Therapist verification of patient self-concepts as a responsive precondition for early alliance development and subsequent introject change.

OBJECTIVE: Social psychological research has indicated that people strive for self-consistent feedback and interactions, even if negative, to preserve the epistemic security of knowing themselves. Without such self-verification, any interpersonal exchange may become frustrated, anxiety-riddled, and at risk for deterioration. Thus, it may be important for therapists to meet patients' self-verification needs as a responsive precondition for early alliance establishment and development. We tested this hypothesis with patients receiving cognitive behavioral therapy for generalized anxiety disorder-a condition that may render one's self-verification needs especially strong. We also tested the hypothesis that better early alliance quality would relate to subsequent adaptive changes in and posttreatment level of patients' self-concepts. METHOD: Eighty-four patients rated their self-concepts at baseline and across treatment and follow-up, their postsession recollection of their therapist's interpersonal behavior toward them during session 2, and their experience of alliance quality rated after sessions 3-6. RESULTS: As predicted, the more therapists verified at session 2 a patient's baseline self-concepts (which trended toward disaffiliative and overcontrolling, on average), the more positively that patient perceived their next-session alliance. Moreover, better session 3 alliance related to more adaptive affiliative and autonomy-granting self-concepts at posttreatment. CONCLUSION: Results are discussed within a therapist responsiveness framework.

Multigenerational patterns of parenting-at-risk: A test of interpersonal specificity using copy process theory.

OBJECTIVES: This study tests ways in which the perception of intergenerational continuity in parenting behaviors among child-maltreatment (CM) and non-CM families conform to Benjamin's (2006) Copy Process Theory, which considers three copy processes: Identification (be like him/her), Recapitulation (behave as if he/she is still present and in charge), and Introjection (treat myself as he/she treated me). METHOD: Across two home visits and a laboratory session, 171 mothers of preschoolers (M = 3.7 years) completed the SASB Intrex Questionnaire relative to herself, her history with her parents, and her present relationship with her child. RESULTS: Mothers' retrospective reports of her interactions with caregivers were correlated with the quality of self-reported parenting processes in interactions with her preschooler. Analyses indicated high rates of intergenerational copying in both samples for each copy process. While copying in general was observed in nearly all mothers (roughly 80%-90%) and emphasized warm, securely attached patterns, the copying of hostility and/or lack of affiliation occurred in copied profiles for about one-third of mothers. About the more problematic profiles, CM mothers tended to rate themselves as being in the child-like position they experienced in their own childhood, with themes involving hostile control perceived from their child. By contrast, non-CM mothers copied disaffiliative themes primarily in relation to themselves. CONCLUSION: Findings verify that interpersonal patterns and internalized relational histories are important keys for understanding CM risk. The use of a method that offers interpersonal specificity at the level of individual profiles has application to clinical practice with at-risk parents.

Of Love and Death: Death Anxiety, Attachment, and Suicide as Experienced by College Students.

Drawing from the mental health crisis present on college campuses, we investigate the psychological processes associated with suicidal ideation among undergraduate students. Specifically, we used Terror Management Theory to investigate how individuals who have a history of suicidal ideation handle traditional death anxiety in coordination with Benjamin's theory underlying Interpersonal Reconstructive Therapy to explore specific attachment-based mechanisms that may allow for exceptions to the perceived meaning of death. Results show it was the fantasy of suicide itself, including its relevance in the lives of others, that was used to alleviate fear of death among the suicidal.

Case formulation of interpersonal patterns and its impact on the therapeutic process: Introduction to the issue.

Authors included in this issue of the Journal of Clinical Psychology: In-Session come from diverse theoretical orientations but discuss methods of case conceptualization that share these assumptions: (1) that interpersonal patterns are salient to a good understanding of patient personality and problems and (2) that an individual formulation is helpful in responsively tailoring in-session processes to meet therapeutic goals. We believe these assumptions resonate with many practitioners working across settings, levels of severity, and theoretical orientations. Each author offers an overview of theory as well as a detailed case description that emphasizes the implications of each formulation for the subsequent process of therapy. A final paper provides commentary across the source papers. The issue is thus evocative not only about clinical practice issues but also of underlying theory. It speaks to the challenges and possibilities of transtheoretical integrated practice and research within our focal domain of common interest, interpersonal relationships.

