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Wise Counsel Interview Transcript: An Interview with Lorna Smith Benjamin, Ph.D. on SASB and the Structure and Treatment of Personality Disorders

David Van Nuys, Ph.D.

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David Van Nuys: Welcome to Wise Counsel, a podcast interview series sponsored by CenterSite, LLC, covering topics in mental health, wellness, and psychotherapy. My name is Dr. David Van Nuys. I'm a clinical psychologist and your host.

My guest today is Dr. Lorna Smith Benjamin and we will be discussing the assessment and treatment of personality disorders. Lorna Smith Benjamin, Ph.D. is professor of psychology, adjunct professor of psychiatry and founder of the Interpersonal Reconstructive Therapy Clinic, University of Utah Neuropsychiatric Institute. She received her undergraduate degree from Oberlin College and her master's and Ph.D. in psychology from the University of Wisconsin in Madison, Wisconsin. She's received many awards over the course of her career, including the Bruno Klopfer Award for outstanding long-term professional contribution to the field of personality assessment. Dr. Benjamin also served as an advisor to the DSM IV Workgroup Access II. In addition, she has written extensively, including two books. One is titled Interpersonal Diagnosis and Treatment of Personality Disorders, and the other is Interpersonal Reconstructive Therapy: Promoting Change in Non-Responders.

Now, here's the interview. Dr. Lorna Smith Benjamin, welcome to Wise Counsel.

Lorna Smith Benjamin: Thank you, I'm happy to be here.

David: Yeah, I'm glad to have you. Let's start out with your background. How did you get interested in psychology in the first place?

Lorna Smith Benjamin: Oh, I think that happened when I was in Oberlin College taking a psychology class and George Heise, a fresh graduate from Harvard who had worked with Skinner, introduced me to the idea of behaviorism. At that time it was purely descriptive and I just was fascinated. He put his dog on the desk - and the dog's nickname was Edward - and he said, "Watch Edward; let's study his behavior." And he just handled that in such a way that I thought, oh, this is really pretty good.

David: Did Edward do any special tricks or anything as the result of operant conditioning?

Lorna Smith Benjamin: Well, no, that would be at the advanced level. For example, he sniffed and walked around and that was exploratory behavior, and when I later on became a graduate student of Harry Harlow's at the University of Wisconsin primate lab, I got to see baby monkeys and baby monkeys growing up; and exploration is a really important dimension of cross-species, important dimension of mammalian behavior. And, indeed, I think curiosity and exploration are pretty important in human development too. So, he just right there, just on the desk, showed a trait that I can see operative even in my clinical practice today.

David: Yes, and Harry Harlow, of course, did landmark work. Were you at all involved in his wire monkey surrogate mother studies, or had that already happened when you showed up?

Lorna Smith Benjamin: It was happening when I was there. I got to be one of the graduate students that was up in the night, trying to feed the babies, keep them alive. It hadn't been done in captivity before that. Yeah, that was the late '50s; it was a very interesting time, I must say.

David: Oh, yes, what an exciting background. So is that where you did your doctoral work then? Was that at Wisconsin?

Lorna Smith Benjamin: Yes, my dissertation was with Dr. Harlow and I compared the psychoanalytic view of thumb sucking to what I decided would be a learning view of thumb sucking. And that, too, started a trend that's still with me today, in that the question was: if you deprived baby monkeys of the chance to suck enough during feeding, then they should be allowed to displace the sucking - the unmet sucking energy discharge - on their thumbs. And so, in other words, thumb sucking was an indication of lack of satisfaction during feeding. And I thought, no, by learning theory, thumb sucking probably is a residual of the pleasure of sucking while eating. And so I designed a little study to compare the two and I'm happy to say learning theory won.

David: And it's interesting in your current work - and we'll get to that in just a moment here - in your dissertation work that you just described, you were attempting to reconcile some psychoanalytic thinking with, or at least to test it against, some more modern theories. And it seems to me that's a thread that's stuck with you throughout your work.

Lorna Smith Benjamin: Yes, it has.

David: Okay, well, you've specialized in personality disorders. How did you come to do that?

