Interpersonal Reconstructive Therapy for Passive–Aggressive Personality Disorder
In Interpersonal Reconstructive Therapy for Passive–Aggressive Personality Disorder, Dr. Lorna Smith Benjamin shows her approach to working with clients who exhibit this disorder. Interpersonal reconstructive therapy assumes that maladaptive personality patterns such as passive–aggressive behavior are a repetition of behavior that was once appropriate to the client within the context of his or her childhood family experiences. Therapy involves recognizing these repeated patterns and understanding where they come from and why they continue.
In this session, Dr. Benjamin works with a 53-year-old man who has a history of chronic pain and unstable employment. She works with him to help him come to an awareness of the recurring relationships in his life and to see the sources of these patterns in his past.
This video features a client portrayed by an actor on the basis of actual case material. However, unlike the actor, who remained in the role, actual patients are more responsive to the interventions and begin to collaborate and work on change.
In the year before the client, Arthur, was referred for treatment, his father had died and his youngest daughter was diagnosed with multiple sclerosis. Arthur experienced problems with chronic pain over the years, but in this past year, in which he has also had problems at work and with his wife, the pain worsened.
After a number of diagnostic sessions at the Veteran's Administration (VA) hospital and several failed attempts at medical treatment of the pain (including a trial on an antidepressant combined with a benzodiazepine), Arthur went on short-term disability. His claim for long-term disability was denied, however, and he returned to work after 3 months. Still complaining of pain, Arthur was referred by the VA for treatment at a private pain management clinic. When this proved unsuccessful, Arthur was referred for psychotherapy, but he failed to follow through.
Arthur was born while his father was serving in the U.S. Army during World War II. His early childhood memories of his mother were of consistent caring and warmth. However, when Arthur was 3 years old, his father returned from the war and the family dynamics changed radically. According to Arthur, his father was cold and rejecting toward him and interfered with his relationship with his mother by sending him away whenever he saw the two of them together.
His father's discipline was harsh. For example, when Arthur did not obey his father immediately, his father would switch his legs with tree branches. At first his mother objected to his father's treatment of him. Arthur remembers her coming to his room and putting salve on the cuts from the switchings and comforting him. However, this soon changed as well, as his mother became pregnant 3 months after his father returned.
The pregnancy was difficult, and Arthur's mother was confined to bed rest for the last 3 months. Arthur's father sent him to stay with a relative during that period, despite his mother's objections. When Arthur returned after his sister's birth, his mother seemed withdrawn, and she no longer stood up for Arthur when his father mistreated him.
Arthur remembered that after his sister's birth, his father's behavior became even more antagonistic. He seemed to make a point of showing Arthur how much he loved his little girl and how this contrasted with his contempt for Arthur. Slaps across the face and humiliating taunts were commonplace. Arthur was given responsibilities for helping around the house that were beyond his capabilities and then was punished when he did not perform according to his father's expectations.
Arthur's other two siblings were born over the next 3 years. Arthur's father was rather indifferent to them, but he rarely abused them. If, however, they showed affection toward Arthur, they too would become objects of his father's scorn, so they tended to stick together and keep a distance from Arthur. Arthur's mother seemed resigned, and she rarely interfered with his father's "discipline."
When Arthur was a teen he was expected to do not only his own chores but also his sibling's chores. When anyone failed to keep up with their responsibilities, Arthur was physically punished. Slaps often turned into pushing and shoving. Once when Arthur attempted to defend himself, his father hit him with his fists. After this incident, Arthur simply submitted to whatever punishment was meted out.
Still, Arthur harbored a secret wish to gain his father's approval. When Arthur was a senior in high school and doing poorly in all but his art class, he abruptly quit school. He impulsively joined the Army, hoping to win his father's approval. His father did briefly relent from harassing him, saying that Arthur may have made the right choice for the first time in his life.
During basic training, Arthur was hurt during a hazardous field exercise. His left leg was badly injured, incapacitating him from active service. He was given an honorable discharge and VA benefits. Returning home, Arthur found his father brutally critical of him, accusing him of deliberately getting injured because he was not fit for military life.
Arthur fled his parents' home in Allentown, Pennsylvania, vowing never to return. He took the first bus that was scheduled for out of state and ended up in Cleveland, Ohio. He stayed at a YMCA for awhile and then hitchhiked to Norwalk, when he heard that an automobile factory was opening there. He was hired soon after.