Using interpersonal reconstructive therapy to address comorbid problems organized by attachment-based learning: The case of Don.

Feature heterogeneity and diagnostic overlap occur regularly among patients in clinical settings. In interpersonal reconstructive therapy (IRT), a case formulation focused on patterns learned in close attachment relationships guides intervention choices. This study illustrates how IRT formulation and treatment proceed, and how it may also fail when there is not close adherence to underlying principles. Don is a music professor in his 40's with a significant trauma history and complex diagnostic profile that includes many hospitalizations and suicide attempts. He qualified for several diagnostic and statistical manual of mental disorders personality disorders via formal diagnostic interviews (obsessive-compulsive, avoidant, passive-aggressive, narcissistic), as well as major depression, generalized anxiety, and substance abuse. Don's formulation demonstrates how self-destruction can function as a "gift of love" to internalized representations of important caregivers. Data from work with patients like Don confirm the usefulness of Benjamin's IRT lens for navigating comorbidity, as well as the importance of underlying principles of change.

A brief overview of safety planning in interpersonal reconstructive therapy.

Most research to date with Interpersonal Reconstructive Therapy (IRT: Benjamin, 2006) involves application with patients who qualify for the acronym "CORDS": Comorbid, Often Rehospitalized, Dysfunctional, and Suicidal. A case formulation (CF) based on interpersonal copy process theory defines links between presenting symptoms and patterns of affect, cognition, and behavior that invoke safety or threat and were learned and internalized in close relationships. The "gift of love" (GOL) hypothesis is that the wish to receive love and acceptance from specific internalized attachment figures organizes and propels problem patterns and their associated symptoms. Through a series of steps, IRT seeks to help patients become aware of and learn about their copied patterns, including where they were learned, the role they play in maintaining connection with internalized attachment figures, and their functions in the present. The goal is to help a patient differentiate from their "family in the head" and pursue healthy behaviors and self-concepts. With awareness and differentiation comes the possibility of letting go of problematic quests for love and acceptance from the internalized attachments and to choose healthy alternatives instead. As an integrative method, safety planning in IRT shares much with other approaches. What is unique is how therapists utilize the CF to guard against unsafe behavior as an ongoing part of the treatment process with patients with suicidality. This article provides an overview and illustration emphasizing these unique aspects of the IRT approach to safety planning in the context of individual psychotherapy with adults. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Erratum: Therapeutic Atmosphere in Psychotherapy Sessions. Int. J. Environ. Res. Public Health 2020, 17, 4105.

The authors wish to make the following correction to their paper [...].

Therapeutic Atmosphere in Psychotherapy Sessions.

There is uncertainty concerning what the active ingredients in psychotherapy are. The First Experimental Study of Transference interpretations (FEST) was a randomized controlled trial of the effects of transference work (TW) in psychodynamic psychotherapy. Women with low quality of object relations (QOR) showed a large positive effect of transference work, while men with high QOR showed a slight negative effect. The present study aimed to expand the knowledge from the FEST by investigating the therapeutic atmosphere with Structural Analysis of Social Behavior (SASB). Two-way ANOVAs were conducted to investigate differences between SASB cluster scores between subgroups. The therapeutic atmosphere was characterized by Protect-Trust, Affirm-Disclose and Control-Submit. Multilevel modeling was used to assess the relationship between a therapist variable and outcomes for men and women. Contrary to expectations, no significant differences in therapeutic atmosphere between subgroups (with or without TW in women with low QOR and men with high QOR) were observed using the process measure SASB.

Affiliative interpersonal behaviors during stress are associated with sleep quality and presleep arousal in young, healthy adults.