Lorna Smith Benjamin: How did I come to do that? I think I've always been very interested in interpersonal interactions. That, again, comes from loving to try to understand behavior and loving animals. I guess I'm bragging; I have a daughter who's a veterinarian. And I made observations of monkeys and tried to codify them with this thing called Structural Analysis of Social Behavior - and infants. And my goal with that - the SASB, Structural Analysis of Social Behavior, was to try to have a way, a language, of conceiving of interactions that would help capture what actually happens in psychotherapy. So, interpersonal interactions and the SASB kind of put me in the domain of social interactions; and that evolved quite naturally into a study of personality disorders when the DSM III came along and tried to objectify the diagnostic system by getting rid of theory that would involve unmeasurable concepts like unconscious conflict and replaced that theory with descriptions that were more or less behavioral. And so, if I'm interested in behavior and know something about it, personality disorders was a good place to be. I think it probably crystallized when Allen Frances, who was editor of the DSM IV, invited me to write a book on personality disorders.

David: That will certainly crystallize things, no doubt about that. Now, clearly you have very strong credentials as a researcher. Are you also trained as a psychotherapist?

Lorna Smith Benjamin: Oh my, yes. I was trained back in the '50s and '60s and '70s when psychodynamic therapy was the treatment of choice, and I value that deeply. I was lucky; I also had Carl Rogers as a supervisor for six months.

David: Oh, my goodness.

Lorna Smith Benjamin: Yes, he was there at the University of Wisconsin in the early '60s and I met a lot of the greats in family therapy, because as Carl Whitaker came there, my colleagues in the department of psychiatry at the University of Wisconsin, Madison, invited them for a series of seminars. I got to be their escort and drive them around Madison, so I made some personal contacts too. I still love psychotherapy; I think it's a tremendous mistake for it to be consigned to the margins these days, as appears to be the case, in both psychology and psychiatry.

David: Okay, well, that's a different discussion, a very interesting one, and perhaps we'll have that in a subsequent interview. But coming back to personality disorders, I suspect that many of our listeners are lay people rather than researchers or therapists, so perhaps you could give us a quick definition of personality disorder and list the major types.

Lorna Smith Benjamin: Oh, well.

David: Off the top of your head. If that's too much, we can just keep moving along.

Lorna Smith Benjamin: No, no, the personality disorders right now in the handbook for diagnosing, called The Diagnostic and Statistical Manual or the DSM, are defined by a list of traits or symptoms. And this was created by committee - committee of wise clinicians in my opinion - and there were originally, when the DSM III began it's objectification of the psychological disorder manual, there were 11 original disorders. And they can be grouped in roughly three clusters and they have names like paranoid personality disorder for the eccentric cluster; and then there's the dramatic-erratic cluster, borderline personality disorder's an example there. And then there the anxious-neurotic cluster - it's not quite the name, but that's the idea - and you have, say, avoidant personality disorder or obsessive-compulsive personality disorder there. They have names like that you've probably heard, and there's lists of traits to define them. Each disorder is defined by a list of traits. For example, obsessive compulsive personality disorder is defined by traits like: perfectionism, compulsion to make lists and lists of lists; need to control so that things turn out correctly.

David: Okay, that gives us a good idea. Now, another thing, the DSM distinguishes between clinical disorders and personality disorders. Is that right? And give us a thumbnail sense of the difference between the two.

Lorna Smith Benjamin: Well, yes, the clinical disorders are assigned to Axis I and they include the ubiquitous various versions of depression, depressive disorders, and anxiety disorders and also the thought disorders of schizophrenia and the more severe psychotic, delusional disorders. Those are clinical disorders and my take on it is those are considered to be the primary mental disorders. There are five other axes and the personality disorders come on the second axis of the DSM. They're primarily behavioral and I think they're viewed as kind of modifiers of how the person copes with his or her clinical disorders. So if you have, for example, an obsessive-compulsive personality disorder and you're depressed, you're probably going to take your medicines in a regular way. But if you are borderline personality disorder you might be more erratic about it. So the relationship between personality and clinical disorders is controversial; there's a lot of overlap. In the DSM V, the new manual, the whole thing may be revised but that's where we are today.

David: Yes, and the idea of personality disorder sounds kind of pejorative. I mean, having symptoms of some sort is one thing but being told that you have a personality disorder might seem equivalent to condemning your inner essence. Can you comment on that?

