An Interview with Lorna Smith Benjamin, Ph.D. on SASB and the Structure and Treatment of Personality Disorders
David Van Nuys, Ph.D. Updated: May 29th 2009
In this edition of the Wise Counsel Podcast, Dr. Van Nuys interviews Lorna Smith Benjamin on SASB and the Structure and Treatment of Personality Disorders. Dr. Benjamin, a psychologist, is the inventor of SASB or Structural Analysis of Social Behavior which is a formal and rigorous system for understanding the specific character and nature of a person's interpersonal interactions. Though SASB was originally developed as a way of understanding primate social behaviors, Dr. Benjamin realized many years ago that it would provide an excellent basis for studying personality disorders and helping to identify ways that these complicated and by their nature very social problems could be effectively treated with psychotherapy. For approximately the past 30 years she has rather tirelessly worked to do that, most recently through her development of Interpersonal Reconstructive Therapy (IRT). It is Dr. Benjamin's (and my own) contention that it is exactly the unique maladaptive interpersonal patterns identified by the SASB process which cause personality disorders to occur. The collection of behavioral criteria used to diagnose personality disorders as described in the DSM do not cause these disorders, but instead are themselves caused by the underlying maladaptive interpersonal patterns.
Dr. Benjamin was educated at Oberlin College and did her doctoral work in psychology at the University of Wisconsin, Madison under the tutelage of the famous primate researcher Harry Harlow, known for his "wire mother" monkey studies that all undergraduate psychology students read about. She was a graduate student in Harlow's lab at the time of those studies, one of her duties being the care and feeding of the baby monkeys. She describes having been drawn to the study of psychology based on an early love of behavioral observation, and in particular the realization that psychology was a field where she could devote herself to the study of animal behavior.
The Structural Analysis of Social Behavior (SASB) was first drafted in 1968 and published in 1973 - a long time ago. It was initially conceived, apparently, as a way to study primate behavior but Dr. Benjamin, who was also trained as a psychotherapist was also keenly aware of the potential for SASB to offer insights into the psychotherapy process. The publication of DSM III in 1980 was a watershed event in the history of mental illness diagnosis, because DSM III was the first version of DSM to have shifted from a primarily Freudian view of mental illness to a primarily statistical and behavioral view of the same. The concept of personality disorders was first formalized in DSM III, and with that publication Dr. Benjamin saw an interesting career opportunity to apply her SASB system to the study of personality disorders and psychotherapy for the same. She reports that her identification as a researcher of personality disorders really crystallized several years later while writing her first book, Interpersonal Diagnosis and Treatment of Personality Disorders, published in 1993.
Dr. Van Nuys asks Dr. Benjamin to describe the personality disorders, which she does. There were originally 11 personality disorders (or PDs), which could be grouped into three primary families of problems based on common interpersonal features. A group of personality disorders characterized by eccentricities and odd social behaviors is exemplified by Paranoid PD. A group of personality disorders characterized by dramatic and erratic relationship behaviors and emotional displays is exemplified by Borderline PD. Finally, a group of anxious or neurotic personality disorders is exemplified by Avoidant PD. The DSM requires that diagnoses of mental disorders be made using a multi-axial diagnostic system which looks at mental problems across five different dimensions of experience. The major clinical disorders such as depressions, anxiety disorders and thought disorders like schizophrenia are made on Axis I, while personality disorders were made separately on Axis II. In Dr. Benjamin's view, this was done to emphasize that PDs were capable of modifying how a person would cope with a primary Axis I sort of disorder, and describes research showing that this is indeed the case. When personality disorders are present, for example, the rate of positive response to simple antidepressant therapy for depression is reduced. She notes that the distinction between Axis I and II is controversial and may be altered in future versions of the DSM.
