Lorna Smith Benjamin

The latest in SASB and IRT

IRT case formulation and treatment models

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.

Every creature adapts to its environment

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.

Iron rules that are no so safe





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?

Reverence for things past

5 comments on “IRT case formulation and treatment models

  1. Dick Eriksson, licensed psychologist,licensed psychotherapist
    February 7, 2014

    Hello Lorna!
    Lovely and inspiring text. I have both your books and you signed my copy of the IRT book when you were in Stockholm , invited by Andreas Birgegard, a number of years ago.

    When is your book “IRT for anger, anxiety and depression” being published and on the market for purchase? I´m really looking forward to reading it and would love to see it on the market soon.

    Best regards
    Dick Eriksson

    • Lorna Smith Benjamin
      February 9, 2014

      Hello to you too!

      I am happy to say that i am finally at long, long, last finishing up. The new book will go out for review soon, and then, hopefully directly to press. whew.. i have taken so much time to look things up, write and rewrite to be sure all is clear and backed by data. and there is the usual problem of keeping language simple and clear enough not to lose the over-busy reader.

      I am coming to the next SPR meeting in Denmark and was just about to write to Andreas to see if we could meet there it would be nice to see both of you again. Possible?

      Thanks for writing.

  2. Dick Eriksson, licensed psychologist,licensed psychotherapist
    March 13, 2014

    Ooohh, sorry for not replying sooner. Thanks for your reply and I´m really looking forward to your book. Regrettably I won´t be going to Denmark. I´m doing a core training in Davanloo´s ISTDP here in Sweden and that has about emptied my budget for travelling. Hopefully Andreas will be going though.

    All the best


  3. Daniel Fox
    September 4, 2019

    Dr. Smith Benjamin: I am continually moved and in awe of the impact and power of the IRT process. As a psychologist who specializes in working with personality disorders I am continually going back to Red and Green concepts and exploring the introject with my clients to create insight to ignite behavioral activation to change. The GOL is powerful for so many. I cannot thank you enough for your brilliance and all you’ve given to the therapeutic community.

    • Lorna Smith Benjamin
      September 4, 2019

      Thank you Daniel Fox. I am hopeful that more therapists will understand the value of (and IRT method for) working with adaptive natural biological reasons for symptoms rather than simply blocking or diverting or suppressing them. If you go to APA, let us get in contact? I’d like to meet you.

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