Lorna Smith Benjamin: Well, yes, I think that that is, in fact, the way people react to that label and even clinicians too. I must say, some labels get applied more frequently than others as a way of saying this person isn't properly responding to medications, and so they must have a personality disorder. But that's not official; it's not sanctioned, but it is kind of a way that it happens sometimes. It's too bad. I think personality disorders just naturally evolve from one's social learning, and we have patterns and when they're constant and when they cluster together in a certain way, we give them the name personality disorder. I don't think there's any moral opprobrium that should be assigned to that, but it is.

David: Well, when we speak about personality disorders does that imply that we know what a "normal" personality looks like?

Lorna Smith Benjamin: Well, there's lots of controversy about that. The received wisdom says we don't; we only know normal relative to what people who aren't in the clinic are doing and are like. I personally do think I can define normal, but that's a whole other story.

David: Okay, maybe that story will emerge a little bit as we continue. Now, I was looking at one of your recent papers and you point out that comorbidity, that is, the presence of both a clinical, symptom based disorder and a personality disorder means the problem will be much more resistant to treatment. Do I have that right?

Lorna Smith Benjamin: That's what the research shows, yes. Depression maybe can respond to a medication if it's not complicated by embedded traits that are maladaptive and might be called personality disorder. If those traits are there it's going to be really hard for the depression to respond to medications alone.

David: Okay, and in that same paper you're critical of older, static models of personality and you argue the need for an approach that's more interactive or interpersonal. Can you take us through that a bit?

Lorna Smith Benjamin: Oh, yes. I think that the diagnostic system itself, whether we're talking about clinical disorders or personality disorders, tends to kind of have check lists of static traits, like we're fixed beings that are the same in some way in every relationship. And I don't think that's a really good way to develop a science since, if we use physics and chemistry as our model, or medicine even, we can see that a study of how things interact is really much more fruitful than just trying to describe their attributes.

David: Yes, that makes sense to me.

Lorna Smith Benjamin: Yeah, I think the infectious theory of disease, for example, is a really good way to illustrate that. For centuries, when someone got sick, they could be given what might be called medications, that is, various herbs. And it would be noticed that this or that herb would relieve this or that symptom, and so it was just kind of descriptive and trial and error and catalog how things go. And that was treating the traits or the fixed list of symptoms. But along comes germ theory - that's an interesting story in itself - and we now understand that disease - an infectious disease - is a reaction to an external agent. And with germ theory, obviously, so much more was possible in terms of understanding cause and developing effective treatment. So interaction really is where the action is in science. Physics and chemistry do it with the quarks and with atoms; elements interact to make compounds. Astronomy does it with the interactions of planets and stars, and interactions of galaxies. Interactions are where the action is.

David: Yes, well, I was impressed by the elements that you propose - the interactive elements - and you suggested that we need to pay attention to 1, context; 2, state or mood; 3, subjective viewpoint; and 4, objective viewpoint. I really like that list and I guess partly it's my commitment, both as a therapist and as a humanistically oriented person, that you included something about the subjective.

Lorna Smith Benjamin: Oh, sure. I think that we've gone slightly robotic in our thinking as scientists when we discount the phenomenology of the individual. After all, how a person sees the world is certainly going to affect how he or she behaves. So the example I think I had in that paper is if somebody has hallucination that tells them that God is telling them to kill everybody in the church because they're sinners, you want to worry about that person because he might take action on that perception, that inner experience. So I really think we should assess people's point of view when trying to understand them. Actually whether we're talking about the clinical disorders like depression or anxiety or whether we're talking about personality disorders like obsessive-compulsive personality disorder, it's really good to start with how the person sees the world in order to understand him or her.

David: Yes, and the other elements that you outline here seem very important: to understand the context in which they're operating, to understand the mood that's driving them at the moment, and to have that subjective view but also the objective view. And you've developed an approach for tracking all of that - incredible, it's kind of mind-blowing what you've done - and you call this approach, you referred to it earlier as SASB, I think, Structural Analysis of Social Behavior. Tell us a bit about how this sort of analysis would be accomplished.

