By: Harold A. Frost, PhD

Children born into this life come with an innate capacity to learn, to grow, to love, and to experience. Children enter this existence ready to receive joy; ready to take on the challenges of this glorious journey called life. If children are born into a warm, accepting environment, there is a much higher probability that they will be able to express their innate gifts and talents, as well as satiate their thirst for love and knowledge. Children who have been subjected to a loving and encouraging environment may come to feel that life is an adventure and are able to experience joy and happiness within themselves, as well as the world. They are able to develop an expansive sense of themselves.

In order for proper developmental processes to occur a child must experience a secure “bonding” or “attachment” to their care givers. As noted by Ross (2000), “The fundamental developmental task of the human infant is attachment. . . .You must attach in order to survive biologically, but also in order to thrive and grow at emotional, intellectual, spiritual, interpersonal and at all possible levels.”

If the bond or attachment between the child and his or her parents is disrupted, this may result in immediate as well as long-term developmental problems. For example, during World War II, it was noted that infant orphans in Europe who were given adequate amounts of nourishment often turned their heads to the wall and died. The mortality rates were incredible. These mortality rates were reversed when these orphans were given adequate amounts of love, stimulation, attention, and affection. It would appear that a child’s need to “attach” to his care giver is absolutely essential. In the words of Ross (2000), “It is developmental suicide to fail to attach. . . . In a normal, human family, attachment is secure and things work out okay.” Sad to say, not all humans are raised in a secure, warm, encouraging environment. Oftentimes children are the victims of trauma and abuse. “The trauma is a variable mix of emotional, verbal, physical, and sexual abuse; neglect; absent parents through divorce, death, drug abuse, imprisonment or mental illness; family violence and chaos; urban violence; cultural disintegration; medical and surgical trauma; and sick family dynamics, rules, expectations, and double binds” (Ross, 2000).

It should be noted not all individuals with ambivalent or insecure attachments are victims of trauma- that is Trauma with a capital “T”. Trauma with a capital “T” is experienced when a person is subjected to stressors of enormous proportions – or what the DSM-IV calls Post- Traumatic Stress. According to Schwartz (2001) trauma with a small “t” is experienced by very sensitive clients who are particularly attuned to negative feedback. These sensitive clients experience normal stress and rejection with the same intensity and severity as someone who experiences more severe stressors such as physical or sexual abuse. Clients with small “t” deserve just as much compassion and empathy as those who experience the more severe form of trauma.

When the child experiences trauma or neglect, he or she typically pulls away and emotionally shuts down. However, as noted above, it is imperative that the child attach to the care giver. In other words, for the child to developmentally “move on” in their life they must come to see their environment and care givers as safe to attach to. In an effort to reconcile the abusive environment with a need to have close, secure attachments, the child will often split, fragment, fracture, or disassociate. In other words, the profoundly negative events must be put on the “back burners” of the mind in order for them to see their care givers as good and safe to attach to. Children will even go as far as seeing themselves as bad in order to reconcile the abusive environment. “It is good to be bad, because only by being bad, by causing and deserving the abuse, can you create an illusion of power, control and mastery” (Ross 2000).

Many years later, those individuals with ambivalent or insecure attachments may show up in our offices. Oftentimes these individuals present with depression, post-traumatic stress, suicidal ideation, selfmutilation, personality disorders, as well as eating disorders. These conditions are often referred to as “treatment-refractory conditions”. They incorporate the so-called “non responder population”. It is typical for therapists to engage these clients with “treatment as usual” (TAU). TAU may include state of the art therapies such as cognitive behavioral therapy, Klerman-Weissman’s Interpersonal Therapy (IPT), Linehan’s Dialectical Behavior Therapy (DBT) as well as pharmacologic interventions to correct alleged “chemical imbalances”. TAU is ineffective because what is being missed is the loyalty that the client has toward his or her dysfunctional family system. The presenting psychopathology, these “problem patterns” or what Benjamin (2003) calls “copy processes” are in fact attempts to earn the love of the Internalized Representations of early Important Persons (IPIR’s). In the words of Benjamin (1993), “Every psychopathology is a gift of love.” Without understanding that the psychopathology that the client has brought into a therapist’s office is in fact an attempt to attach to or secure parental love, even the best therapist will be rendered impotent.