Unfortunately, Arthur reported, his foreman had it in for him from the start. The foreman claimed that Arthur's work was slower than others on the line, and he was issued several warnings. But Arthur felt the foreman was critical of him simply because he was not a local, or even from Ohio. Arthur felt he did not have a chance, and after 3 months, when he sensed he might be fired, he abruptly quit. "The foreman ran the show," he said, "I got tired of banging my head against the wall."
Arthur was homeless for awhile, unable to find another job. He slept under bridges and took his meals at a soup kitchen. He was determined not to return home. It was at the soup kitchen that he met his future wife, Helen. Helen worked as a secretary at a social service agency and did volunteer work at the kitchen. She hoped to go back to school and earn a degree in social work. She was interested in Arthur because he seemed to be one of the few regulars at the kitchen who did not drink. Her father drank the family's money away, and he had died from his alcoholism in his 40s. After a few weeks of chatting in the serving line, Helen began visiting with Arthur for coffee after the meal was over.
Over time, Helen learned about Arthur's childhood and his "bad luck" in the Army and at the automobile plant. She felt he had been dealt a poor hand in life and only needed support and encouragement to get back on his feet again. After 3 months of dating, she invited him to sleep on the couch at her apartment and offered to buy him some decent clothes so that he could be more successful in gaining employment.
After a few weeks of celibate living with Helen, he asked her to marry him someday, after he had proved himself. She accepted and said he did not have to prove himself. Once he landed a job, they could marry. With love and support from one another, she had said, they could both build the life of their dreams.
The prophecy seemed to come true. Arthur soon got another factory job and felt the foreman this time was fair. They married, and Helen started taking a class at the community college in addition to her full-time job. Arthur said she was tremendously supportive and encouraging. She also provided a cozy home for him, as she enjoyed decorating their small apartment and being a creatively frugal cook so that they could save for a house someday.
When they were married for a little over 1 year, Helen became pregnant unintentionally. At about the same time, Arthur's foreman was promoted, and his new foreman "took an instant dislike" of Arthur. It was at this point that Arthur first began complaining consistently about his leg pain, but he refused to seek medical care. According to Arthur, Helen, who was suffering from morning sickness, "changed toward him, too." She no longer seemed as supportive and encouraging, and she finally told him to do something about this leg or to quit complaining about it. Arthur felt abandoned but decided that he would just suffer in silence.
When Helen was 6 months pregnant, Arthur and his foreman had an altercation, and Arthur walked off of the job. Arthur insisted he needed to get into another line of work, but he found nothing for which he thought he was qualified.
Once the baby was born, Helen immediately returned to work and Arthur looked after their baby daughter while ostensibly seeking work, which never materialized. After over 1 year of this, Helen came home with a phone number for a hotel desk clerk position. She insisted that Arthur call while she was there. She told him to take the job no matter what it paid, if it were offered. She was pregnant again, and they would need both incomes just to make it.
Arthur was hired, and he settled into his job fairly easily. It was not a busy hotel, and he liked to chat with the clientele. A third daughter was born 2 years after the second. Arthur changed to the afternoon shift so he could get the children to school and sitters in the morning. This limited the couple's time together in the evening, but that caused no apparent problems. They did not have a lot to talk about besides the children, and both tacitly agreed that raising them successfully was the reason they were together.
When the children were grown, Helen returned to college while she continued to work full time. She had just completed her associates degree and had been accepted at a 4-year university when the couple learned that their youngest daughter, Janice, had multiple sclerosis. Helen cut back on her classes to help Janice adjust to her disabilities. Soon after, Arthur learned from his sister that his father had died.
It was at this time that Arthur's leg pain worsened to the point that he sought treatment at the VA and was placed on short-term disability at work. When his claim for long-term disability was denied, he began talking with Helen about quitting his job. She told him that if he quit, he might as well quit the marriage. Arthur returned to work, but the leg pain continued, and he was referred to the pain clinic, with unsuccessful results. The doctors at the VA concluded that the increase in pain might be psychogenic and referred Arthur for psychotherapy, which he refused.
After listening to his complaints one evening, Helen insisted on going to his next scheduled appointment at the VA to find out why his symptoms were not improving. It was then that she learned that the physicians had exhausted treatment options and that because they could find no physical cause for the increase in his symptoms, they had recommended psychotherapy. After a silent ride home from the appointment, Helen insisted that Arthur call the therapist the VA had recommended, Dr. Lorna Smith Benjamin, while Helen stood by the phone. Arthur scheduled an appointment for 2 weeks later.