Lorna Smith Benjamin: Well, the model itself is based on belief and faith in the theory of evolution. I think we're a herd animal and that the way we are built and function derives from Darwin's principle of natural selection; which, by the way, is hardly random. That's such a controversial subject and I don't understand why because variability is very systematic and it's built in and it means that we can adapt and survive if conditions change. There will be a few of us that will be different enough we can make it; and that variability is distributed according to the normal curve, it's not random. So I have profound respect for the theory of evolution, and if we're a herd animal, then it's clear that sticking together as a herd is primary; so attachment is primary; love, community is primary. And so the SASB attempts to find underlying dimensions to social interactions which, after all, are what define us as a herd animal. There are four, what I call, primitive poles on the model. This evolved from having infants and working with primates and reading a lot in the literature, being a developmental psychologist. The four poles are sexuality and power, and murder and territory.

David: Wait, was murder one of them?

Lorna Smith Benjamin: Well, annihilating attack, yes.

David: That was a rather surprising one on the list; you caught me by surprise there.

Lorna Smith Benjamin: Well, the poles define the absolute maximums of whatever dimension we're talking about.

David: I'm sorry, run through the poles again. I got distracted.

Lorna Smith Benjamin: Well, I'll put them in opposition. Opposite murder is tender sexuality; and that's a primitive basic, it's the maximum of attachment. I'm not talking about sexual behavior. In humans that can get totally weird and can be anything but maximal attachment; but that, too, is another subject. But in the basic evolved norm, sexuality's a bonding phenomenon and murder is a terminating phenomenon, okay?

David: Yes.

Lorna Smith Benjamin: All right, and then orthogonal - meaning at right angles to that axis, murder to love - orthogonal to it is what I call interdependence to independence. And on the interdependence pole there's power - managing and controlling. You have to have that; you have to manage space and available goods and supplies so that some can survive if there are restricted amounts. And control is matched by submission, so that's interdependence pole; and then the other side of interdependence is independence, endorse freedom and freely come and go. So those dimensions - love to hate and interdependence - really give you the basic concepts with which to describe almost anything as being made up of components of those in their various forms. And also multiple codes; that is, some people are pretty skilled at giving more than one message in the same speech, and this can make your head spin if done in one way, and it can make you laugh if done in another way. So this SASB, basically, is a way of unpacking social interactions in terms of those basic underlying dimensions.

David: So, how would you apply SASB in sort of a totally different field of dance? I know that there are systems for actually coding movements as a dancer is moving; is this something that you can apply? That you can code behavior as, say, in a family interaction or something like that or in an interaction between a therapist and a patient?

Lorna Smith Benjamin: Oh, absolutely, it's been done quite a bit in psychotherapy research, the codes of this sort you're talking about, the objective behavioral codes. There also is a parallel measure using questionnaires where people can rate themselves by their own view of themselves in relation to others, and that is in the same metric, uses the same language. But one system is to have the objective observer; the other is to have the person self rate. An example in the family might be what happens, what can you tell, using the SASB if a parent says to a child, "I can't believe you did that; you never do anything right." What is the child likely to do and how will that affect his personality subsequently? Those kinds of questions can be mapped and tracked using the SASB. A quick example: "you never do anything right" - that's coding the parent focusing on the child. The parent is focusing on another person and that is, actually, the first dimension of the SASB model. Is the focus on another person as the parent is focusing on another? Or is it on the self? I'll give you an example of self, perhaps, in a minute. So there's a focus on another person there and then the next question is, is it friendly or hostile? Well, it's kind of hostile - "you never do anything right." Let's say sort of half way between neutral and murderous.

David: That's right.