OBJECTIVES: This study examined the association between stress-related interpersonal behaviors, presleep arousal (PSA), and sleep quality. METHODS: Sixty-four participants (53% female) described a recent stressful interpersonal event that was coded for overall degree of affiliation (warmth vs hostility) and autonomy (independence vs interdependence). Cognitive and somatic PSA and sleep quality were examined using regression with affiliation and autonomy scores as predictors. Specific interpersonal behaviors that comprise overall affiliation were also examined. RESULTS: More affiliation (warmth) was associated with lower cognitive PSA (ß=-.32) and better sleep quality (ß=-.28). Autonomy was not associated with sleep quality or PSA. The specific behavior trust in others was associated with better sleep quality (rs=-.25). CONCLUSIONS: Behaviors during stress reflect underlying dimensions of interpersonal security. Findings underscore importance of interpersonal frameworks for understanding associations between stress and sleep, and provide support for the anthropological theory that interpersonal security is necessary for healthy sleep.

Informative Disagreements: Associations Between Relationship Distress, Depression, and Discrepancy in Interpersonal Perception Within Couples.

This study evaluated the associations between relationship distress, depression symptoms, and discrepancy in interpersonal perception within couples. After completing a series of discussion tasks, couples (N = 88) rated their behavior using the circumplex-based Structural Analysis of Social Behavior Model (SASB; Benjamin, 1979, 1987, 2000). Overall, couple members were strikingly similar in their interpersonal perceptions, and tended to see themselves as friendly, reciprocal in their focus, and balanced between connection and separateness. As hypothesized, however, perceptual discrepancy was related to relationship distress and depression. Relationship distress was associated with discrepancy regarding transitive behavior focused on the partner, while depression was associated with disagreement about intransitive, self-focused behavior. Analysis of affiliation and autonomy revealed that relationship distress was associated with seeing oneself as reacting with more hostility than the partner sees, and perceiving one's partner as more hostile, more controlling, and less submissive than he or she does. Partners of depressed individuals viewed themselves as more controlling than their mate did. Men's depression was associated with disagreement between partners regarding men's self-focused behavior. Results underscore the importance of considering interpersonal perception when conceptualizing relationship distress and depression within intimate relationships.

Reliability, Sensitivity, and Specificity of Case Formulations for Comorbid Profiles in Interpersonal Reconstructive Therapy: Addressing Mechanisms of Psychopathology.

Interpersonal Reconstructive Therapy (IRT) case formulations describe psychosocial mechanisms of affective and personality pathology in ways that enhance the effectiveness of psychotherapy for individuals. With a valid and reliable IRT case formulation, a clinician is in a better position to draw upon effective techniques to maximize treatment effects. The case formulation and treatment models for IRT were described in depth along with the IRT treatment model by Benjamin (2003/2006). Data in this report from 93 adult inpatients with complex and comorbid presentations suggest that the case formulation is highly reliable and unique to individuals, and that symptoms reflect current interpersonal stresses linked to early interactions involving forms of hostility in relation with attachment figures and corresponding to three basic patterns in adulthood: identification (be like him or her), recapitulation (act as you did with him or her), and introjection (treat yourself as you were treated).

Affiliation and control in marital interaction: interpersonal complementarity is present but is not associated with affect or relationship quality.

The principle of complementarity in interpersonal theory states that an actor's behavior tends to "pull, elicit, invite, or evoke" responses from interaction partners who are similar in affiliation (i.e., warmth vs. hostility) and opposite in control (i.e., dominance vs. submissiveness). Furthermore, complementary interactions are proposed to evoke less negative affect and promote greater relationship satisfaction. These predictions were examined in two studies of married couples. Results suggest that complementarity in affiliation describes a robust general pattern of marital interaction, but complementarity in control varies across contexts. Consistent with behavioral models of marital interaction, greater levels of affiliation and lower control by partners-not complementarity in affiliation or control-were associated with less anger and anxiety and greater relationship quality. Partners' levels of affiliation and control combined in ways other than complementarity-mostly additively, but sometimes synergistically-to predict negative affect and relationship satisfaction.

