alcoholism is such a common condition that therapists must be exposed to clients who suffer from it, whether the therapist is the ever evolving landscape of french psychotherapy helene cadot abstract: the article is the keynote address given at the 5th international integrative psychotherapy association conference in vichy, france, april 21, 2011. key words: integrative psychotherapy in france ____________________________ this morning, i would like to introduce the landscape of psychotherapy in france, where integrative psychotherapy has gradually developed: there are now twenty three psychotherapists, with three soon-to-be and five soon-to-be trainers/supervisors. for over twenty years, richard erskine, phd has come to france to pass on this approach. who are the french clinicians who have come to discover integrative psychotherapy? they are already working as psychotherapists, have often had years of training in transactional analysis, gestalt, sometimes psychodrama, they are clinical psychologists, physicians, and for the main part driven by an empirical quest focusing on the following issues: • how to work in psychic care? • how to be a psychotherapist from a true self and not from a role, or a posture to be genuinely in contact? • how to give intersubjectivity its real place? • how to help and keep the therapeutic relationship alive with patients suffering from early or cumulative traumas and with severely dissociated patients? • how to be a psychotherapist in front of a patient who has no dreams, no memories, whose psyche is sometimes in a siderated state? • how to work when words are not available? • how to deal with a body which is speaking, suffering, closed, stiff, sometimes, negated? international journal of integrative psychotherapy, vol. 2, no. 1, 2011 • how to deal with conflicting, suffering, disturbing introjects? 19 • how to elaborate an overall vision of the person, who is a being of flesh, needs (especially relational), affects, desires, hopes and representations? • how to maintain our bearings in the course of long term therapies, through such complexity and in front of so many interactive aspects? • how to have our own place, how to proceed when the good our care aims to bring paradoxically ends up hurting, when juxtaposition pain is triggered and has repercussions on the process and the frame of the therapy? such questions and preoccupations have been alive in me for a long time as a psychologist, psychotherapist, supervisor, trainer… when listening to professionals during supervisions, i have always been called out and interested in this quest –professional, indeedand above all in the deeply human ring it has. i have been moved to observe the intimate, sometimes, solitary aspect of this quest in every person. i have noticed that the approach used by sandor ferenczi, a hungarian psychoanalyst who in his time had courageously faced this very quest, inspired many french clinicians. the same goes with winnicott’s empirical writings, and for others, masud khan who describes in “the hidden self” the obstacles he was faced with, with regressed, schizoid patients for whom the frame of the psychoanalytical cure was not suited; his testimony fraught with great descriptive sincerity unfolds his personal know-how, his failures to make the frame evolve, and he looks very close to us. thanks to deep reflection about: • tactful exploration • involvement from the therapist • attentive and continuous attunement to the patient’s idiosyncrasies • the “keyhole” model, the description of relational needs among others, integrative psychotherapy, especially in the “theory of methods” helps to give an answer to this empirical quest and fuel it; it gives hope to clinicians, sheds useful light on paths that are often difficult to walk and brings this solitary quest to an end. international journal of integrative psychotherapy, vol. 2, no. 1, 2011 psychotherapy can only be contextual, it is rooted in the culture of the country it is practised, it takes the colours of the evolution of society, of rises that crop up, it is crossed by ideologies on mental health, suffering, care, patienttherapist relationship, etc. in france these days, mental health is an exacerbated political stake (see the rebellion of 20,000 psychiatrists against a security drift, present in a bill called the “night of law-and-order”). the title of “psychotherapist” has been the recent focus of a law that many professionals experience as unfair and rather counterproductive. in such social, economic and political environment, when humanistic clinicians and the meaning they attach to their practice are given a rough time, the values carried by integrative psychotherapy are all the more precious, and all the more meaningful to us. finally, be aware that it has 20 international journal of integrative psychotherapy, vol. 2, no. 1, 2011 21 also been collectively beneficial to invest time, energy, creativity in order to make a success of this important meeting with everyone of you all, dear colleagues. author: helene cadot, phd has been a clinical psychologist and psychotherapist for 25 years. she is a certified integrative psychotherapist, trainer & supervisor, doing training in france and central europe. currently she is a member of the csc of iipa and on the editorial board of the integrative psychotherapy journal. she has translated integrative psychotherapy articles and books into french. date of publication: 12.9.2011 international journal of integrative psychotherapy, vol. 9, 2018 73 a review of a guide to the world of dreams: an integrative approach to dreamwork by ole vedfelt, london & new york, routledge, 2017 henrik hass abstract: in a guide to the world of dreams ole vedfelt defines “ten core qualities of dreams”. these core qualities are unique thematic aspects of dreams with particular therapeutic perspectives. the step-by-step structure of the book, which includes theory, illustrative case examples, and practical guidelines, makes this book applicable in the training of all professional therapists. ole vedfelt is a training analyst for the international association for analytical psychology, a dream researcher, and author of the dimensions of dreams. keywords: dream interpretation, dream psychotherapy, dream-complexity, integrative dreamwork, dreamwork manual. _____________________________ a guide to the world of dreams: an integrative approach to dreamwork is structured in three parts: part 1 provides a general introduction to the theoretical and historical perspectives of dreamwork. part 2 goes through the 10 core qualities of dreams from a theoretically integrated perspective. part 3 contains exercises and guidelines for therapeutically integrative work with the 10 core qualities. international journal of integrative psychotherapy, vol. 9, 2018 74 at the outset of part one, vedfelt makes a thorough review of the psychodynamic tradition from freud and jung to the present day. next is a longer chapter about scientific dream research and the dreaming brain, a point of departure for themes of complexity theories and neural network theory. these themes are further developed throughout the book. the neurology described in this book confirm that the dreaming brain is active in the three layers: the vital areas in the neocortex, the brainstem, and the limbic system. portions of the cerebral cortex and “paralimbic” cortex implicated in the refinement of emotions, verifiable intuitive knowledge, social relationships, and creativity are more active when we dream than when we are awake. this underpins the view that dreams process information in significant and meaningful ways. according to vedfelt, the apparently inaccessible language of dreams reflects that dreams are advanced unconscious communication that he describes as unconscious intelligence. the main theme of the book is that dreams are information from our unconscious intelligence to our everyday consciousness. vedfelt states that issues that cannot be resolved during the day with consciousness can be resolved through unconscious intelligence while dreaming. in vedfelt’s vision, the unconscious intelligence while dreaming has a far greater capacity to synthesize knowledge than conscious thought when awake. unconscious intelligence allows people to rehearse problem solving, while remaining in the safety of sleep. the book is abundant in case material that illustrate both theory and practice. one especially touching case is of a young woman about to give birth for the first time with her baby in breach position. the woman dreamed about a complication with the fetus in relationship to her own mother. in therapeutic dreamwork, this woman found strength in taking responsibility upon herself. the following night, she dreamed that her baby told her it was ready to descend. it turned out that the baby had turned during the night and was now headed the right way for the upcoming delivery. how beautiful. earlier in danish, a poetic term was used to describe giving birth: “at nedkomme” (to come down – both literally and metaphorically). this is a touchingly beautiful therapeutic story, yet it is also deeply fascinating that her dream spoke is such precise poetic language. the central portion of the book describes 10 core qualities of dreams while providing a structured step-by-step immersion into vedfelt’s theory. each core quality builds on the previous one thereby giving the reader an understanding of international journal of integrative psychotherapy, vol. 9, 2018 75 the integrative approach to dream work. the 10 core qualities of dreams are designated as 1) dreams deal with matters important to us, 2) dreams symbolize, 3) dreams personify, 4) dreams are trial runs in a safe place, 5) dreams are online to unconscious intelligence, 6) dreams are pattern recognition, 7) dreams are high level communication, 8) dreams are condensed information, 9) dreams are experiences of wholeness, 10) dreams are psychological energy landscapes. these core qualities are vedfelt’s attempt to create comprehensive insight into the function of dreams in human life. humans are seen as self-acknowledging, interpreting, and communicating beings. core qualities 1 – 3 correspond to classical freudian/jungian perspectives. core quality 4 – about safe model simulations – can be tied to both psychotherapist peter levine’s “safe place” and also to neural network models of the mind. in core qualities 5-8, the previouslymentioned primary concern is found: the highly condensed information found in dreams can be viewed as a system of communication