Interpersonal Reconstructive Therapy: Promoting Change in Nonresponders

Lorna Smith Benjamin first published her elegant description of structural analysis of social behavior 30 years ago (1). Based on a “circumplex” model (her usage was my introduction to the term), it remains a sophisticated conceptualization of interpersonal interactions. Like other scientifically oriented psychologists, she has spent her entire career trying to translate clinical models into formal, testable hypotheses—a noble, albeit often futile, aspiration. Despite Benjamin’s efforts to use the structural analysis of social behavior for research purposes, it has proven too complicated and cumbersome and never gained widespread application. The few research studies using Benjamin’s coding system focused primarily on interactions in psychotherapy. I too have felt that the structural analysis of social behavior is an intriguing foreign language, but not terribly practical; and I never did learn the language.

Benjamin has now developed interpersonal reconstructive therapy, the treatment described in this volume, to further codify her hypotheses about what promotes interpersonal change. In part, interpersonal reconstructive therapy derives from her structural analysis of social behavior model, but it is also an amalgam of clinical wisdom from many different approaches to therapy (both dynamic and behavioral), bolstered sporadically by research findings on psychotherapy outcome and process.

Although interpersonal reconstructive therapy is marketed as a treatment for “nonresponders,” “difficult” or “treatment refractory” cases—wouldn’t we all like a treatment for these patients?—it is a generic therapy. Just as the structural analysis of social behavior model can be applied to any interpersonal interaction, interpersonal reconstructive therapy would seem to be appropriate for anyone who engages in interpersonal interactions, which is to say everyone. We all have important people in our lives and we all have internalized them; thus, her therapeutic model applies to all of us.

Interpersonal Reconstructive Therapy is an articulate synopsis of Benjamin’s therapeutic approach. It lays out her assumptions, values, and clinical hypotheses, often using visual displays such as figures, diagrams, and flow charts and offering numerous clinical anecdotes. Benjamin has a clear sense of what she wants to do with the patient in each session and how to direct the therapy through different stages of change. She exhibits sound clinical judgment and is unafraid to tackle the most difficult and dangerous crises (including suicidal and homicidal behavior as well as psychotic experiences). She inspires confidence, and I would happily refer patients to her.

My qualms about this book are more stylistic than substantive. Benjamin oversimplifies. When the subject is as complex as interpersonal interactions, narrative is more illustrative than visual representation. Her acronyms—such as IPIR for important persons and their internalized representations or DLL for developmental learning and loving—are used repeatedly and end up being annoying. She describes a fundamental psychological conflict as being between “red” and “green,” referring to the regressive resistance that must be given up and grieved for and the growth collaborator that fosters such letting go. Not only does she use this language with the reader, she uses it with patients as well. For all her wisdom and intellectual sophistication, Benjamin lacks nuance.

Steeped in attachment theory, Benjamin believes that nonresponders are stuck because they are reacting to internalizations. If therapists focus on these internalizations rather than the manifest symptoms, more progress will be made. According to her theory, patients give “gifts of love” to their internalized representations in order to stay in psychological proximity. They use one of three “copy processes”—“be like him or her,” “act as if he or she is still there and in control,” “treat yourself as he or she treated you.” Once patients understand their history and gain insight into these patterns, then they will be able to block the pattern and “enable the will to change.” Of course, giving up the fantasy of the IPIR is easier said than done.

Benjamin is at her best when she articulates the values and assumptions underlying her approach, especially with regard to balancing dependency and autonomy and the inappropriateness of justice as a goal of therapy. She has a vision of psychological health that many therapists are reluctant to acknowledge. Unfortunately, Benjamin oversells her treatment. She claims it has empirical support, but this is limited to a few case studies and testimonials from former students and supervisees. As with the structural analysis of social behavior, I fear that interpersonal reconstructive therapy will not gain widespread acceptance, even though its author has developed such a powerful model for understanding interpersonal interactions.