Depression, relationship quality, and couples' demand/withdraw and demand/submit sequential interactions.

This study investigated the associations among depression, relationship quality, and demand/withdraw and demand/submit behavior in couples' conflict interactions. Two 10-min conflict interactions were coded for each couple (N = 97) using Structural Analysis of Social Behavior (SASB; Benjamin, 1979a, 1987, 2000a). Depression was assessed categorically (via the presence of depressive disorders) and dimensionally (via symptom reports). Results revealed that relationship quality was negatively associated with demanding behavior, as well as receiving submissive or withdrawing behavior from one's partner. Relationship quality was positively associated with withdrawal. Demanding behavior was positively associated with women's depression symptoms but negatively associated with men's depression symptoms. Sequential analysis revealed couples' behavior was highly stable across time. Initiation of demand/withdraw and demand/submit sequences were negatively associated with partners' relationship adjustment. Female demand/male withdraw was positively associated with men's depression diagnosis. Results underscore the importance of sequential analysis when investigating associations among depression, relationship quality, and couples' interpersonal behavior.

Transference interventions and the process between therapist and patient.

Interpreting the transference has been considered a core ingredient in psychodynamic psychotherapy. The effects of analyzing the transference are probably dependent on certain characteristics of the interventions themselves and the context in which transference interventions are given. The present study describes the development and use of a therapy process rating scale (Transference Work Scale; TWS) constructed to identify, categorize, and explore work with the transference. TWS has subscales that rate timing, content, and valence of the transference interventions, as well as response from the patient. Transcribed segments (10 min) from 51 different patients were scored with TWS by 2 independent raters. The interrater agreement on the TWS items was good to excellent. Clinical examples of transference work were also rated using the Structural Analysis of Social Behavior (SASB). TWS and SASB supplement each other. TWS might be a potentially useful tool to explore the interaction of timing, category, and valence of transference work in predicting in-session patient response as well as treatment outcome.

Comparing the interpersonal behavior of distressed couples with and without depression.

OBJECTIVE: This study compared the interpersonal behavior of distressed couples with depression in one partner (n = 23) to distressed couples without depression in either partner (n = 38). METHOD: Participants (mean age = 44 years old) were recruited at an urban outpatient mental health center. Couples discussed the three best things in their relationship, and their interactions were coded using Structural Analysis of Social Behavior (Benjamin, 1987). RESULTS: Self- and partner-focused hostility were associated with actors' and partners' relationship distress. Actors' hostility towards partners was positively associated with partners' depression status, but negatively associated with partners' depression symptoms. Actors' control behavior was positively associated with their relationship distress. Whereas the behavior of depressed individuals did not differ from a control sample of nondepressed individuals, partners of depressed individuals displayed more partner-focused hostility and submissiveness than controls. CONCLUSIONS: Results underscore the importance of considering partner effects when conceptualizing depression within distressed relationships.

Tailoring common treatment principles to fit individual personalities.

The American Psychological Association Task Force headed by Castonguay and Beutler (2006) distilled general treatment principles common to all therapies from the empirical literature. As part of this work, Critchifield and Benjamin (2006a, 2006b) summarized principles for treatment of personality disorder. The principles are pragmatic in the sense that they are based on evidence of what works, and clinicians are encouraged to apply them in ways that fit the unique presentation and needs of a given patient. An important element of the recommended approach is that it be coherent, well-coordinated, and agreed upon by the patient. Additional principles emphasize the importance of an individual's attachment and trauma history. A complex case example is presented to illustrate one way in which emphasis on an individual's relational learning history can be used to further refine and extend wisdom inherent in the cross-cutting principles and move in the direction of an integrative treatment that is closely tailored to specific case features. A research approach is also outlined for how to test the validity of principles that prescribe differential use of technique to address diverse patient presentations.

Assessment of repeated relational patterns for individual cases using the SASB-based Intrex questionnaire.