It should be noted that these “problem patterns” will persist, even after one leaves their family of origin. It has been noted in the book, Invisible Loyalties (Boszormenyi-Nagy, Spark, 1973), that these “problem patterns” persist well after the individual leaves their family. These patterns will continue to exist even when they move far from their family of origin or even after family members die. A case in point: I once had a client who had married and divorced three alcoholic husbands. It should be noted that in all three cases, the alcoholism was not active during courtship. It was only after the client was married for several months that the client would find bottles of alcohol underneath the bed or the couch. She appeared to have an uncanny ability to discern and become attached to men who struggle with alcoholism. Exploration of her family of origin found that her father was an alcoholic. It is my opinion that the client’s ability to find and marry three alcoholic men is a function of her “loyalty” to her relationship and her desire to connect with her alcoholic father.

As noted by Dr. Lorna Smith Benjamin in her recently published book, Interpersonal Reconstructive Therapy (IRT), “Problem patterns are linked to learning with important early loved ones via one or more of three “copy” processes: (1) Be like him or her; (2) act as if he or she is still there in control; and (3) treat yourself as he or she treated you. Dr. Benjamin gives the following example, “If a female child lives with a relentlessly critical parent, the child is likely to become critical and displeased with herself.” As mentioned above, “the copying is maintained by fantasies that Important Persons and their Internalized Representation (IPIR’s) ultimately will provide the desired love if the client’s living testimonies to the IPIR’s rules and values is good enough. This illustrative client, who morbidly criticizes and disapproves of herself, is treating herself as an important loved one treated her (Ross, 2000 would call this “attachment to the perpetrato”.). In an often unrecognized way, applying that old view to herself represents incorporation of the perceived parental rules and values. Such intense devotion to relentless self-criticism suggests a continuing wish to please that parent. In other words, a client may be continuing to strive to have the “secure attachments” that were lost or missing during childhood.

Again quoting from Dr. Benjamin, “Since the relationship with the internalization is immensely powerful, treatment must focus sharply on grieving and letting go of these fantasy residues of early attachments . . . . There are five steps in IRT, each requiring activities that facilitate selfdiscovery (psychodynamic) and self-management (behavioral). All steps address a basic conflict between the Regressive Loyalist (Red; the part that seeks the approval of the IPIRs) and the Growth Collaborator (Green; the part that comes to therapy for constructive change). The five steps are as follows: (1) collaboration (the therapy relationship); (2) learning about patterns, where they are from, and what they are for (insight); (3) blocking problem patterns (crisis and stalemate management); (4) enabling the will to change (in steps that compare to Prochaska’s transtheoretical stages of change); and (5) learning new patterns (via standard behavioral technology).

The Problem is Not the Problem

The reason that “non responders” do not respond to therapy as usual (TAU) is because the problem patterns associated with the important persons and their internalized representations have not been acknowledged or responded to by attending therapists. Such is the case with eating disorders. Oftentimes the function of the eating disorder is to be a distraction from the intolerable feelings that originate from the problematic patterns that were set up in the eating disorder victim’s family of origin.

Traditionally, approaches to the treatment of eating disorders focus on the symptoms themselves. Oftentimes the treatment of eatingdisordered behavior is the rigid management of the problem by emphasizing issues of weight and consumption of food. It can be argued that an exclusive focus on symptom reduction without dealing with the adaptive function(s) of the eating disorder will not only be ineffective but will most likely result in the eating-disordered client experiencing relapse. This would be analogous to a client presenting with strep throat and being exclusively treated with an antiinflammatory such as ibuprofen. While there might be a temporary reduction of the symptoms that are concomitant with strep (soreness of the throat and fever) the strep throat will continue to persist. To effect a cure for strep throat the proper antibiotic must be introduced in an effort to kill the streptococcus.

Eating-disordered clients are often reluctant to “give up” their symptoms because they have become intertwined with their personalities and are adaptive in their functions. Kim Lampson Reef, a psychologist, and a recovered eating disorder client herself, explains it this way:

“An eating disorder victim can be seen as someone who is shipwrecked at sea. She is desperately holding on to her life preserver in an effort to stay afloat. Along comes a helicopter in which a rescuer is reaching out for the shipwrecked victim. The rescuer shouts, “I’m here to save you.” The victim responds by shouting, “I’m glad you’re here. I need to be saved.” Without saying anything else, the rescuer starts pulling on the victim’s life preserver. At this point, the victim starts fighting off the rescuer, yelling, “What are you doing? I don’t want you to touch my life preserver. This is what has kept me afloat.”