Dr. Van Nuys and Dr. Benjamin talk about the way that personality diagnoses are sometimes inappropriately used as a way to judge people. Dr. Benjamin acknowledges that this sort of thing does happen but finds it unfortunate. In her view, some people arrive at having personality disorders based on their unique social learning and that when this happens there needs to be a way to understand the nature of the problem and how to remediate it. Moral judgments about the goodness or badness of particular disorders are not helpful.
Dr. Benjamin is critical of the static, symptom based nature of present day personality disorder diagnoses. In her mind, it doesn't tell you anything about why a personality disorder has occurred to note that it has resulted in extremes of emotionality and a fear of abandonment, or a similar set of symptoms and signs. It is far more fruitful to look at the interpersonal interactions that people with personality disorders experience, in their present day interactions and also in the past. This is where the SASB model shines.
SASB is based on a view of primate mammals such as human beings as being creatures which have evolved according to the theory of evolution to have selectively favored the reproduction of characteristics which enhanced survival. Primary among these characteristics is the human need for social affiliation and attachment. In Dr. Benjamin's view, humans are herd or social animals with a deep rooted biological need to form bonded relationships with one another in order to help insure mutual survival.
SASB pays attention to four "primitive poles" of primate social behavior: sexuality, power or pecking order, murder or aggressive attack tendencies and the need to acquire and hold territory. It pays attention to these primary behaviors as they play out within a particular context which it strives to understand in a holistic manner by paying attention to mood states, and the subjective and objective viewpoints of the various individuals who participate in interactions.
The four primary poles are described and rating within SASB using two dimensions: desire for affiliation, taking the form of love when high and taking the form of attack when low, and interdependence, which can vary between controlling behaviors and behaviors which grant freedom.
These dimensions of affiliation and interdependence play out across three different focuses on the self that can occur in an interpersonal interaction: A person can be focused on another person, they can be focused on themselves, or they take on the focus of the introject, which is what is happening when a person focuses on themselves but from the perspective of another person they know or knew, rather than from their own perspective. These are confusing ideas at first encounter, so Dr. Benjamin offers an example to help clarify things.
In the example, a parent says to a child, "You never do anything right". This event can be viewed and coded in any of the three focuses described above.
If the perspective of the parent is to be coded, the focus is clearly aimed at another person (the child), the interaction has an attacking or hostile quality, and the intent is to control rather than to emancipate the child. SASB characterizes this configuration of dimensions and focus using the term "Blame". The experience of the interaction from the perspective of the parent is the feeling of desire to attack the child.
If the perspective of the child is to be coded, the child's focus is very likely to be on himself, so a self-focus, the interaction has a hostile quality and the likelihood is that the child ends up feeling controlled. SASB characterizes this configuration of dimensions and focus using the term "Resentful Submission". The experience of the interaction from the perspective of the child is the feeling of protest against the parent's attack, or perhaps, over time as an introject of the parent's attack develops, a feeling of being deserving of the attack.
The introjection focus is in many ways the most interesting and the most damaging. If this interaction is repeated multiple times, ultimately the child will form a mental representation of the interaction in his mind and start to view himself through the same critical, "Blaming" perspective originally enacted by the parent, except in the absence of the actual parent being there to act the situation out. The child will almost certainly fail to discriminate his own perspective from that of the introjected parental perspective and will become harshly self-critical and self-attacking as a result. From the perspective of the introject, the experience is one of being deserving of being attacked. In Dr. Benjamin's opinion, this sort of thing can contribute greatly towards this child's ultimate vulnerability to depression or similar clinical Axis I disorders despite the fact that the child might have otherwise been initially healthy.