matrices between unconscious intelligence and everyday consciousness. core quality 10 focuses on existential, spiritual and religious experience. as a special application, vedfelt demonstrates how dreamwork based on these ten core qualities can support trauma work in a separate chapter. the third portion of the book is a richly detailed manual for practical dreamwork with the 10 core qualities. everything from the ethical aspects of dreamwork to how to record one’s own dreams. guidelines are provided for each core quality with structured exercises, so they can be thematically taught one core quality after the next. employing a built-in summary element, each chapter links back to the previous core quality’s practical and theoretical aspects. this book is relevant for anyone working with dreams. vedfelt’s model with its ten core qualities is inspiringly innovative while also including significant classical perspectives. this book is not just about understanding the client or oneself in relationship to dreams, rather its emphasis is on how the unconscious intelligence of dreams reflect humanity’s extremely high potential as communicating beings – dreams are a mirror into our deep commonality. dreams mirror human intelligence and poetic reality. international journal of integrative psychotherapy, vol. 9, 2018 76 author: henrik hass is a danish psychotherapist mpf, a member of both the danish association for psychotherapy and the educational board of the danish association for psychotherapy. henrik has a ba in philosophy and religious studies from university of copenhagen. hass has contributed to an anthology: "the potential of the unconscious cybernetic psychology in practice with the essay the necessary complexity." alcoholism is such a common condition that therapists must be exposed to clients who suffer from it, whether the therapist is the search for clues landy gobes abstract: this article is the keynote address given at the 4th international integrative psychotherapy association conference in lake bled, slovenia. the author describes her journey in therapy and her experiences as a client searching for clues and unraveling what was “missing”. ____________________________ detectives and psychotherapists have a lot in common. they both use keen observation and acute listening skills. they are both experts at understanding human nature. they study the history, relationships, and life experiences of their subjects, seeking the truth by trying to understand the forces acting on them and their motives for behavior. i’ve been a detective for as long as i can remember. when i was a teenager, i read sherlock holmes and edgar allen poe and i collected nancy drew books in the same way that i read and collect mystery novels now. i am fascinated by the search for clues, and i enjoy that searching with each of my psychotherapy clients. i experience the thrill of the chase as we discover together what has happened in the client’s life, how those experiences have affected him, and what it all means for him today. the cognitive work is seldom enough by itself, but it enhances and gives meaning to the physiological, affective, and behavioral aspects of the psychotherapy that we do together. as is true for many of us, i believe that i was drawn to be a psychotherapist in order to solve the mystery of my own life. i had what seemed to be an ideal middle-class childhood. i was an only child of parents who allowed reasonable privileges and set reasonable limits. i had a bicycle when i was 8, a horse to ride at 11, and a car to drive at 16. what more could any kid want? both at home and at school, i worked hard to be perfect in everything. i was a good kid, i made good grades, and i was praised by my parents and my teachers. the mystery? i had a vague sense that something was missing, and i always seemed to be waiting for something. international journal of integrative psychotherapy, vol. 1, no. 1, 2010 51 when i was in my 40’s, managing a husband, a house, and 6 children, i read about transactional analysis. i could immediately feel the shifting of the ego states inside me, and some of the cognitive mysteries began to be solved. i went to graduate school, and i got transactional analysis training, and had some ta therapy. i learned that abandonment by my parents was my deepest fear, but that didn’t make sense to me. i knew i had been a wanted, only child of two people who took good parenting very seriously. until this point i had been searching for clues in my remembered childhood, unable to get back beyond my own adaptive defensive systems to the earliest years of my life. although i didn’t remember my infancy, i had heard the family stories about it. they said i was born with infantile eczema in the days before there was any medication for it. they pinned my sleeves to the mattress, and later, they put splints on my arms, so that i would not scratch my face. the doctor had told my parents not to hold me close to them. he did not want me to scrape the eczema scabs off my face. my parents recounted with pride that i had learned to hold my bottle with my feet. but these were just stories to me; i had no memories of the events. my eczema was gone by the time i was one year old. in my 50’s i went into individual therapy – this time in integrative psychotherapy. i prepared myself, as always, to do whatever unpleasant thing was expected of me. to my surprise, i felt understood and appreciated and respected. looking back i see that i had been expecting to be shamed. instead, my therapist listened to me with interest, asked questions, and accepted whatever i told him with no demands for behavior change. my childhood and lifetime experiences had left me convinced that i could only have a relationship with someone if i perfectly met their needs and requirements. this therapy relationship was different! i know now that what my therapist did was attune to me, inquire about me, and involve himself in our therapeutic relationship in such a way that i did not feel alone. i realized, for the first time, that my parents had shamed me for wanting physical contact with them. their misattunements, their lack of inquiry into my thoughts and feelings, and their over-involvement with my successful adaptations to them had left me feeling very lonely, even though i had not been alone. when i experienced a connection with my therapist during a therapy session, my defenses would melt, and i would feel the terror of the aloneness that i had been successfully not feeling for many years. these sessions were painful; but solving the mystery, understanding what had happened, was rewarding. the energy i had used to defend against that painful loneliness could now be used in internal integration. another aspect of my therapy involved transference. i will try to describe this from my point of view from within the therapy. my memories of my early childhood were not visual memories. and yet, during the therapy, when my international journal of integrative psychotherapy, vol. 1, no. 1, 2010 52 international journal of integrative psychotherapy, vol. 1, no. 1, 2010 53 therapist inquired about my experience of my relationship with him, i would see my mother in the back of my mind. for example, if my therapist had been away, he would ask me if i had missed our sessions. even while i was saying “no,” i would see my mother walking away from my crib. once, i “saw” my mother standing out in the hall listening to me as an infant crying alone in my room. i realized that before i could talk i had had to learn not to cry in order to get her to come in to me. since i could not have actually seen my mother from that perspective, i assume that these were pictures my mind made to illustrate my early relationship with my mother – answers to the mystery i had been trying to solve. now i know why i felt so terrified of abandonment. i had experienced it as a baby! i was alone and scared and no one was picking me up or holding me close. recovering this memory and solving this mystery changed my life. i was no longer lonely, no longer waiting for my mother to come pick me up, and best of all, i stopped waiting for any of my transferential versions of that early longing for my mother. to understand the theory and methods of bringing unremembered events and feelings into a client’s awareness, i recommend you read richard erskine’s articles on script that are posted on his website. he has broadened eric berne’s definition of script to include pre-verbal experiences, early attachment patterns, and implicit experiential conclusions. i also recommend the chapter on inquiry in his book, beyond empathy. each time i re-read that chapter i become a better therapist. i am very grateful that my search for clues led me to richard and to this organization and to all of you here today. thank you. author: landy gobes, msw, lcsw is a psychotherapist and consultant in west hartford, ct, usa. she is an integrative psychotherapy trainer and supervisor, a teaching and supervising transactional analyst, and a fellow of the institute of integrative psychotherapy. international journal of integrative psychotherapy, vol. 7, 2016 85 a review of the manual of regulation-focused psychotherapy for children (rfp-c) with externalizing behaviors: a psychodynamic approach by leon hoffman, timothy rice, & tracy prout. new york, ny: routledge, 2015. 