In a similar fashion, eating disorder clients fight with their therapists. They often refer to their eating disorder as their “best friend”. Their eating disorder is what has kept them afloat and they are very reluctant to let it go. It is not that these clients do not see the consequences, both physiologically and psychologically, of keeping their eating disorder, but their eating disorder is the “bailing wire” that is holding them together and is helping them deal with the insecure attachments of their childhood.

A Fortuitous and Intuitive use of (IRT) with an Eating-Disordered Client

Back in the late 80’s, I met a young woman by the name of Sharon. Sharon was brought into therapy by her husband, Bill, who was very concerned about Sharon’s bulimic behavior. During the intake it was noted that she was working at a local restaurant. What was intriguing was the fact that Sharon would not only work her shift, but she was frequently asked to work another worker’s shift. Sharon could not simply say “no”. The only times Sharon was able to leave work on time was when either her husband came and actually dragged her out of the restaurant, or when Sharon hid in the restaurant’s bathroom until the person who always requested her to work had already started her shift.

Sharon was initially seen on an outpatient basis but her behavior deteriorated to the point where she needed to be hospitalized. She was admitted to a local medical center for a period of approximately six weeks. There she received therapy as usual, e.g., dietary counseling, individual therapy, group therapy etc. At the end of her six-week stay, Sharon was binge and purge free. While happy at her success, I viewed it as tenuous at best. For an extended period of time, she was able to white knuckle it through her days and remain binge and purge free. She moved and I did not see Sharon for a period of approximately two years. She re-entered therapy in 1990. Prior to returning to therapy she had given birth to a beautiful baby girl. When she returned to therapy, she was worse then she was two years previous. Once again, she was hospitalized for her acute eating disorder symptoms. Upon her rehospitalization, she reported that she was binging and purging at a frequency of twelve times a day. It was interesting to note that Sharon would never purge in her home while her husband was present. She always wanted to give the impression that she was “OK” and that she was never upset at anything. She would always wait until he left the house or was off to work. It was during her second hospitalization that I noted the overprotective behavior of her husband. Bill would always speak for her, and she was never allowed to speak for herself.

In an effort to help stop Sharon from binging and purging, an NG tube was placed. The rationale behind this was that it was very difficult to purge with an NG tube placement. This did not deter Sharon, however. One day she got a comb, reached into the back of her mouth, and was able to pull her NG tube out. At that time, she cut her NG tube at the point of the back of the throat, thus allowing her to purge if she desired.

To be honest, I was becoming very discouraged. It seemed that everything I had learned about treating eating disorders was not working. One day, grasping at straws, I blurted out in therapy, “Sharon, do you love your husband?” At that point, Sharon burst into tears and responded by saying, “I have to love my husband.” I then responded by saying that “while it would be very nice if she loved her husband, she did not ‘have’ to love her husband.” I then started to review once again Sharon’s earlier life.

Investigation into Sharon’s childhood found that she was adopted. As a result of being adopted she had already experienced broken attachments. When I asked her about her relationships with her adoptive parents Sharon reported that there was much tension between her and her adoptive father. She stated that her father was a perfectionist and would become very impatient with her as he tried to help her with homework. On many occasions, when she could not understand a particular math problem, her father would break the pencils they were using in half and throw them against the wall. While Sharon’s father did not ever physically abuse her, she did witness, on at least a couple of occasions, him becoming very impatient with her adoptive mother and hitting her. Sharon found her father’s behaviors repugnant to her nature. It would seem that she made an unconscious agreement with herself that she would never be like her father and hurt other people’s feelings. In essence Sharon was saying, “I am the exact opposite of you. I devote my life to being everything you are not, and I want you to know it, admit you were wrong, and make it up to me. Love me after all.” (Benjamin, 2003) Apparently, part of this unconscious agreement was to never say “no” to anybody, because it would hurt their feelings. After discovering why she had such a difficult time in saying no we were able to go back and discover other times in her life when her inability to say no caused her considerable consternation and grief.

