problem patterns, treatment focuses consistently on activities that facilitate grieving and letting go of the residuals of Red attachments so that the Green parts can grow stronger. The overall IRT therapy process is described simply by The Learning Speech: "Therapy involves learning about your patterns, where they are from and what they are for. Understanding your patterns might lead you to decide to change, and then you can begin work on learning new patterns that may work better for you" (Benjamin, 2003, chapter 3).

The most difficult phase of IRT is enabling the wish to change. The patient has to decide to let go of the wishes and grieve the loss of what never was and never can be (or cannot again be) so that he or she can be more appropriately present in the here and now. Once the fantasies in relation to the internalization are abandoned, opportunities for learning more constructive alternatives can be used to provide new emotional learning for how to relate to others in ways that have a chance to result in reciprocal and genuine (i.e., uncoerced) love and affection.

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