The latest in SASB and IRT
This description is based on: “Interpersonal Reconstructive Therapy” by Benjamin 2003/2006, copyright Guilford press; and from “IRT for anger, anxiety and depression,” Benjamin draft, Copyright 2012 American Psychological Association
The IRT case formulation method links symptoms to the subjective perspective of the patient. Using a natural biological view of psychopathology and of mechanisms of change, the IRT clinician develops a case formulation that helps patients understand how to focus their efforts to change more effectively. Suppose for example, a patient is angry or anxious or depressed even though there are few objective reasons for it. No matter how seemingly “irrational,” the assumption in IRT is that affect based symptoms of mental disorder correspond reasonably to internalized messages about safety and threat received from attachment figures during the time the genes of the nervous system were being expressed or silenced or changed by epigenetic process.
Suppose a patient was deprived of whatever he cared about – a pet, a friend, a model airplane he built, a doll house she loved. From the patient’s perspective, important loved ones did not want him or her to care. The primitive brain’s apprehensions of such messages about safety and threat are not logical; rather, they simply reflect whatever was modeled and/or requested. Evolution has provided that the child will copy whatever is going on in his or her environment by implicit learning as demonstrated more obviously by language learning in childhood. There are 3 ways to copy apprehensions, affects and behaviors (ABC1s): Be like him or her; act as if he or she is still there and in control, and treat yourself as you were treated. These are “iron rules” if they relate to safety and threat.” The child’s experience of copying is that he or she is doing what he or she is supposed to do; that will bring affirmation, love and protection. Because of the goal is to be affirmed loved and protected, the process of copying is called a Gift of Love (GOL). So when a person is adhering to maladaptive instructions for how to be, the package of apprehensions, affects and behaviors is malaptive and comprises symptoms. In this example, the patient is upset whenever he or she starts to care and promptly undermines whatever it is that he or she was about to commit to. The feelings, the behaviors and the sense of what is right are all maladaptive; they are symptoms of “personality” and affective disorder.
The treatment method is to recognize the related chatter from internalized representations of attachment figures (Family in the Head) and develop the courage to defy the compelling but maladaptive rules and ultimately let go of the vaguely apprehended fantasy that family in the head will affirm, love and protect the patient for such long standing loyalty to their rules and values. Understanding a case formulation helps a patient maintain motivation to engage in “old brain” exercises to recue the affect regulators properly. The “insight” itself is only a guide to change. It might compare to watching a video of an expert golfer to guide one’s practice of a golfing skill. Repetitive practice on one’s own is essential; understanding helps assure that the practice is focused effectively. Teaching the old (subcortical) brain new tricks takes much effort, many many repetitions, and great patience and determination. There is no “Brief therapy” for the old brain any more than there are “brief roads to expertise” in music or athletics or art or any other form of complex activity that requires cortically guided change of subcortical processes. IRT is a longer- term psychotherapy.
Interestingly, I have recently had two cases from my private practice that had quit in frustration because of lack of progress (their view) and unwillingness/ inability to relinquish GOLs (my view). Several years later, they suddenly managed friendly differentiation from the symptom relevant aspects of family in the head and rapidly, even dramatically, changed in very positive ways. I was grateful they were willing to write and tell me about it. This was evidence of latent learning during the therapy process. I have seen that in the IRT clinic too. There, patients are treated for many years if needed. Sometimes, severely disturbed individuals blossom: they get educated if necessary, find and enjoy and do well at work, relate well to their spouses and children and indirectly change whole family systems in part by their own obvious enjoyment of and competence in life. Unfortunately, such results take so long, and we are such a small operation, the sample is tiny. But how many times did humans have to go to the moon to show it could be done?