It was during her late teens when she met and started to date Bill. She described their relationship as being “the best of friends”. Despite being a close friendship, there was never that romantic chemistry on Sharon’s part. On the other hand, Bill had become very enamored with Sharon. In Sharon’s words, “he pushed the relationship”, and after several months of dating, he proposed to her. As you might have guessed already, Sharon could not say “no” and the two married.

While Sharon never viewed Bill as abusive, she did find him to be very controlling. Because she was so committed not to hurt anyone, she would never defend herself against her husband’s control.

An example of Bill’s controlling behavior was when the extended family gathered to have a family prayer, he often prayed out loud for her to be blessed to “stop throwing up”. As one might conclude, Sharon found this very demeaning and very controlling.

During the course of therapy, we concluded that it might be best for Sharon and Bill to have a separation. While Bill was reluctant to do this, Sharon readily agreed. Sharon took her newly-born baby girl with her to live with her mother and father in Colorado where she worked in a clothing establishment in a local mall. As a result of her insight concerning her unconscious decision not to hurt anyone, she learned to become more assertive. What I found extremely intriguing was that her bulimic behavior dropped to zero almost instantly. Not only was her bulimic behavior eliminated, but she was able to avoid relapse and seemed to do so without effort.

The separation between Sharon and Bill eventually concluded in divorce. Several years after the divorce Sharon and I had the opportunity to review her situation. She informed me she had remained binge and purge free and in addition that she had remarried. She went out of her way to inform me that the gentleman she was now married to was one of her own choosing and that she loved him very much. I was feeling a bit guilty, as it would seem I had helped to initiate the split between Sharon and Bill. Sharon assured me that I was not to feel guilty, and in fact indicated that the insight into the copy processes involving her and her father which incorporated her lack of desire to hurt anyone was the thing that saved her. She was very, very happy in her second marriage, and she now had two additional children.

A Current Example of Using IRT with a Stuck Eating Disordered Client

In my outpatient practice I have been seeing a client by the name of Barbara intermittently for approximately the last five years. Initially, I met her in an outpatient group that employed Linehan’s Dialectical Behavior Therapy (DBT). I perceived Barbara as being quite bright and she readily grasped the concepts of what was being taught. Nevertheless the group had little impact on her eating-disordered behavior.

After the DBT group I did not see Barbara for approximately two years as she was already seeing another therapist. Shortly after the birth of her first child she terminated with her old therapist and asked if she could see me on an individual basis. In outpatient therapy we ended up doing “therapy as usual”. I initially employed cognitive behavioral therapy in an effort to challenge her cognitive errors regarding her body weight and size. Nothing worked! Even her two visits to the dietitian seemed to entrench her even deeper into her eating-disordered behavior. Outside of therapy she would often spend long hours going to pro-anorexic web sites where she would envy and obsess over the skinny bodies that were being portrayed. Every stressor that she would experience in her life seemed to entrench her deeper and deeper into her pathological coping behaviors.

Recently, as I started to use Interpersonal Reconstructive Therapy (IRT), I shared my findings with Barbara. Using the “Copy Process Speech” outlined in her book (Benjamin, L.S. , 2003) I said, “I believe that everything [in one’s life] makes sense. Usually problem patterns we have in adulthood reflect things we learned as children. The connections often are quite direct. What we do as adults often copies early patterns that we learned from mother or father or others. There are three ways to do it: Be like him or her; act as if he or she is still there; treat yourself as did he or she. For example, I notice that you are [a perfectionist] and you have been talking about how your father also [was a perfectionist] . . . . Do you see other connections? . . . Here are some that I see, although they will need further checking.”