- What is your impression of Arthur?
- How typical or atypical are his life experiences and his current behavior?
- What do you believe are the core issues for Arthur?
- What is the utility of these initial formulations?
- What overall goals for therapy do you suggest?
- Before you read the next section, what topics and issues do you think will be addressed in the initial sessions?
Notes on Previous Sessions
Session 1: In this 90-minute session, Dr. Benjamin obtained the history previously described, making notes about patterns that seemed to recur and the style with which the patient interacted with her. Arthur described his history in a rote way and often had to be prodded to elaborate. He emphasized his suffering and his feelings of resigned helplessness. He complained that others had been unable to help him, and he said that he hoped that this would be different.
Dr. Benjamin briefly explained the nature of her therapy and asked whether he would like to try a few sessions to see whether he thought it could be helpful to him. She provided Arthur with a consent form and printed information about billing and cancellation policies.
After the session, Dr. Benjamin formulated some initial hypotheses about Arthur's copy processes. She made a tentative diagnosis of passive–aggressive personality disorder. She noted that his "Regressive Loyalist" was in near total control, and she hypothesized that like many people with this personality disorder, Arthur may be dominated by unacknowledged anger at, and wish to punish, an early figure by his suffering. In Arthur's case, that central figure was his father.
Session 2: This second 90-minute session began with Dr. Benjamin reviewing Arthur's history and filling in areas that she had found to be incomplete. She talked in more detail about how therapy might help him. She explained that it could help him recognize certain patterns that were causing him problems now, discover where they came from, and understand what they were and are for. With this knowledge, he could decide whether to change. If he found that although the problem patterns may be understandable given his history, they were causing him more harm than good, he could decide to use therapy to learn new ways to think about himself and to relate to others.
Arthur had difficulty taking this in, but he agreed that he was interested enough to return for more sessions. Dr. Benjamin was not surprised at this, knowing that it often took several sessions for clients to comprehend this new way of looking at things and to lower their defensiveness to hear how it applied to them.
Arthur spent the remainder of the session recounting his complaints about his supervisor at the hotel, the VA doctors, and his wife. Dr. Benjamin suggested that in the next session they might look at what these situations had in common and whether any patterns appeared to emerge. She asked Arthur about the consent form and billing, and he agreed to bring it with him to the next session, saying that his wife Helen was still reviewing the material and contacting his insurance company.
After the session, Dr. Benjamin realized how irritated she had been by Arthur's passivity and knew that she would need to be conscious not to repeat the familiar pattern of arguing and demanding and being seen as critical. To use the countertransference instead of acting it out and to convince Arthur that she was "on his side" while helping him to learn about and change his patterns would be a challenging task.
Session 3: Dr. Benjamin began this 50-minute session by asking Arthur whether any thoughts or feelings had been evoked by the previous session. Arthur stated that he did not remember having any reactions. He said that he had told Helen that the session went well, at which point he suddenly remembered that he had again forgotten to bring the consent form, but promised to bring it to the next session. He also promised to discuss the payment options with Helen and come to some closure on that issue.
When Dr. Benjamin asked Arthur what he would like to work on in this session, Arthur replied that he did not know. When offered alternative themes, Arthur insisted that Dr. Benjamin choose, because she knew more than he did about therapy.
Arthur's negativity and passivity elicited two reactions that are common among therapists working with such patients. At times, Dr. Benjamin experienced a pull to "get tough" with Arthur and give him direct advice. At other times, she felt a passive hopelessness about the therapy and was tempted to do nothing. Realizing that acting on either impulse would lead to an impasse, she again directed Arthur's attention to the idea of interpersonal patterns and about making connections between the dynamics of past relationships and current ones. She stressed that this awareness could provide Arthur with more freedom of choice and life satisfaction.
Dr. Benjamin continued to try to engage Arthur's "Growth Collaborator" by reinforcing positive behaviors in the previous week, such as being on time for work 4 out of 5 days, which was an improvement over previous weeks. Arthur countered her positive statements with complaints that the boss only noticed the day he was 10 minutes late. He went on at some length describing his boss's unreasonable reaction to this tardiness, stressing that others were late as well, but his boss never seemed to notice their tardiness.
Dr. Benjamin asked Arthur whether this reminded him of his family, where his siblings' transgressions were ignored and his were harshly punished. Arthur said that it "could be," but he seemed puzzled as to the relevance this would have in his present situation. Dr. Benjamin concluded the session by saying that perhaps the relevance of the patterns would be more clear to him when they explored his feelings about his family in more depth.