236 pp. katie aafjes-van doorn abstract: it is not often that i keep therapy manuals as bedtime reading and that i go through them cover to cover, but the manual of regulation-focused psychotherapy for children (rfp-c) with externalizing behaviors (rfp-c; hoffman, rice, & prout, 2015) was a real pleasure to read. this book, with its theoretical and empirical foundations and additional clinical resources, is much more than just a manual. the authors make clear theoretical links between dynamic theory, behavior therapy, and neuropsychological research and therefore potentially appeal to a wide range of clinicians and researchers alike. although it is very text heavy, and some additional diagrams (e.g. ‘triangles of conflict’) would have made it even stronger, overall the layout of the book is very user friendly. it, for example, presents text boxes of little summary statements in each chapter as well as many clinical examples and transcripts of patient and therapist speaking turns. also, the additional resources provided in the appendices, such as, the adherence and outcome measures, can easily be used by the child, parent and therapist. key words: treatment manual; integrative; children; psychodynamic ______________________ integration of theories and techniques conceptually, regulation focused psychotherapy seems to be a well puttogether integrative treatment approach based on psychodynamic theory. rfp-c appears to have many commonalities with leigh mccullough's affect phobia therapy (apt; mccullough et al., 2003). like mccullough’s writings on systematic desensitization of affect, this book on rfp-c puts forward a therapy language that international journal of integrative psychotherapy, vol. 7, 2016 86 can be understood by clinicians from different theoretical orientations. the manual offers a clearly structured and moment-by-moment guidance through the treatment interventions, explicitly stating how these interventions link with a psychodynamic understanding of the pathology development of externalizing behaviors. the book uses familiar analytic terms like “defenses”, “objects”, “countertransference”, and “internal conflict” and for clinicians less familiar with these concepts, it offers a comprehensive theoretical background of its analytic roots and rationale. in line with psychodynamic theory, rfp-c underlines the importance of letting the child's play emerge; following the child's lead rather than attacking the defenses. in the book, the authors argue that externalizing behaviors are meaningful, protective and understandable defenses a child uses to regulate (un) conscious emotional states. different from the traditional anger-management interventions that arguably hold a directive and more judging view of ‘maladaptive coping’, rfp-c offers a refreshingly open-minded approach in which the child can experience some well-needed sense of agency. a limitation of the psychodynamic conceptualizations used in rfp-c, as with many other psychodynamic models, is its lack of attention to contextual factors such as social diversity and culture. although the influence of religion and cultural background in how parents might understand their child's behavior is mentioned briefly on page 107 and 110-111, the authors don’t elaborate on how this relates to parent-involvement in the treatment and the potential settings where this treatment can best be offered. psychology students in professional schools, as well as professionals in community mental health services (e.g. mfts and lpccs) who end up using this manual would benefit from examples as to how the interventions might be adapted to different cultural groups or systemic issues (e.g. parents who don't speak english or do not support therapy, or do not want to engage etc). although the authors present rfp-c as a psychodynamic treatment model, the approach clearly integrates aspects of behavioral therapy, experiential and client-centered approaches. for example, experientially-oriented clinicians will appreciate the descriptions on experience-near interventions, in-session processes (i.e. experiential therapy), and the concrete examples from short-term dynamic therapy. also, rogerian counselors will appreciate the rfp-c’s emphasis on common factors, such as respect, understanding and non-judgmental exploration of the child's externalizing behaviors and the parents/systemic unhelpful behavioral patterns. my worry with labeling this approach as a psychodynamic model and with using traditional analytic jargon in the manual, is that it might be off-putting for many clinicians who don’t identify as psychodynamic clinicians but who could potentially benefit from using this book. however, the opposite could also be argued. it is possible that other terms used in the book, like international journal of integrative psychotherapy, vol. 7, 2016 87 “implicit emotion regulation”, “mentalization” and “linking of emotion/thoughts and behavior” as well as the explicit use of adherence measures, the prescriptive nature of the manual and the short-term 16-session format itself are hard to swallow for traditional psychoanalysts. this means that, although the intention of the authors is clearly to offer an integrative conceptualization of externalizing behaviors, the sheer fact that the book caters to different modalities at the same time might be its downfall. it might mean that rfp-c will appeal to neither psychodynamic nor cognitive behavioral therapists, possibly limiting its target audience to clinicians who identify as integrative therapists. integration of research into practice regardless of therapeutic orientation, a strength of hoffman, rice and trout’s (2015) book is its translation from research into real-life clinical practice. first, the authors elaborate extensively on the evidence-based underpinnings of rfp-c, including recent research findings from the field of affective neuroscience. the clear link between neuroscientific findings and the treatment interventions strengthen its appeal to a wider scientific community as well as the face validity for clinicians, families and researchers alike. not unimportantly, it seems likely that a grant application for a treatment trial of rfp-c would be more successful because of this explicit neuroscientific basis. for example, using the concept of externalizing disorders, rather than specific, narrowly defined clusters of symptoms in traditional diagnostic categories (the authors describe the dsm -iii, iv and v criteria for odd and adhd) follows the research domain criteria initiative (rdoc; insel et al. 2010), rdoc of the national institute for mental health neatly. future clinical research trials evaluating the implementation of this manual in clinical practice might contribute substantively to the current evidence-base for this client group. hopefully, the results from the initial research trials will be able to tell us more about the short and long-term effects of this manualized rfp-c treatment on neurological/ behavioral and affective changes in the children. in my view, this manual has the potential to become a great evidenced-based integrative approach for children with externalizing behaviors and their families that can be applied in different settings and conducted by clinicians from different theoretical backgrounds. one concern with regards to future evaluations of rfp-c in clinical practice is that the manual offers flexibility in the content of the child sessions. although clinicians might appreciate the freedom to personalize their approach to each child, these idiosyncratic child sessions might jeopardize the generalizability of the research findings. the authors have tried to address this by providing adherence international journal of integrative psychotherapy, vol. 7, 2016 88 checklists related to the different sessions in the appendices, but these scales seem very broad still. terms used in these checklists, such as “collaboration”, “alliance”, and “non-judgement”, are very subjective constructs and research on the inter-rater reliability of these scales seems warranted. in sum, this comprehensive book on rfp-c by hoffman, rice and trout (2015) is a useful theoretical, research and clinical resource in addition to being a practical psychotherapy manual. it gives a thorough background on psychoanalytic theory, neuroscientific research and clinical concepts as well as clear guidelines on implementation of an integrative approach to treating children with externalizing behaviors in clinical practice. the authors need to be commended in that they have managed to successfully integrate different psychotherapy theories and languages, while building a bridge between neuroscientific psychological research and clinical practice. i sincerely hope this rfp-c manual will get more clinicians interested in integrating dynamic conceptualization and behavioral interventions and will show how useful this integration can be for working with children who present with externalizing behaviors. author: dr. katie aafjes-van doorn is a licensed clinical psychologist and psychotherapy researcher. she currently works as postdoctoral research fellow at the derner institute for psychological services, adelphi university, new york and will be joining the faculty at ferkauf graduate school of psychology, yeshiva university, new york in fall 2017. her teaching and research interest is in evidence-based psychodynamic psychotherapy as well as its potential moderators and mediators of change. she has written several empirical papers and co-authored an introductory book on clinical psychology, and chapters on process-outcome research and research in clinical psychology. references insel, t., cuthbert, b., garvey, m., heinssen, r., pine, d. s., quinn, k., wang, p. (2010). research domain criteria (rdoc): toward a new classification framework for research on mental disorders. the american journal of psychiatry, 167(7), 748–751. doi: 10.1176/appi.ajp.2010.09091379 hoffman, l., rice, t., & prout, t. (2015). manual of regulation-focused international journal of integrative psychotherapy, vol. 7, 2016 89 psychotherapy for children with externalizing behaviors: a psychodynamic approach. new york, ny: routledge. mccullough, l., kuhn, n., andrews, s., kaplan, a., wolf, j., & lanza hurley, c. (2003). treating affect phobia: a manual for short-term dynamic psychotherapy. new york, ny: the guilford press. date of publication: 29.7.2017 international journal of integrative psychotherapy, vol. 12, 2021 1 review of integrative psychotherapy: a mindfulnessand compassionoriented approach by gregor žvelc and maša žvelc, routledge, 2021 john hallett1 gregor žvelc and maša žvelc have developed the first systematic, comprehensive expansion of the theory and methodology of integrative psychotherapy (ip), a method originally developed by richard erskine. they have built on the model by correctly pointing out that mindful awareness has been an integral part of ip, even though it has not been explicitly written about in those terms. as true integrative psychotherapists, they have integrated their mindful and compassion-oriented approach with the models of erskine and other colleagues (erskine, 2015; erskine et al., 1999). žvelc and žvelc’s foundation in psychotherapy theory and methodology is clearly ip, and they give an excellent overview of it in the beginning of the book, emphasizing how at its heart, their work is a relationally focused psychotherapy. it is also apparent that they have been influenced by buddhist philosophy, but regardless of what a reader’s spiritual sensibility might be (or even if they do not have one), gems of insight and practical ideas can be gleaned from this book. anyone who has studied ip will find the žvelcs’ approach understandable, and