I further explained to Barbara the concept of “psychic proximity”. Again using the “speech” employed by Benjamin, L.S. (2003), I continued, “So you see that in many ways you are being faithful to the rules and values that you learned when you were little. The question remains: Why do we do that? Why do we keep on following those old ideas, especially when they don’t work so well any more? Well, often it is because without realizing it, we are trying to ‘get it right’ with (Dad, Mom, brother, significant peers). It is like we do it the way they seemed to want it in hopes that they will approve and be pleased. It is as if we hope that maybe things could be better after all. ‘Every psychopathology is a gift of love.’ Does that make any sense [for you]? . . . The gift of love hypothesis (GOL) suggests that copy processes are maintained by wishes for psychic proximity to the IPIRs. By acting according to the IPIR’s perceived rules and values, [you the client] are attempting to receive the IPIR’s approval. ‘If I do this well enough, long enough, faithfully enough, THEN maybe you will love me.'” Again as noted by Benjamin, L.S. (2003), “Appeal to earlier ‘relationships’ represented by IPIRs is more likely in less secure individuals, and in individuals under stress.”

As I related the principles of IRT therapy to Barbara she started to have profound “aha” experiences. At one point she exclaimed, “Do you mean that I have been doing all this crazy stuff in an effort to secure love from others?” In an effort to better identify and elucidate the copy processes that Barbara had embraced from her childhood I had Barbara redo her autobiography. Not only does her autobiography give insight on her “copy processes” but one can clearly see the foundation from which her eating disorder behavior developed. Consider the following patterns from excerpts of Barbara’s autobiography: Perfectionism – Barbara was a perfectionist in everything she did. Her perfectionism appeared to be a driving force with her eating disorder. Consider this insight from her autobiography:

. . . She (my sister) was the screwed-up one so I had to be the perfect one. Dad always said I could do anything if I put my mind to it. He is very perfectionistic, so I get that from him. If I’m not satisfied with something, I will do it over and over again until I’m satisfied. I won’t ask for help either. I have to do it on my own, just like my dad. He has a hard time asking and accepting help also. I guess I tried to be like my dad because I wanted him to love me. I knew he did and he does, but he never said it or showed it. I wanted so much for my dad to give me a hug and tell me he loved me, even when I did stupid things. He never did. Instead, I would hear, “You stupid kid. What did you do that for? What’s the matter with you? You know better than that.” I felt very stupid. I wanted him to say it was okay to make mistakes and that he still loved me. I felt I was just a disappointment to him. I wished I had been a boy. Maybe he would have loved me more and done more things with me. . .

The copy process involving perfectionism may be stated something like, “Dad, your rules and views on being perfect are my rules and views on being perfect. I will hold faithfully to them now and forever. When you see how powerfully you have affected me, you will love me more!!” Part of Barbara’s attempt at being perfect was to reduce her body weight and size. She wanted to be “perfect” just like those women whose pictures she was downloading from the pro-anorexic web sites. While Barbara’s father was disgusted with Barbara’s weight loss this only drove Barbara to try even harder in her effort to manage her body size and weight. Again, “When you see how hard I am trying you will finally come through with the love and affection that I so desperately need.”

Emotions – Barbara thought that it was a sign of weakness to have emotions. In the four years that I have worked with her I have only seen her become emotional once. Even then she quickly pulled her emotions inside and put on a stoic front. Studying Barbara’s autobiography it is easy to see why Barbara has such a difficult time dealing with her emotions:

He [my dad] has a hard time with his emotions because his dad was very hard and abusive to him. As I’m told, Grandpa’s parents were very, very strict people. Dad and Grandpa had a hard time with their emotions and now I do. I have a hard time expressing myself. Whenever I cried, dad would say, “Stop your crying.” So now I can’t cry in front of anyone. I hear my dad saying, “What are you bawling about?” So if I cry, I have to be alone. Dad never abused me in any way. He did spank my bare butt once. From then on, I was a very good kid, always trying to do my best so dad would love me and give me hugs. All of my friends’ dads would hug them when they would come home from school or from playing. I was so jealous. Why didn’t my dad do that? Was something wrong with me?

The “copy process” that contained Barbara’s attitude on emotions might be stated: “Dad I am like you. Both of us refuse to recognize and deal with our emotions. This means I love and forgive you. We are birds of a feather. See how I provide testimony to you. Please love me for it.” As we all know, one of the adaptive functions of an eating disorder is to numb oneself. Undoubtedly Barbara used her eating disorder for affect regulation. Given Barbara’s affective instability and her desire to put up a stoic front, it is easy to see how her eating disorder could emerge as a relatively safe mechanism for regulating different tension and feeling states. Throughout her days the variability, range, and seeming unpredictability of her different moods and emotions may have become overwhelming and disorganizing for her. The concrete and repetitive act of becoming overinvolved with her body probably serves as an integrating function, allowing her to reliably create a predictable affective and cognitive state.