Repeated interpersonal patterns are central to case conceptualization and treatment planning in interpersonal and attachment-based approaches to therapy. In this study, raters (133 college students, 165 inpatients) provided data on the Intrex questionnaire (Benjamin, 2000) about self-treatment, relationship with a significant other, and remembered interactions with parents in childhood. Within-subject profiles were inspected for precise behavioral matches conforming to 3 "copy process" (CP) patterns: identification (behaving like an important other), recapitulation (behaving as if the other person is still present and in charge), and introjection (treating the self the way another did). We observed CP evidence in most individual ratings. Consistent with expectation, nonclinical raters tended to copy a securely attached pattern of affiliation, low hostility, and moderate degrees of enmeshment and differentiation. Only patients copied maladaptive behavior at greater than base rate expectation. We discuss implications and provide recommendations for use of Intrex in individual assessment of CP.

Structured Interview of Personality Organization (STIPO): preliminary psychometrics in a clinical sample.

In this article, we describe the development and preliminary psychometric properties of the Structured Interview of Personality Organization (STIPO), a semistructured interview designed for the dimensional assessment of identity, primitive defenses, and reality testing, the three primary content domains in the model of personality health and disorder elaborated by Kernberg (1984; Kernberg & Caligor, 2005). Results of this investigation, conducted in a clinical sample representing a broad range of personality pathology, indicate that identity and primitive defenses as operationalized in the STIPO are internally consistent and that interrater reliability for all 3 content domains is adequate. Validity findings suggest that the assessment of one's sense of self and significant others (Identity) is predictive of measures of positive and negative affect, whereas the maladaptive ways in which the subject uses his or her objects for purposes of regulating one's self experience (Primitive Defenses) is predictive of measures of aggression and personality disorder traits associated with cluster B personality disorders. We discuss implications of these findings in terms of the theory-driven and trait-based assessment of personality pathology.

Internalized representations of early interpersonal experience and adult relationships: a test of copy process theory in clinical and non-clinical settings.

Studies connecting childhood experience and adult psychopathology often focus on consequences of abuse and neglect. Copy process theory (Benjamin, 2003) states that constructive as well as destructive experiences shape adult behavior with surprising interpersonal specificity. Childhood perceptions and social learning are encoded in memory and then "copied" in 3 basic ways in subsequent relationships: Identification (behaving as he or she behaved), Recapitulation (behaving as one behaved when with him or her), and Introjection (treating oneself as he or she was treated). The first step in evaluating copy process theory is to verify that the predicted correspondence between adult relational patterns and internal representation of early experience can be observed in different adult samples. Remembered interpersonal patterns from childhood and perceptions of adult relational patterns were measured using the Structural Analysis of Social Behavior (SASB). Strong evidence was found for each copy process in a sample of psychiatric inpatients (N = 161) and a college sample (N = 133). Positive and negative behaviors were copied in both. Evidence suggests that gender, patient status, and rated state may influence whether, and in which forms, copying occurs.

The relational context of aggression in borderline personality disorder: using adult attachment style to predict forms of hostility.

Attachment theory provides a framework for understanding and predicting critical aspects of aggression in the personality disorders. An association between borderline personality disorder (BPD) and insecure forms of adult attachment marked by high relationship anxiety has been repeatedly observed in the empirical literature. Aggression also has been linked to insecure attachment. The present study extends previous work by exploring the degree to which the underlying attachment dimensions of relationship anxiety and avoidance are associated in BPD with the following forms of hostility: (a) direct aggression (verbal or physical) initiated towards others, (b) expectation/perception of aggression from others (including "reactive" counteraggression when/if provoked), (c) aggression directed towards the self in the form of suicidality or parasuicidality, and (d) affective experience of irritability or anger. The issue was studied in a sample of 92 patients diagnosed with BPD. Results show significant association between more fearful forms of attachment (simultaneous presence of relationship anxiety and avoidance) and the more reactive form of aggression involving expectation of hostility from others. Self-harm was significantly associated only with relational avoidance while anger and irritability were associated only with relational anxiety. Implications for understanding relational aspects of BPD aggression in research and clinical work are discussed.