it may even provide words or concepts for experiences that the therapist has had with clients. i had a number of “aha” moments when i found something they wrote offered an interesting theoretical explanation for a phenomenon or experience, particularly with the chapter on physiological synchrony. however, my intent in this review is not to summarize the book but to highlight some of the authors’ differences with and additions to ip as written about by most other ip psychotherapists. the book is extremely well researched and includes an extensive bibliography. among the main influences on the žvelcs’ theoretical thinking are daniel siegel (2007, 2012), s. c. hayes (hayes et al., 2012) (who 1 john hallet, m.a.r. psych., ciipts; e-mail: jhallettbc@me.com international journal of integrative psychotherapy, vol. 12, 2021 2 developed acceptance and commitment therapy or act), s. w. porges (2011, 2017) (the polyvagal theory of the autonomic nervous system), and bruce ecker (ecker et al., 2012) (memory reconsolidation). the first part of the book introduces žvelc and žvelc’s system of psychotherapy, which they call mindfulnessand compassion-oriented integrative psychotherapy (mcip), and later chapters explain their methodology with many clinical examples. their concepts will be familiar to integrative psychotherapists, but the žvelcs bring a mindful and compassion-based sensibility that i found thought provoking and that spurred my interest in approaching my clients in some different ways. their model differs from others that focus on teaching mindful techniques to be used by clients. they broaden their approach by using mindful awareness and compassion in a moment-to-moment practice in themselves that provides the foundation for an attuned, healing relationship. they propose that the first task in a therapy session is for the therapist “to focus their mindful attention onto themselves” (p. 164). the authors highlight the difference between what they term the narrative self or personal sense of self and the observing self, which becomes a primary learning objective in every session by drawing the client’s attention to these differences in an experiential way. although this may sound like a simple concept, they write extensively about how it involves a slow process that can be profoundly transforming. the observing self can be taken simply to mean the part of us that observes (the adult ego state), but the žvelcs see the observing self manifesting as something more: as mindful, nonjudgmental awareness of our experience, with an expanded awareness of “transcendence and spirituality, interconnection, compassion, stable perspective and a container of experience” (p. 37). an important component of žvelc and žvelc’s model is their differentiation between the observing self and the personal sense of self. the latter is connected to the self-narrative we have built up over our lifetime. this includes how we think of ourselves, who we are (“i’m a loser,” “i’m a kind person,” etc.), how we experience ourselves in relationships (“i always get rejected in the end,” etc.), and how we see life. in ta terms, this is our script sense of self. the authors have developed a visual model (drawn as a triangle) that is used to track a client’s mindful awareness from moment to moment. one state of experiencing is being in our narrative self, in which our sense of self is completely identified with our experience and is only our thoughts, feelings, and sensations. this is a normal state for many of us most of the time. another state is the self being distanced from experience, in which there is no awareness of thoughts, feelings, international journal of integrative psychotherapy, vol. 12, 2021 3 and sensations, in other words, dissociation. the third state is the observing self, the loving witness to inner experience, which mcip works to strengthen by having a client practice connecting with it throughout a session. theirs is a fluid model reflecting the fact that awareness fluctuates between the narrative self and the observing self, with optimal functioning and health found in being in the observing self as much as possible. mindful awareness helps us to be fully present and at the same time not identified with our narrative self. although i am familiar with the concept of the observing self, especially from my own meditation practice, i never considered making it explicit with clients. instead, i had used the concept of the adult ego state, which requires more explanation. “observing self” is much simpler. recently, when doing an awareness exercise with a client—starting with physiological awareness and moving to feeling and then thought—i brought his awareness to the presence of his observing self, which was noticing and reporting the awareness. to my surprise, he said excitedly that he had never realized that before. he asked if it was normal and whether it would be useful to remind himself about it, which led to a wonderful teaching moment. he realized how doing that would help him regulate affect, something with which he had struggled. one of the most interesting parts of the book and an important contribution to ip theory is žvelc and žvelc’s chapter on physiological synchrony and its crucial role in psychotherapy. they cite theory and research that explains how physiological synchrony forms the most basic component of what creates a safe environment for clients in the cocreated therapeutic relationship through such mechanisms as emotional contagion, mimicry, and mirror neurons. they suggest that the therapist’s autonomic nervous system (ans) state profoundly affects the therapeutic work. they go so far as to say it is the fundamental factor in psychotherapy. the essence of their distinctive approach to integrative psychotherapy could be summarized by saying that the heart of effective therapy is the therapist keeping himself or herself in a regulated state through mindful awareness. doing so, in turn, coregulates the client’s states as the person learns to attend to their own ans states through mindful awareness and compassion. for example, a client of mine who recently terminated shared his experience of therapy, which coincidentally illustrates the importance of the therapist’s selfregulation. he wrote he was appreciative of my ability as a therapist to be “a steady presence even in the volatility of my emotions. seeing someone unshaken by my suffering but still there to talk.” the žvelcs have been influenced by the work of siegel (2007) and porges’s (2011, 2017) polyvagal theory. porges posited that humans have neuroception, international journal of integrative psychotherapy, vol. 12, 2021 4 the ability to unconsciously scan their environment rapidly to determine safety. they then react from a hierarchy of three autonomic nervous states, the adaptive one allowing for social interaction, health, and growth (ventral vagal state). the other two are defensive states reacting to danger: one activates fight/flight behaviors, and the other activates immobilized behaviors. these correspond to optimal arousal, hyperarousal, and hypoarousal. having outlined these theories, žvelc and žvelc then discuss their implications for psychotherapy. first, when therapist and client are both in the zone of optimal physiological arousal, this leads to a therapeutic bond with feelings of connection and understanding. citing this research and its therapeutic implications is an important addition to our understanding of attunement and presence. erskine has talked about the difficulty of defining presence, and the žvelcs’ help to define it in a more concrete way through physiological presence. they closely attune to the client’s physiological arousal state and watch for signs of dysregulation. “we help them to recognize when they are approaching dysregulated states, then we coregulate them and finally help our clients to regulate them for themselves” (p. 63). to this end, therapists must have a “continuous mindful awareness of one’s own physiological states during the session” (p. 63). this mindful awareness activates ventral vagal regulation, which helps coregulate the client’s physiological state. the other way a therapist induces the ventral vagal state in a client is through active or explicit regulation, which involves leading clients into a mindful, selfcompassionate state. this is done through promoting “awareness of ans states, naming them, and assessing their intensity,” which, in turn, “decentres the clients from their experience and gives them a sense of control and safety” (p. 71). the authors’ reference to scientific explanations for the reality and importance of physiological synchrony provides us with an explanation for why eye movement desensitization and reprocessing (emdr) is such a powerful tool. although what happens with emdr is the rapid processing of emotional material, it would not be successful without the coregulation provided by the therapist. i have not practiced emdr from a mcip position—that is, while constantly monitoring my own physiological arousal level—but i postulate that in using tapping with clients for the bilateral stimulation, i am regulating my own arousal level as well as theirs. this is probably why i feel calm regardless of the client’s level of hyperarousal. their arousal often reduces quickly after intense emotion, which is further reinforced by the “time out” between sets of tapping so the person can report on what they observed, thereby connecting and strengthening the observing self. international journal of integrative psychotherapy, vol. 12, 2021 5 because of the central role žvelc and žvelc see physiological synchrony playing in psychotherapy, they have expanded the notion of attunement by adding a sixth component to the keyhole model (erskine et al., 1999). they call it physiological attunement, which is in addition to rhythmic attunement. this is an important addition to the keyhole model and should be added to the ip teaching model. another modification žvelc and žvelc make to the original ip model is deemphasizing the concept of life scripts. they refer instead to relational schemas, which they categorize as either adaptive, which means constantly evolving, or dysfunctional. life scripts are thus made up of dysfunctional relational schemas and are the dysfunctional part of the self-narrative (an important concept in their approach). the žvelcs replace the script matrix with what they term “the self-narrative system [which is] a self-reinforcing, lived and embodied life-story, which gives the experience of