Direct Messages about Physical Appearance – Like many eating disordered clients Barbara received messages that her physical appearance was important. Like many women, the main source for these early body image messages was her own mother.

In the middle of the twelfth grade, my mom made a comment that I was getting chubby. I thought I was fine-average, like most girls. But those words made me go on a diet. I must have lost a lot of weight because Laurie told Wendy that she was worried about me because I was so thin. We didn’t have a scale so I didn’t know how much I weighed. After a while, I gave up on the diet. I did exercise a lot, though. My mom was always taking an aerobics class or something, so I thought I had to. Mom always talked about dieting for as long as I can remember, even though she didn’t need to. I guess, in some ways, I followed her. She would always look her best, even just going grocery shopping or to the post office. She still does. I think that’s where my need to be clean and look good comes from. She would always talk about how she needed to get into shape. She would go out walking a lot. Sometimes I’d go with her. It was while we were on our walks that I started to compare myself with other girls. I compared every part of my body-legs, arms, and butt, but most girls were like me. Some were a little thinner and some a little larger. I got the idea in my head that my butt was bigger than my friends, so I starting wearing baggy sweaters and shirts to cover my butt. I still do that a lot of the time. It didn’t help either that my dad would make comments like, “That will make you fat!” Or “That will give you pimples” if I was eating chocolate or a doughnut.
The “copy process” from her relationship with her mom was, “I am like you. This means I love and forgive you. We are birds of a feather. See how I provide testimony to you by me being involved in an eating disorder. Please love me for it.”

Physical Intimacy and Sexual Relations – As a teenager Barbara sought the validation and recognition that she never received from her father through relationships with different young men. As a result of her vulnerable and needy position she was often taken advantage of in emotional and sexual ways. This had a disastrous negative effect on her view of physical intimacy as a way to express love and caring. She wrote the following about her relationship with a young man named John:

. . . . By mid-October, my grandparents were going to New Mexico for the winter, which they did every year. They asked if I would like to go with them. I didn’t really want to, but I had a bad asthma attack, so my parents wanted me to go and see if my asthma would improve there. Now, in a way, I’m glad I went and spent the time with my grandparents because the next summer, my grandpa, died of a heart attack. It was kind of boring there at first because where my grandparents lived was where all the snow-birds went and there was no one even close to my age there. It was all old people. It was nice and relaxing at first, and then I became very bored. One day I met a guy name John. My grandma already knew him because the year before, my cousin Lisa stayed with them and she went out with John. It didn’t work out. I wished she would have warned me about him. It would have saved me so much agony and self-hatred. I started dating John regularly that month. I was glad to be getting out of the house with someone my own age. He was really nice and cool the first few dates. Then he started to get more aggressive. I told him to back off because I wasn’t ready for that kind of a relationship. My first time would be with someone I loved and would spend the rest of my life with. Of course, he didn’t like that, but he did back off, for a short time anyway.

Then, one night, he told me he loved me. I didn’t believe him. He didn’t really know me yet, not who I was deep inside. He knew my outside and he didn’t really care about my inside-what made me who I was. How can you love someone and not really know them? What he said next really took me by surprise. He said, “I want to have sex with you!” My mouth dropped open. I didn’t want that and I told him so. He wanted to show me how he felt about me, with sex. I should have told him right then and there to take a hike. I didn’t. Somehow I couldn’t. Even though I knew his love wasn’t real, I still liked the attention he gave me. I liked having someone hug me and hold my hand. I was getting the affection I craved and that I had needed for so long. He was always bringing up sex and he knew I didn’t want that because I told him that from day one. I guess he thought of me as a challenge or something.