Lorna Smith Benjamin: Somewhere in there. And then the next question on the vertical axis is - when you're focusing on other, the vertical axis gives you the choices of control versus endorsed freedom. Well, this is hardly endorsing freedom in the child and it is certainly controlling. Going on the range from absolute micro-management of every thought and action and feeling to letting a person go totally free, we'll go just a little bit of half the way, let's say, towards neutrality on that dimension. And that puts us on the full model at the point appropriately enough "accuse and blame". So that's part of what's called "hostile enmeshment". Now the child will match that by focus on self, typically - it's not guaranteed but this will be the natural draw because I think we're hardwired to respond in predictable ways to what others do, otherwise there wouldn't be any order in the troop, right? So, focus on the self - what's called the complementary dimensions - child's not going to be terribly friendly in reaction to "you never do anything right", so let's put that half way toward "desperate protest" from the neutral point and bring it down half way on the submissive dimension and we get "appease and scurry" or maybe "sulk and act put upon". So you blame a child, you put him down; he's going to show resentful submission to summarize it. And that, in turn, will affect his self concept if done on a long-term basis by the process that Harry Stack Sullivan first called introjection. It basically means you're going to treat yourself like you've been treated, especially by loved ones. So the child who's told "you never can do anything right" is soon going to be telling himself, "I never do anything right." And that is coded on the introject surface of the SASB model as "be guilty and have a bad self" concept. So if that goes on into adulthood the child is going to have what's called "poor self esteem" of this particular sort. And also, if that self criticism is too pervasive, it'll comprise a big component of depression. So a child who's taught to believe he's no good, never does anything right, is going to be pretty self critical and resentfully compliant; and helplessness and despair are components of depression. So there's a direct link between Axis II personality pattern and Axis I clinical disorder of depression. And I think the boundaries are very fluid; that certain interpersonal positions set you up for the clinical disorders and that's just one example of how.

David: Yes, that's a beautiful example. It's hard to probably for listeners to really visualize this in the full specific detail in which you're able to implement it. Now, are we talking about three axes here?

Lorna Smith Benjamin: Potentially, but in the present form there's three surfaces, three different planes - that is, flat surfaces, three of them. And those define the types of focus; there's focus on other, as I just illustrated with the parent; focus on self that I just illustrated with the child; and then intrapsychic, turning focus inward, which I illustrated with the idea of self criticism in terms of treating oneself as one has been treated. On each of those planes, the two orthogonal axes with those primitive poles exist. They have different names depending on the focus; so hate to love is the horizontal axis on each of the 3 planes. On focus on other, it's attack or murder others; when turned inward on the third plane, focus on introject, it's annihilate self or suicide, for example. If attack is coded on the self surface, the intransitive reactive surface, it's desperate protest, a cry of being murdered. It matches murder; and suicide is the introjection of murderous attack.

So, if a child, for example, is raised believing that his existence has ruined his parents' life and everybody'd be better off if he was dead, he's going to be suicidal. And these principles get acted out by the wisdom of some of our novelists and movie writers. That particular one, the child murdering to please the parent because he shouldn't exist, is in the amazing movie called Jude, or Jude the Obscure. Just briefly, it's a story about a poor mason and his wife who wander from pillar to post to find work and shelter and food. They have the son from his first marriage and they conceive two more children, so they have three children, and they have a very hard time making it, getting food and lodging. They're often rejected; this would be back in, I think, the early 1800s, I'm not sure of the exact time. But there was no room at the inn for them because of the children. And this goes on for years and one day the parents come home and they find the two younger children stabbed to death, apparently by the oldest son, who'd hanged himself. He left a note indicating times would be better for them now without the children. So, he seems to have introjected his treatment as a perceived unwanted entity and he gives his parents what he thinks they most want; and, of course, it wasn't. And their marriage was destroyed. But there's a lot of wisdom out there; it just hasn't quite made it into the profession, in my opinion.

David: Yes, well, one of the things that struck me was, by applying your model, you have generated a number of very specific descriptive words - and I'm wondering what the number is. I'm thinking of this page that I saw and I don't have it in front of me, where you kind of showed a map; it was kind of a personality map with all these very specific words and a number next to each, so that if a person was four on this dimension and a four on this other dimension and a two on this other dimension, then they were a 4-4-2, and that had a very specific description. Am I making any sense?

Lorna Smith Benjamin: Yes, oh yes, sure. I'm delighted you ask; I have to confess that you're referring to the full version of the SASB model, which is my absolute favorite, but I hardly use it and that is because editors and others complain that it's too complex.

David: Yes.

Lorna Smith Benjamin: I don't think it is too complex for what it aspires to do and what it can do. So, typically, people use simplified versions of the SASB model where there's a lot fewer points and more familiar categories. But this wonderful Ferrari version of the SASB has, actually, 36 subdivisions of each of those three planes. So there's a total of 108 altogether. It's a very fine resolution.