identity and continuity of existence” (p. 94). the self-narrative can be positive and functional, a change from the script matrix model. in terms of implications for psychotherapy, the žvelcs emphasize clients developing a new relationship with their dysfunctional internal relational schemas through mindfulness and compassion. this approach is shaped by s. c. hayes’s (hayes et al., 2012) acceptance and commitment therapy (act). while dealing with old schemas, new adaptive ones are being formed through the relationship with the therapist. these two types of schemas can coexist. the žvelcs explain how dysfunctional schemas are changed through a process called memory reconsolidation, which follows a theory and clear methodology as outlined by ecker and his colleagues (ecker et al., 2012). they use this methodology as a catalyst for changing beliefs relating to the self-narrative. those interested in learning more about this process should read chapter 6 in the book or refer to the work of ecker et al. (2012). self-compassion is another concept in ip that is not new, but žvelc and žvelc make it a central component in their methodology and give many examples of how it is incorporated into most sessions. they offer guided exercises plus excerpts from session transcripts in which clients connect with self-compassion. this is where the transcendent part of the observing self can emerge spontaneously and has a spiritual quality that reinforces the interconnectedness of all humans. the last part of the book is filled with examples of how the authors make all the interventions a trained ip psychotherapist would but from their mindful and international journal of integrative psychotherapy, vol. 12, 2021 6 compassionate approach. their methodology involves mindful processing not only in how the client accepts inner experience but also to process and transform emotions, physical sensations, and cognitions. that is, they bring their mcip sensibility to the therapeutic processes that are already an established part of ip. this means the therapist inviting the client “to become aware of their moment-tomoment subjective experience with curiosity and acceptance” (p. 17). although an ip psychotherapist might think that is already what they do in general, the žvelcs’ interventions are guided by this every step of the way. this is difficult to convey in a review but will be clear in reading the transcripts of interventions and sessions found in the book. the authors also outline their model of mindful processing for troubling emotions and trauma, for which they devised a schematic drawing explaining the steps involved. this approach draws heavily on the theory of memory reconsolidation (ecker et al., 2012). the book finishes with a chapter on compassion, which žvelc and žvelc describe in two parts: having mindful awareness of one’s suffering and pain and bringing compassion to one’s suffering. they present numerous ideas about how this can be done. reading integrative psychotherapy: a mindfulnessand compassion-oriented approach presents ip psychotherapists with an opportunity to review their practice and examine their assumptions about what works and why as well as a chance to open up to new perspectives and approaches. growing professionally is an ethical responsibility for a psychotherapist, and reading žvelc and žvelc provides just that. references ecker, b., robin, t., & hulley, l. (2012). unlocking the emotional brain: eliminating symptoms at their roots using memory reconsolidation. routledge. erskine, r. g. (2015). relational patterns, therapeutic presence: concepts and practice of integrative psychotherapy. karnac books. erskine, r. g., moursund, j. p., & trautmann, r. l. (1999). beyond empathy: a therapy of contact-in-relationship. brunner/mazel. hayes, s. c., strosahl, k. d., & wilson, k. g. (2012). acceptance and commitment therapy: the process and practice of mindful change (2nd ed.). guilford. international journal of integrative psychotherapy, vol. 12, 2021 7 porges, s. w. (2011). the polyvagal theory: neurophysiological foundations of emotions, attachment, communication and self-regulation. norton. porges, s. w. (2017). the pocket guide to the polyvagal theory: the transformative power of feeling safe. norton. siegel, d. j. (2007). the mindful brain: reflection and attunement in the cultivation of well being. norton. siegel, d. j. (2012). the developing mind: how relationships and the brain interact to shape who we are (2nd ed.). guilford. relational withdrawal, attunement to silence: psychotherapy of the schizoid process richard g. erskine[footnoteref:2][footnoteref:3] [2: institute for integrative psychotherapy, vancouver, canada] [3: deusto university, bilbao, spain] abstract this article describes the psychotherapy methods that were effective with a client who unconsciously relied on the schizoid process of splitting of the self. harry guntrip’s writings about the schizoid compromise and donald winnicott’s descriptions of the true self and the false self are discussed. alternative concepts—the vital and vulnerable self and the social self—are presented along with the methods of supported withdrawal and therapeutic description. keywords: schizoid, schizoid process, schizoid compromise, true self, false self, harry guntrip, donald winnicott, phenomenological inquiry, therapeutic description, relational psychotherapy, countertransference, withdrawal, silence, attunement, inquiry, involvement. -------------------------------------adopt the pace of nature: her secret is patience. ralph waldo emerson (n.d.) ------------------------------------- violet was a confusing and, at times, difficult client who taught me about relational withdrawal and the importance of attunement to silence in psychotherapy. although i had previously worked with clients who were afraid of making intimate connections and struggled to talk about their inner life, i did not appreciate the significance of their urge to withdraw from relationships. prior to working with violet, i practiced psychotherapy in an active and engaging way, particularly with depressed clients. i encouraged individuals such as violet to make both internal and interpersonal contact by asking them to talk about their feelings in the first person, to look me in the eye when talking, and to engage in social activities that included participating in an ongoing therapy group. however, violet’s way of being with me challenged my therapeutic approach and stimulated me to think and transact differently. she was the first of several clients to teach me about the schizoid process. violet came to individual therapy with a variety of complaints. she was a 52-year-old professional writer who was unproductive in working on her new novel, disappointed that her previous book had received only minimal praise, and “disgusted with being fat.” she was disheartened because her husband alternated between ignoring her and controlling her. the most revealing thing she said in our first session was that she binged on sweets to ease the feelings of loneliness and hopelessness that would sweep over her. her stories included a number of self-condemning comments. i was surprised by her remark that she was “fat” because she did not appear that way to me. violet was stylishly dressed, and her conversation was extremely polite. my first impression of her was that she was depressed. in our psychotherapy sessions, violet would go into detail about her current life, often reciting what she did day by day while avoiding talking about internal sensations or feelings. she did voice some disgruntlement about her family life and gave several examples of how she was compliant with whatever her husband or members of her extended family wanted. i was amazed that she could provide detailed information about various situations in her life but there was no revealing of herself. instead of looking at me, she looked at the carpet or over my shoulder. often i experienced that she was talking at me rather than to me. throughout the first year of our psychotherapy sessions, i responded empathetically to violet’s stories, which to me sounded both aggravating and depressing. i actively listened, even though i sometimes felt drowsy while she talked. perhaps my drowsiness was an integral part of her, as yet, untold story. i knew i was missing an emotional connection with her. it was up to me to remain attentive to my misattunements with violet’s rhythm, affect, and perhaps her developmental level of functioning and, importantly, to decipher what was occurring in our intersubjective process (stolorow et al., 1987). unlike my psychotherapy with other depressed clients, my sessions with violet tended to focus more on current events and to emphasize how violet could change her behavior. for example, i talked to her much more than i usually would about a healthy diet, maintaining a consistent schedule for her writing, and how to have an intimate relationship with her husband. at the same time, i tried to neutralize her continued self-criticism by pointing out her accomplishments and encouraging her to think positively. still, my interventions seemed to have limited impact. i thought it would be beneficial to include in violet’s psychotherapy some expressive methods that had been effective with other clients who were living with compliance, self-criticism, and reactive depression. on several occasions, in response to some aspect of her storytelling, i asked violet to imagine her husband sitting on a chair in front of her and to express her anger at her husband’s demands. she refused and became silent for the rest of the session. as an alternative, i asked her on a few occasions to look at me and tell me about her anger. each time she turned her head away and went silent. i was intrigued by how long she could remain silent. i questioned myself: was my use of cognitive-behavioral and expressive methods a countertransference reaction? if so, to what was i reacting? i discussed my work with violet in supervision. the supervisor only reinforced what i was already doing and addressed neither my lack of attunement to violet nor her lapsing into long silences. so, in my introspection, i searched for what was missing in our therapeutic relationship. i realized that i was not making full interpersonal contact with violet. just like her, i was not fully present. i was confused by her. i did not understand how she functioned. no wonder i periodically felt drowsy or found my mind wandering to other situations. it was evident to me that in the absence of any