Session 4: To be viewed.
- Were the initial sessions as you expected?
- As you read the summary of the preceding sessions, were there any areas or topics that you thought should have been covered but were not?
- What other information would you seek to assess the patient?
- Before viewing the tape, what do you think will unfold in the taped session?
- What issues will be discussed?
- What will the relationship between Dr. Benjamin and Arthur be like?
Stimulus Questions About the Videotaped Session
In the opening moments of the session, Arthur relates that he has again forgotten to bring the treatment consent form, and he defers responsibility for this and for selecting a payment plan to his wife.
- What feelings would this kind of behavior elicit in you?
- How might you, as the therapist, use these feelings to help accomplish therapeutic goals?
- What would your typical or "natural" behavioral response be toward Arthur?
- Would that response prove therapeutic for this patient?
Early in the session, Dr. Benjamin asks Arthur how he would like to use their hour. Arthur persistently experiences difficulty in stating his agenda or goals for therapy in general and this session in particular. He simply states, "I am here."
- Whose responsibility is it to set the therapy agenda?
- To the extent that the patient is expected to partially or largely set the agenda, what are some ways you might help him do so when he defers?
- How did Dr. Benjamin proceed?
About 10 minutes into the session, Arthur states that Xanax reduces his leg pain and improves his feelings of well-being overall. Dr. Benjamin points out a possible connection between Arthur's emotional state and his pain intensity, a pattern that Arthur has said his wife and coworker have noted.
- What would you, as his therapist, do with this information?
- Under what circumstances might you refer him back to his physician to consider resuming antianxiety medication?
- How might you use the comment that others noted a pattern in Arthur's behavior?
About 25 minutes into the session, Dr. Benjamin offers a tentative formulation of one of Arthur's life patterns, which started with his father: People are critical of him even when he does his best. This theme runs throughout important relationships in his life as a "copy process" in which Arthur behaves as if his father were still there and in charge. Arthur has come to anticipate and perhaps even evoke this criticism, so that it becomes a self-fulfilling prophecy.
- What is the therapeutic utility of this formulation?
- How does Arthur seem to respond to it?
About 29 minutes into the session, Dr. Benjamin describes "being sort of stuck here in an impossible Catch 22" because Arthur habitually agrees with or defers to her. Dr. Benjamin asks, "How am I going to get in touch with a part of you that wants to work for you and that isn't just trying to please me? I wonder."
- What do you think she is trying to accomplish by making this process observation?
- Do you think any progress was made through her sharing her own experience of feeling stuck?
About 34 minutes into the session, Dr. Benjamin characterizes Arthur's conflict as a contest between his Regressive Loyalist and his Growth Collaborator.
- Do you think that Arthur understood these terms?
- How did you respond to this choice of terms?
- Are there other terms or constructs you might use to characterize this conflict?
- To what extent would it be valuable to further explain such terminology?
In the closing moments of the session, Arthur rejects Dr. Benjamin's observation that he is angry, as he did earlier in the session. This time Dr. Benjamin accepts his statement and replies, "I guess I was putting my hopes on you." This leads to Arthur discussing how his father would not allow him to be angry.
- How did Dr. Benjamin's response seem to facilitate the patient's further exploration?
- What might have occurred if Dr. Benjamin had instead replied, "You certainly look angry"?
The behaviors that are indicative of personality disorders are frequently ego syntonic, that is, the person regards the maladaptive behavior as a natural and desirable part of his or her personality. In passive–aggressive personality disorders such as Arthur's, the patient commonly procrastinates, dawdles, "forgets" things, and in general, indirectly or passively expresses covert anger.
- By the end of the session, do you have a sense that Arthur might eventually be able to recognize these behaviors as problems for himself and begin to work on his own behalf?
- What evidence from the session supports your answer?
- What, specifically, do you think might help Arthur do this?
- What did Dr. Benjamin do or not do to engage Arthur's Growth Collaborator in this task?
- Did the session progress as you anticipated?
- Was Arthur as you expected? Was Dr. Benjamin?
- What are your general reactions to the session?
- What did you feel was effective in the therapy?
- What do you think were the strengths and weaknesses of this approach?
- Now, after reading about Arthur and viewing this session, what are your diagnostic impressions or characterizations of his problems?
- How would you proceed with Arthur's therapy?
- How many sessions will it take?