Dr. Van Nuys asks Dr. Benjamin about a SASB diagram he encountered while doing preliminary research for this interview which contained a large number of finely nuanced descriptions of interpersonal stances like "Blame" and "Resentful Submission". Dr. Benjamin responds by noting that there are several versions of the SASB system, some of them containing more detailed and finely nuanced positions than others. The full model contains a total of 108 separate interpersonal stances which offers wonderful high-resolution description of interpersonal interactions, but which is also completely overwhelming to use from a practical point of view. The more simplified models collapse these many interpersonal stances down to a more manageable number and ultimately yield a lower resolution but more usable snapshot of interpersonal interactions. I (Dr. Dombeck) liken the difference between the full SASB model and the simplified models to the difference between a full SLR camera and a simple point and shoot camera. The SLR takes much better pictures, but is too bulky for practical daily use. The point and shoot, on the other hand is easy to use, but the photos it takes don't blow up to poster size very well.
At Dr. Van Nuys' prompting, Dr. Benjamin describes her Interpersonal Reconstructive Therapy (IRT), a psychotherapy for helping people with treatment resistant personality disorders based firmly on the SASB methodology. In IRT, SASB is used to help patients understand the interpersonal origins of their present day interpersonal problems as well as the exact nature of their present day interpersonal problems. It is also used to help patients conceptualize how to get from their present day position within the SASB model to a position more representative of "normal", which is defined in SASB terms as essentially a position of "Friendliness" occupying the middle ground between extremes of love vs. hate and control vs. emancipation.
Dr. Benjamin uses the example of the self-critical child described above to illustrate how IRT might work. That child, as an adult is perhaps suffering from a tendency towards vicious self-criticism, a pervasive sense of self as a failure, and a resulting tendency towards almost disabling depression. Using SASB to model the origin of this introjection Dr. Benjamin is able to help this patient understand the mechanics of this self-criticism. In effect, the introjection is acted out repetitively out of habit and also out of a sense of intense loyalty to a person who the child needed to attach to at a vulnerable age; a parent the child loved fiercely even if that parent sometimes was critical. Though the parent may be long deceased, the introjection of that parent's critical interpersonal stance lives on within the now adult child as a mental representation. In Dr. Benjamin's words, "Almost all of mental disorder is a form of autoimmunity or self-sabotage that is done out of love".
The treatment plan that flows from this interpersonal analysis might be that it becomes necessary for the child/patient to renegotiate his internal relationship with the internal representation of the parent. Dr. Benjamin points out that this process of renegotiation need not require the child to start hating the parent or otherwise become hostile towards the parent. Instead, the patient can learn to assert himself in relationship to the internalized introjection of the parent (My term, not Dr. Benjamin's!). This process of learning to renegotiate the relationship is aided and moderated by newer representations of more healthy, respectful relationships such as occurs between the patient and the therapist, or between the patient and the patient's spouse, family or circle of friends.
Dr. Van Nuys expresses his admiration for Dr. Benjamin's skillful integration of concepts which are at once profoundly psychodynamic and also amazingly behavioral and measurable. She responds by suggesting that it is always a good idea to do as much integration of existing sub-fields within one's discipline as possible. She is currently researching her third book which will describe IRT strategies for addressing anger, anxiety and depression problems, and has been struck by the important findings in developmental neuroscience which she sees as providing a neurological basis for some of her SASB foundational concepts such as the primacy of attachment in understanding interpersonal behavior.
I, Dr. Dombeck, have been aware of Dr. Benjamin's work since my graduate training days in the middle 1990s, but it is telling to point out that I never learned about her in a class, but instead stumbled onto her book somewhat randomly while browsing in a bookstore. I very much concur with Dr. Van Nuys' closing statement regarding Dr. Benjamin's work - that it is a terrible shame that this work is not more widely known and taught. Together, SASB and IRT fit well with the current "post-cognitive" psychotherapy zeitgeist characterized by successful attempts to integrate psychodynamic insights with (cognitive) behaviorist scientific rigor. SASB and IRT remind me very much of Jeffrey Young's Schema Therapy, for example, and there are other echoes with modern day treatments for Borderline Personality Disorder such as Kernberg and Clarkin's Transference Focused Therapy. It just so happens that Dr. Benjamin got to this important place some 30 years ahead of the pack.