David: Yes, and that really was one of the questions I was going to get at, which is it does, in fact, seem so comprehensive. I mean, it's mind-blowingly comprehensive and seems like a wonderful window onto human behavior on the one hand; and on the other hand, if I imagine myself as a clinician trying to get all of that into my head and be able to use it, it would feel pretty overwhelming.

Lorna Smith Benjamin: Yes, exactly. And that's exactly why the simplified versions are used more often. In my personality disorders book the single word, simplified cluster model is used, so that the whole domain, for example, of hostile control is reduced to one word: blame. But on the full model, it begins near the control pole as enforced conformity, and then as you go step-wise toward the murder pole, becomes intrude, block, restrict; put down, act superior; accuse, blame; delude, divert, mislead; punish, take revenge; rip off, drain; approach menacingly; and annihilating attack. You can sense the increase in the hostility as I go through those steps. And all of that gets just lumped into blame in the simplified model. But it's easier to use. Even so, this has been around since - well, my first draft was 1968, first publication was 1973. And it's used a fair amount, but it's hardly universal. I think it should be, but it isn't.

David: Yeah, well, I can agree with both of those. It certainly looks like it should be and I can see what the problem would be. in terms of people really investing the time and energy that you have, in developing all of this. And they wouldn't have to re-invent the wheel, but it would take some effort to learn it. What are the implications of your structural approach for treatment?

Lorna Smith Benjamin: Well, I think that it's a really good idea to know what you're treating and where it came from before you go ahead and start doing techniques. And so this requires integrative thinking and very thoughtful diagnostic workup. So the SASB model is useful in describing the problem in the first place, and describing it accurately; and also in defining goals. I've used it to develop a whole clinical approach called Interpersonal Reconstructive Therapy and the SASB is integral to the description of interactional patterns and in tracking how those patterns evolved. I gave you one example, the self criticism and then another, suicide - tracking all of those things. So the Interpersonal Reconstructive Therapy, called IRT, gives the clinician a kind of a summary of the results of work with SASB and guides the treatment by providing diagrams about steps to take and things to do for a particular problem patterns. Let's see, working with the example I chose, suppose someone is really self critical and they're just really viciously shredding themselves and they can't stop it. And they've had instruction on the unrealistic nature of their self criticism, but they can't help it; they keep doing it. Well, I've learned that since they're doing it because someone they loved thought it was appropriate, their view - not that it was, but their view - they keep doing it in order to please that person, as that person now is residing in their mind. That's called internalized representation. John Bowlby, a psychoanalyst, first talked about internal working models. Children are guided by imitation and by what they've seen being done, not only to them but to others. Children do what they see, so here this person is criticizing himself because it was done to him by a loved one, and he's doing it, I believe, because he wants to please that loved one. It sounds kind of counter-intuitive, but I believe, in fact, almost all of mental disorder is a form of auto-immunity or self-sabotage that's done out of love. Now, that probably sounds completely wacky, but I really, really believe it's true because attachment is so important to us. So here we have this self critical person treating himself badly because his dad did, and he loves his dad, and that's what he's supposed to do. What does that mean for treatment? Well, first of all, it's good for him to understand that that's what he's doing; and then he needs to renegotiate his relationship with that internal version of dad. It's important to know that's not necessarily how dad actually was or still is, but it is how he sees it. So he has to renegotiate that relationship with the internal dad - the family in the head, I call it.

David: Yeah.

Lorna Smith Benjamin: And that involves what's technically called differentiation, which means you've got to separate from those commands and beliefs. You don't have to be hostile - IRT is a family friendly approach - it's perfectly possible to have your own mind and go your own way and still be loving in relation to others. You have to change the rules somewhat and it's not easy; and it helps to have a definition of what's normal and the SASB does provide a definition of what's normal. I've gotten that from the theory of attachment as primary and from lots of data that compares people's ratings of themselves and others, and objective observers' ratings and interactions when they have symptoms and when they don't. And it may sound awfully simple, but friendliness - genuine friendliness, not fake friendliness, not complex friendliness - genuine love of others is very healthy and it is the norm, and that's the therapy goal. So if you accept that - that friendliness that's only moderately enmeshed, not absolute control, not absolute deference, and moderately separate, not ships in the night, but basically friendly, moderately interdependent and moderately separate - that's the therapy goal. So here's this person who's shredding himself out of love for his father, and trying to get the internal father's approval by adhering to the internal father's rules and values; he needs to separate from that and develop his own rules and values. If he has kind people along the way, they're called buffers and they can maybe override the message from the original problem message. But the therapist is a very important part of giving a new and more benign message, if the therapist is genuine and works well. So that he begins to have new internalizations; hopefully a friendly spouse, hopefully neighbors and relatives who are friendlier and he begins to transform the relationship with the family in his head. So, that's the treatment plan. It's easier said than done, but that's a somewhat long answer to a fairly complicated question: how do we get to be this way and what do we do about it?

