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

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