emotional connection between the two of us, i compensated by becoming increasingly behavioral in my interventions. eventually, i became aware of a parallel process: my focus on behavior change mirrored both her mother’s and her husband’s attempts to control her behavior. my countertransference was in my wanting something to happen … so i focused on expressive methods, cognitive understanding, and behavioral change to ward off my worry about not being an effective psychotherapist. it became clear that i was not providing the kind of psychotherapy violet needed. still, i continued to rely on therapeutic methods that had been effective with other clients. i encouraged violet to make more interpersonal contact with me, to see my face, and to speak directly to me. i talked about my feeling sad for her and irritated at her mother’s behavior toward her. i used relationally connecting words such as “we” and “us.” i wanted her to experience my listening to her and taking her seriously. however, looking me in the eye was particularly difficult for violet. the more i encouraged her to be interpersonally contactful, the more she responded with either self-criticism or silence. whenever i made any inquiry of her—whether it was phenomenological, historical, or about how she coped with a situation—she would either respond superficially or turn her head in silence. throughout the first year and a half of our work together, i asked violet many questions about her childhood and the nature of various interactions within her family of origin. i received abbreviated responses. our sessions continued to be filled with stories of her current life. session after session i listened intently to violet’s descriptions of what was happening to her two children, her discontent with her husband, and her difficulties with writing and food. not only did she repeat stories, but, as time went on, they became more elaborate. sometimes violet did not remember what we had previously talked about; it was as if she had not been present. i was concerned about her continued self-criticism and spent time in each session challenging how she negatively defined herself. i questioned myself as to why she continued coming to psychotherapy sessions. i told myself that she must be receiving some benefit because she never missed a session. and i wondered about violet’s unrequited relational needs and if she was unconsciously struggling to make an impact on me, or to define herself, or to find security. when i asked violet to evaluate her experience of our psychotherapy sessions, she was pleased. she said that they were much more helpful than her previous two attempts at psychotherapy. i was amazed. what was helpful? when i asked for details, she could not describe what she meant. all my attempts to make the work with her interpersonal seemed like a failure to me. i felt inadequate. yet violet continued to come to our sessions in spite of her husband’s many attempts to stop our work together. useful metaphors we continued in this same pattern for almost 2 years. at that time, i was studying psychoanalysis, particularly the british object relations perspective (greenberg & mitchell, 1983; kohon, 1986; sutherland, 1980). i was impressed by the writings of michel balint (1968), ronald fairbairn (1952), masud khan (1963, 1974), margaret little (1981), ian suttie (1988), and donald winnicott (1974). i particularly admired the writings of harry guntrip (1968, 1971) and his descriptions of working with clients who withdrew from relationship in a “schizoid compromise” (guntrip, 1962, p. 277). jeremy hazel (1994) collected several journal articles by guntrip that depicted how he developed an understanding of the schizoid phenomena and suggested a relational orientation to psychoanalysis. donald winnicott (1965, p. 17) had used the terms true self and false self to describe the fragmentations in an individual’s personality when there is an emotionally overloading disruption in the child’s internal stability and sense of self. he depicted the true self as the source of needs, feelings, and spontaneous self-expressions that become split-off, disavowed, and desensitized—“the equivalence of complete psychic annihilation” (greenberg & mitchell, 1983, p. 194). winnicott delineated the false self as someone who hides behind an emotionless façade and cannot allow themself to be either spontaneous or relaxed and quiet because they are constantly attending to the criticisms and demands of significant others. i realized that these theories were only an approximation of what happened within my clients when as a child they lived with constant misattunement, ridicule, and stress. however, the theory served as a useful metaphor in guiding my therapeutic involvement with clients. the theory was also helpful because it stimulated my thinking about early relational disruptions, intrapsychic processes, and archaic forms of self-stabilization. i was faced with a puzzle: • was violet’s polite and proper presentation her true self or her false self? • did violet have a true self? • if so, who was violet’s true self? • what sort of neglect or trauma would force the true self into hiding? • if there was a hidden true self, how could i build a healing relationship with the emotionally authentic violet? • did the so-called false self serve necessary functions or was it pathological? • what if the concept of true self and false self did not represent what was occurring inside violet? how could i then make sense of her superficial stories, the lack of interpersonal contact, and the absence of any vitality, emotions, or vulnerability? playing with this puzzle enabled me to expand my thinking. i explored the theory of the true self and the false self from a nonpathological perspective that redirected attention to the concept of self-in-relationship. who we are is always contingent on other people with whom we have been in relationship; therefore, our sense of self is always cocreated in each relationship. this concept of self-in-relationship inspired me to reexamine my attitude and way of working with violet. i was uncomfortable with the terms true self and false self because they did not depict how i experience my client(s). the words “false self” imply deceit, whereas “true self” implies something worthwhile. these terms seem to suggest that something was wrong with the person who had a false self, even though perhaps winnicott’s false self had some important homeostatic functions such as stabilization, regulation, continuity, or pseudoattachment. keeping winnicott’s ideas about splitting in mind, i thought about two aspects of violet’s sense of herself. she had a social self that achieved a semblance of relational attachment by accommodating to the requirements of significant others. she also had a vital self and vulnerable self (erskine, 1999) that subliminally experienced feelings, needs, and energy but remained protectively internal and isolated. i began thinking of violet (and, later, other clients like her) as someone who learned to hide her vitality and vulnerability. she created a social façade (i.e., a false self) in order to give the impression of some form of relational attachment—a persona that anxiously adapted to the expectations of others while hiding her own sensitivity and vitality. her attachment pattern was isolated and different from either an anxious or avoidant attachment pattern because she longed for a comforting relationship (ainsworth et al., 1978). violet’s isolated attachment pattern was the result of childhood attempts to self-stabilize and self-regulate her fear of being invaded and controlled (erskine, 2009; o’reilly-knapp, 2001). an essential psychotherapy were donald winnicott, harry guntrip, and the other writers mentioned earlier describing my client violet? i thought so. even though they provided some general guidelines about psychotherapy for clients who managed their life via a schizoid process, i was left without a specific therapy plan. guntrip (1968) described how a person is driven into hiding out of fear and then experiences a deep, sequestered loneliness that drives them out of hiding back into an adaptive interface with the world. such a person is constantly caught in the struggle between hiding or connecting to others, but in an adaptive way. guntrip (as cited in hazell, 1994) defined the necessary psychotherapy of the schizoid process as the provision of a reliable and understanding human relationship of a kind that makes contact with the deeply repressed traumatized child in a way that enables one to become steadily more able to live, in the security of a new, real relationship, with the traumatic legacy of the earliest formative years, as it seeps through or erupts into consciousness. … it is a process of interaction, the function of two variables, the personalities of two people working together towards free spontaneous growth. (p. 366) winnicott described the essential ingredients of an in-depth psychotherapy for clients who manifest a schizoid process as providing a respectful, understanding, reliable environment, one that the client never had and needs if they are to redevelop out of inner conflict and inhibitions. such an environment allows the person to find out for themselves what is natural for them. both guntrip and winnicott encouraged a psychotherapy that focuses on the client’s internal processes and not specifically on cognitive insight or behavioral outcome, one that provides a healing relationship to a traumatized and psychologically fragmented client (hazell, 1994; little, 1990; winnicott, 1965). i was impressed by the loving commitment that these psychotherapists had for their clients. i too felt a profound responsibility toward violet even though i was confused, felt drowsy, or searched for how i could help her change. what if i followed guntrip’s advice and made contact with the deeply repressed instead of focusing on interpersonal contact or change? i made a commitment to myself to respect her silences, to support her withdrawal, and to create a safe place for the deeply repressed to express herself. this required that i be consistent and dependable in providing a secure therapeutic relationship, even though i did not understand her unexpressed affect or tendency to withdraw. guntrip, winnicott, and their colleagues were defining an essential psychotherapy that focused on the client’s internal process, one that provided a healing relationship (erskine, 2021). discovering a vital self we were now near the end of our second year of psychotherapy. i