One night, when we went out, after he picked me up, he said that our plans had changed. We weren’t going to the movies. He had to make a stop at the drug store. Instantly I knew what he was getting. He came out with a small paper bag. I had tears in my eyes and told him, “No, I don’t want to. I want to go home.” He said, “Okay, we don’t have to. Let’s just go for a drive and talk. I won’t try anything.” What a dummy I was. I believed him. Where we went was somewhere out in the boonies. Nothing was around us. Nothing. He wanted to get in the back of his truck and look at the stars. He made me feel so low, and said that I was a terrible tease and I had to have sex with him. . . I prayed for someone to come by so I could yell for help, but it was dark and no one was around. I felt I had no choice. “Either do these things that he asks or he will rape you!” my mind said. I tried to do as he wanted, but I just couldn’t and finally, he pushed me away. I was so disgusted and felt so dirty. Afterwards, I said, “Take me home!”. . . . I was depressed and hated myself. I was no longer sweet and innocent like he once said I was. He corrupted me.

As a result of her relationships with the different young men that she dated, Barbara learned the axiom “Sex is dirty, rotten, and bad so only do it with the one you love!” She was conditioned to find physical intimacy as something repulsive to her nature. Her negative feelings about sex resulted in her being unable to consummate her marriage until the sixth month of her marriage. Barbara’s sex life within her marriage is all but nonexistent. The “copy process” that she learned from her relationships with different men was, “I will do the opposite of what you want from me until you admit I am right and you are wrong. I want you to accept me on my own terms. Please love me ‘as is.'” It should also be noted that by being involved in an eating disorder, Barbara effectively reduced her sex drive. The eating disorder allowed her to be “asexual” thus giving her permission not to have to deal with anything sexual. As implied above this had a profoundly negative effect on her marriage.

Unlike Sharon, just because Barbara gained insight into her “copy process” her eating-disordered behavior did not just cease to exist. In therapy, Barbara is currently in the process of grieving and letting go of the fantasy residues of early attachments. Compared to where she was prior to being introduced to IRT principles and concepts she is now making significant progress and appears to be highly motivated. As her therapist I am actively trying to block old maladaptive patterns while at the same time helping her to recognize and embrace new, more effective coping behaviors.


It is my fear that as I relate Sharon’s and Barbara’s cases I make IRT sound too simple. The process of helping the client recognize their patterns, and then come to an understanding of where they came from and what they are for, is a tedious one. Oftentimes it takes weeks to formulate a case. In addition, once IPIR’s and copy processes are identified they must be self-validated by the client. If in fact the client embraces the case formulation they must then decide whether they want to change. It is only after making the decision that they want to change that clients can begin the work of learning new and better patterns. Benjamin (2003), notes that IRT is not a short-term therapy. Successful termination of an IRT client is to be seen in terms of months and years instead of weeks.

Another fear in presenting this model is that it might be perceived as another way to “bash parents”. As one colleague noted, “Parents are the most crapped on people in psychology.” Benjamin (2003) herself goes out of her way not to endorse the “justice model” where the goal in therapy is to find out who screwed up the client and then to mete out some kind of punishment in hopes that this will help facilitate the client’s healing. It must be remembered that problem patterns or copy processes are a child’s perception of parental rules and regulations. It is also important to note that parents are also “victims” of the environment in which they were raised. I feel that it is categorically wrong to automatically imply malicious intent to parents’ interactions with their children. I know of no case when after a child was born the parents gathered at their child’s crib and said, “What can we do to mess this kid up!” Speaking of how she was raised one of my clients noted, “My parents did the very best they knew how.”

It has been my argument that eating disorder symptoms need to be viewed as an adaptive function given the context in which they have developed over time. It is my thesis that in many cases eating disorder symptoms are adaptive responses to problem patterns associated with important persons and their internalized representations. Treating eating disorders should focus not only on symptom reduction, but also on understanding their development, purpose, and function. Treatment should emphasize resolution of underlying psychological and emotional conflicts that perpetuate the eating-disordered behavior. Interpersonal Reconstructive Therapy provides a useful framework by which eatingdisordered behavior can be understood and worked with in a therapy setting.

Benjamin, L.S. (2003). Interpersonal Reconstructive Therapy: Promoting Change in Nonresponders. New York: Guilford Press.
Ross, C.A. (2000) The Trauma Model: A Solution to the Problem of Comorbidity in Psychiatry. Richardson, TX: Manitou Communications, Inc.
0000 Schwartz, M. (2001). “Treating Eating Disorders From A Self- Psychology And Attachment Disorders Conceptual Framework.” San Diego: IAEDP Conference