Via priviate communication, Dr. Benjamin has asked that we offer the following clarification regarding her interview:
Towards the end of the interview she uses the word "microbiology" when she meant to say "neurobiology".
She regrets not offering an example of a specific personality disorder when asked by Dr. Van Nuys to define personality disorders. If she could do it over, she would have offered an example such as OCPD, and pointed out that this PD manifests in the form of perfectionism, a preoccupation with lists, and a need to control other people so that things are done "right".
Links Relevant To This Podcast:
Dr. Benjamin, a professor of psychology at the University of Utah in Salt Lake City has a faculty web page you can view.
Lorna Smith Benjamin, Ph.D., F.D.H.C., is Professor of Psychology, Adjunct Professor of Psychiatry and Founder of the Interpersonal Reconstructive Therapy (IRT) Clinic, University of Utah Neuropsychiatric Institute. She received her undergraduate degree from Oberlin College, and her MA and PhD in psychology from the University of Wisconsin, Madison, Wisconsin.
Her many honors include Phi Beta Kappa, Summa Cum Laude, Oberlin College; Distinguished Research Career Award International Society for Psychotherapy Research, Santa Barbara, CA, June, 2002; Bruno Klopfer award for outstanding, long-term professional contribution to the field of personality assessment, March 2007.
Since 1987 she has been a Professor with the Department of Psychology, University of Utah, Salt Lake City as well as Adjunct Professor, Department of Psychiatry, University of Utah. From1996-99, she served as Director of Clinical Training in Psychology and in 2001, she served as Chair of the Executive committee. She is currently consulting editor for the Psychiatry and the Journal of Personality Disorders. Dr. Benjamin also served as an advisor to DSM-IV work group, Axis II. 1989 -1994; she was an invited participant in a preliminary meeting for DSM-5 at NIMH in Washington DC, April 2005.
Widely published, her writings include: (1996). Interpersonal diagnosis and treatment of personality disorders, 2nd Ed. N.Y.Guilford Press. Issued in paperback, 2003. (2003). Interpersonal Reconstructive Therapy: promoting change in Nonresponders. New York: Guilford Press. Issued in paperback, 2006 with new subtitle: a personality-based treatment for complex cases.
Her work is fantastic! - Paula C. Miceli - Aug 17th 2012
I found Dr. Benjamin's first book on Interpersonal Diagnosis during my first external practicum at the start of my training. I later came to attend her workshop series in London Ontario after she released her IRT book. Part of her success is surely related to her foundation in attachment research (e.g., Harry Harlowe). What I like about her models is that she is able to take the information in the DSM about personality disorders, and translate it into a model that can be followed from a psychological perspective. For a psychologist, or like me, an intern, this means that we can begin to understand what might have occurred in the earliest stages of life, and how our actions in therapy can increase the probability that positive change may occur. People who have personality disorders often have numerous difficulties, and can't find a way to shift out from under the weight of these problems. Dr. Benjamin's models increase the astuteness of the clinician and provide a framework and descriptive language. An amazing woman all around.
I finally understand - Doug McKee - May 29th 2009
It has finally become apparent that the basic reason for the total failure of the current mental health care to find a single "cure" in over a hundred years is simply a matter of focus.
Had any of you worked on understanding how "successful" individuals work instead of why defective ones don't, you would have a specialty that could actually be of benefit to mankind.
Editor's Note: Actually, there is an entire movement within psychology, "Positive Psychology" which focuses on understanding and improving mental health - based on the study of "successful people" - as opposed to mental illness - based on the study of "defective people". Our own Elisha Goldstein, Ph.D. writes a blog which is very much in this positive vein. Though the positive focus is a much needed counterpoint to research on the disorder side of the house, I find it hard to understand where your anger comes from. How is the case that work devoted to ameliorating the suffering of "defective" people (your term, not ours) is not of benefit to mankind?