David: Okay, both in reading about your IRT approach and in listening to you talk about it, I'm really struck by the way it integrates psychodynamic and cognitive approaches. You're clearly very widely read and catholic in your approach - I don't mean in the religious sense - but broad in the things that you integrate in your work here.

Lorna Smith Benjamin: Well, thank you. I sure try to do that. I think that all that's known is just incredible and I think we all should be responsible to know as much about it as we can, and integrate it thoughtfully. It is really silly to go off on our own special little tracks and not connect constantly with the state of the art in other related disciplines, so I'm now writing a third book on using IRT to treat anger, anxiety, and depression; and I'm doing a whole chapter on neurobiology which is unbelievably exciting in terms of how the developmental theorists study it. And I can integrate it, I can absolutely integrate it with the therapy that I do with my personality disordered clients. It's just a quick, quick overview of it. When I read the developmental neurologists, I see, oh, there's a neurology for the threat system and there's a neurology for the safety system. And the safety system is what Bowlby called a secure base. And sure enough, that's what the herd needs, the mother monkey provides a safe haven, a safe base; and if she is reliable and protective and provides nurturance and all of that and allows autonomy and exploration - that is a vital feature of developing health, the ability to explore autonomy within a safe setting. Mother watches over; if a snake comes she gets afraid the baby senses her affect and runs to her and safety. So there's the threat system and the safety system always acting in opposition. And, certainly, the threat system trumps everything because you really don't want to deliberate and wait around when there's danger in the jungle. And so our patients come to us with the safety system and the threat system fused because their safety system, the parent, was - if they've been abused, maltreated - also their threat system. And all rules are wacked and this is a big, big problem and it helps explain why it's so hard to help people give up these old self sabotaging habits. It's because their safety system has taught them that these self sabotaging things are what they're supposed to do. They seek safety in threat, in other words. So it's really stabilizing for patients to see how and why what they're doing doesn't make sense, where it came from, and where they need to head.

David: Yes, well, that certainly makes sense to me. Boy, we could just go on and on here, there's so much more that I would like to talk to you about, but I think it's probably time for us to wrap up here. I'm so glad that you're writing another book; I really think that your thinking and your work deserves much wider exposure than it's had so far, and I hope that you're training a cohort of students to carry on your work.

Lorna Smith Benjamin: Well, thank you very much. I appreciate that; I'd like to agree with it. I'm sort of past retirement age but I'm really devoted to this. I think it is really useful and I hope to help people understand that and use it more and more. And I appreciate the opportunity you've given me here to maybe nudge it ahead just a step.

David: Okay, well, Dr. Lorna Smith Benjamin, you've been very generous with your time and information. Thanks so much for being my guest today on Wise Counsel.

Lorna Smith Benjamin: Thank you, my privilege.

David: I hope you found this interview with Dr. Lorna Smith Benjamin as informative as I did. Unfortunately, I hadn't heard of her work until quite recently when a colleague suggested her to me; and I was out to dinner this evening with three other senior therapist friends and only one knew of her work. I think that's a real shame. I came away from the material of Dr. Benjamin's that I read in preparation for the interview, as well as from the interview itself, tremendously impressed by the scope and power of what she's done. I think her work deserves much wider recognition, and I certainly hope I've given it a boost here. You've been listening to Wise Counsel, a podcast interview series sponsored by CenterSite, LLC. If you like Wise Counsel, you might also like ShrinkRapRadio, my other interview podcast series, which is available online at www.shrinkrapradio.com. Until next time, this is Dr. David Van Nuys, and you've been listening to Wise Counsel.