had been puzzling for weeks over the questions of false self and true self that i have already mentioned. i wondered if the quality of my psychotherapy would be different if i thought of violet’s silence and withdrawal as her attempt to protect a vital and vulnerable aspect of herself and her polite, proper, and superficial presentation as a social façade that had at least two important functions: protection and attachment. i also gave considerable thought to the gestalt therapy concept of contact and interruptions to contact (perls et al., 1951). clearly, there were many contact interruptions in our relationship: i did not feel a connection to the essence of who she was, she did not express emotions, and she most likely was not in contact with her internal sensations. she told stories and i listened, but we still had almost no interpersonal contact. i wondered what would happen if i encouraged violet to focus on her internal experience instead of telling me her stories. when there was a pause in violet’s storytelling, i invited her to close her eyes and stay quiet for a few moments so that she could sense her internal experience. at first she was frightened by the prospect of doing this in front of me. encouragingly, i again asked her to close her eyes, to be quiet, to feel her internal sensations, and to not speak for a while—to concentrate on the sensations that were happening inside of her. she appeared to withdraw into herself. i was not sure if she was turning inward to feel her internal sensations or just returning to a familiar hiding place. i was concerned about the possibility that she was merely complying with my request as she had learned to do with her mother. violet remained quiet for a few minutes. she then opened her eyes to see if i was still present. i assured her that i would stay present as she went inside. we experimented with her closing her eyes and going to what she called her “quiet place.” at first she was able to withdraw for only a minute. then, little by little, we extended the time to several minutes. by the end of the session, she said that it was a “quieting experience.” i was not sure what her words meant, but her body seemed softer and more relaxed. the next session began with violet again telling a detailed story about her family life. after a short time, i interrupted by asking her about her experience in the previous session. she said that she was afraid to “go internal” in front of anyone because “what i have inside is private. no one can know it.” i asked her how she had experienced me in the previous session when she was in her quiet place. she said that she was “scared, but it was ok because you did not try to control me.” it was evident to me that violet’s quiet place was her attempt to self-stabilize and create a place of security. i told her that i thought it was important for her to visit her quiet place and that we explore what she was experiencing. i also said that i was willing to accompany her, and i promised that i would do my best to not invade her. i also talked about how we had been rehashing stories about her family and that in my view not much had changed in the past 2 years. she disagreed with me and said, “you listen to me. you never criticize or define me. you are gentle with me. that is why i come back.” we concluded that session by agreeing that we had seldom talked about her internal experiences and that in the previous session we had begun an important exploration. in the next session, i invited her to experiment with closing her eyes and attending to her internal sensations. i told her that i would remain physically still but that i would watch over her in a protective way. she then withdrew into her quiet place and remained silent for 15 minutes. when she opened her eyes, violet said that i had discovered her secret, “my quiet hiding place. it has been my private place, all my life.” over the next several months we often experimented with violet withdrawing from external contact and making internal contact with her feelings, needs, and body experiences. in the beginning of this experimental work, she was without any words. she had sensations in her body, but she did not know how to speak about them. violet described her quiet place as being in her childhood bed with the covers and pillow pulled over her head. in one session she said, “there are a lot of things in there that i don’t want to feel.” as she said that, i realized that i had been feeling increasingly protective of her; i could sense her intense vulnerability. i imagined myself sitting in her bedroom, vigilant, quiet, and ready. my imagination was essential in keeping me focused on violet’s vulnerability during our long periods of silence. interestingly, i never felt drowsy or distracted when violet had withdrawn into her quiet place. i was always alert and interested in her internal experience. this was very different than the sleepiness i periodically felt when she previously told me detailed stories about her family conflicts. whenever violet was recounting her current, day-by-day stories, i watched for little signs that she was withdrawing: averting her eyes, leaving long pauses, or jumping from one story to another. she was telling me in a coded way about the attachment disruptions in her life and her desperate attempts to feel secure. her stories were a metaphorical message about how she required my sensitivity to her unique rhythm and her need for security in our relationship. at that point, during most of our sessions, i reserved some time to invite violet into her vulnerable place. my task was to be patient, respect her silence, provide time for her to make internal contact, and encourage her to feel both the internal safety of her quiet place and the safety of our relationship. i spoke to her in a soft, reassuring voice and made comments such as “it’s important to have a quiet place,” “it’s so necessary to feel safe inside,” “there is no need to hurry,” and “i am right here watching over you.” i talked slowly and with a voice tone i might use if i were speaking to a frightened child. i provided long pauses between my statements to allow violet time to experience and process any affect related to what i was saying. as violet withdrew into her imagined bed, “covered by blankets and pillows,” i relaxed and did some deep yoga breathing to keep myself centered and fully present. i kept my eyes on her and listened to her sighs and other soft sounds while i watched her physical movements. i did not try to make something specific happen. but i wanted to create the time and place for violet to feel both the security of her quiet place and my nonintrusive, caring presence. as the months progressed, i discovered that her quiet place was not so quiet. it was also a place of fear, sadness, and profound loneliness. in some sessions, when violet withdrew to her imagined bed and covers, she was desperate to escape the memories of her mother’s control. she had many examples, at various ages, of how hurt she had felt by her mother’s criticism. from deep in her chest she would cry with spasms of heartbreak, sorrow, and loneliness. in the beginning of this therapeutically supported withdrawal, her cry was without sound, and in subsequent sessions, her cry became a full vocal cry. i remained present, listening, and periodically responding with compassionate sounds and mirroring what she had been feeling. it then became apparent to me that her highly detailed stories, her quickly jumping from one story to another at a speed that did not allow for any dialogue, was an unconscious strategy to help her not feel her loneliness. she was unconsciously looking for interpersonal connection and simultaneously fearing any human closeness. on some occasions, after a long period of what she called “going internal,” violet would make sounds that were a combination of mournful crying and disgust. these were accompanied by gestures of pushing with her hands. she was without words to express her diversity of feelings. she often emerged from her withdrawal in physical and emotional distress, struggling to tell me about the various incidents of neglect and the constant criticism from her mother. my task throughout all this therapeutically supported internal work—like the job of parents with young children—was to help her develop a language so that she could communicate her internal distress and needs, her vitality and vulnerability. as our psychotherapy continued in the following months, violet actively expressed an array of feelings. in some sessions she would withdraw into the vulnerability of her internal world, one in which she remembered being terrified of her mother coming physically close to her. violet described how she would try to escape both her mother’s touch and her “mean words” by imagining that she was in her bed with the covers pulled over her head. she was proud as she reported how she could “hide in bed” even when sitting at the family dinner table. violet had changed. some days she could now describe her personal experience, physical sensations, and various feelings. learning from the client when i first learned to support violet’s withdrawal into her quiet place, i often made phenomenological inquiries such as “what are you feeling?” or “what do you need?” (erskine et al., 1999; moursund & erskine, 2003). i discovered that my inquiries interrupted violet’s withdrawal. she would open her eyes and start to tell me some story about her current life rather than respond to my inquiry. phenomenological inquiry was an essential form of connection with most of my clients, and i was curious why it was not working with violet. i realized that there was an important theme in the stories violet had been telling me over the past 2 years. both her mother and her husband constantly labeled her. they both defined who she was. as a child, and now as a wife, she struggled to conform to their definitions of what she should feel and how she should think and act. violet described how the only freedom she had from their definitions was when she withdrew into her quiet place and did not have to accommodate herself to their definitions and expectations. i pointed out that the theme of being labeled and defined was present in many of her stories and that perhaps she experienced my inquiries in a similar way. she agreed, saying that she experienced them as a definition of her, sometimes as “a demand that i be different.” over the next few sessions, we made some fascinating discoveries about our relationship. when i would ask violet “what are you feeling?” she translated it to mean “what you are feeling is bad.” when i inquired about what she needed, she interpreted it to mean that something was wrong with her for having needs. when i inquired about her physical sensations, she tensed her body because she did not know how to act. violet was constantly accommodating, altering herself to fit what she imagined my expectations of her were, a clear example of transferring old emotional memories into our relationship. at first, understanding the transference was difficult for violet. she could not see her own accommodating reactions, although she could experience the juxtaposition between my behavior and the criticizing, controlling, and judgmental behavior of her family. she began to be more relaxed with me and more willing to spend time in her quiet place. i experimented with limiting the amount of phenomenological inquiry i used with violet. when she would withdraw into her quiet place, i was silent, observant, present, and feeling protective. at first my not inquiring provided violet with an opportunity to go deeper into her internal experience. she could feel her sadness and fear. when she was withdrawn—imagining hiding in her childhood bed—she would alternate between being frightened about making any sound and then quietly crying. but eventually she became worried that my silence meant that i had gone away. i was in a dilemma. if i inquired, i interrupted her internal experience. if i was silent, she would interrupt her withdrawal because she was worried that i was not present. in another session, i invited violet to withdraw to her safe bed. there were about 15 minutes of silence during which i watched over her in the same way that i watched over my children as i sat by their bed at night when they were sick. i watched violet’s labored breathing and the tension in her clenched hands. i said, “you must be so scared.” violet nodded her head. i was surprised because i realized that i had just defined her experience. a couple of minutes later i again said, “you must be so scared. it is important to have a safe hiding place.” she again nodded her head. after another 2 minutes of silence, i offered, “it is so important to hide in your quiet place, particularly when you are sad.” she again nodded, her breathing returned to normal, she unclenched her hands. when violet opened her eyes, she said my description of her internal experience was important because it meant that i understood her and that she was not alone. i was surprised. we discussed how my description of her internal sensations was different from her mother’s and her husband’s criticizing definitions of her. she described my voice as “tentative” and my tone soft, “not a definite, authoritarian voice” like those she was used to in her family. later, with other clients who used relational withdrawal to self-stabilize, i again discovered the effectiveness of using therapeutic description as i learned to do with violet. therapeutic description provides the client with validation of their often unspoken emotional and physical experience. it is based on attuning oneself to the client’s unverbalized sensations and experiences and helping the person form a language to talk about their physical and emotional sensations. it offers an understanding so that the client can further articulate their previously unspoken experiences and the profound effects of relational disruptions. it provides a vocabulary for previously unspoken experiences to be acknowledged and eventually talked about. therapeutic description also provides an interpersonal connectedness from psychotherapist to client. it is not the same as interpretations or explanations that are given to other types of clients to enhance their cognitive understanding of psychological dynamics. therapeutic description involves a sensitive attunement to the client’s way of being that includes timing, tone of voice, and carefully observing the client’s nonverbal responses to the descriptions. however, if therapeutic description is used too early, it can be experienced as defining or invasive. violet provided the best definition of therapeutic description when later in the psychotherapy she told me how she experienced my comments: “it is as though you knew my internal experience, my fear of relationship, the safety in silence, the importance of hiding, and the depth of my loneliness. you helped me find the words to talk about my inner life. now i am more alive most of the time.” in summary violet continued her psychotherapy for 4 years. we had many sessions during which she would go to her quiet place, sometimes for 20–30 minutes. during those long periods of silence, i practiced how to be therapeutically quiet: to not intervene and to tolerate my uncertainty about what was happening within violet. i periodically spoke, but only to reassure her that i was watching over her or to provide some sparse therapeutic descriptions. gradually, i acquired an intense patience, one that is so necessary in working with clients who use relational withdrawal and silence to self-stabilize and self-regulate. i was watchful of every breath, sigh, and movement she made. i listened to her silence and compassionately worried about her speechless struggle. there were often times when there would be a long silence, but she was eventually able to describe her body sensations, sob in her loneliness, and be angry at her mother while still often being scared of “getting it wrong.” in several sessions during which violet imagined being in her safe bed, she would sit up and tell me about the neglectful events in her childhood, the strict rules she lived with, and her mother’s constant demands for “perfect behavior.” i observed the tension in her arms, neck, and legs as she talked about her mother. sometimes, when i pointed out that her body tension might indicate that she was angry, she would begin by shrugging her shoulders and saying, “i don’t know.” but, as we focused on the language of her body, she began to recognize that she was angry. in our fourth year of working together, we were talking face-to-face. most of my transactions with violet were composed of phenomenological and historical inquiry that was designed to help her discover and put into language her emotion-filled but never-talked-about childhood experiences of parental neglect and control. during this phase of the psychotherapy, i did not use therapeutic description. that sensitive way of communicating was reserved for the times when violet was silent and withdrawn into her hiding place. the therapy was now focused on violet’s becoming aware of herself. we paid a good deal of attention to her body sensations and various emotions. i acknowledged her memories and validated her emotions. many sessions included my helping her put her untold story into words. i prompted violet in defining herself. i shared with her how she had influenced me and how i had to change the orientation of our psychotherapy. at first, she did not believe me, but eventually she said, “in the beginning you wanted me to do something different, something i didn’t know how to do, just like the other therapists. but then you changed. you got softer and quieter. that helped me be me. did you really change because of me?” in response to my various inquiries, violet told me stories about her marriage. i could hear violet’s anger at her husband’s criticism and control. she was still reluctant to do any active anger work, but she was now able to say “i don’t like it” and “i don’t want it.” she and her husband began to have arguments for the first time in their almost 30 years of marriage. she was now defining herself, refusing to comply with her husband’s demands, and expressing what she wanted in her marriage. violet’s husband became enraged at the changes she exhibited at home. he demanded that she terminate therapy. he threatened divorce. she was terrified of being alone. at the beginning of the next meeting after his threat of divorce, she shook with fear as she announced that this was her last psychotherapy session. she said that her husband had intensified his demands that she stop her therapy. a wave of sadness swept over me. violet had made some significant changes in her ability to express both her vitality and her vulnerability. at least in my presence she was neither putting on a social mask nor withdrawing. i did not know what to say to relieve her distress. i was dismayed; our ending was so abrupt. several years later i met violet on the street. she told me that she was living alone in her own apartment and that it was she who had initiated the pending divorce from her husband. he now opposed the divorce, but she was determined. she angrily said, “i’ve had it with his control. i’m now almost 60, and it’s time i live my own life. i’m coming back to see you once this is all over. i have more work to do.” although i never heard from violet again, i will always be grateful that she taught me about the schizoid process and the importance of the psychotherapist supporting the client in making internal contact with the vital and vulnerable self. i came to appreciate the therapeutic results that come from being attuned to my client’s silence, and i rediscovered the profound effects of relating to my clients from a nonpathological perspective. references ainsworth, m. d. s., blehar, m. c., waters, e., & wall, s. (1978). patterns of attachment: a psychological study of the strange situation. lawrence erlbaum. balint, m. (1968). the basic fault. tavistock publications. emerson, r. w. (n. d.). [quote]. retrieved from https://www.brainyquote.com/search_results?q=adopt+the+pace+of+nature %2c+emerson erskine, r. g. (1999, 20 august). the schizoid process: a transactional analysis perspective [opening address]. international transactional analysis conference, san francisco, ca. erskine, r. g. (2009). life scripts and attachment patterns: theoretical integration and therapeutic involvement. transactional analysis journal, 39(3), 207–218. https://doi.org/10.1177/036215370903900304 erskine, r. g. (2021). a healing relationship: commentary on therapeutic dialogues. phoenix publishing. erskine, r. g., moursund, j. p., & trautmann, r. l. (1999). beyond empathy: a therapy of contact-in-relationship. brunner/mazel. fairbairn, w. r. d. (1952). psychoanalytic studies of the personality. routledge. greenberg, j. r., & mitchell, s. a. (1983). object relations in psychoanalytic theory. harvard university press. guntrip, h. (1962). the schizoid compromise and psychotherapeutic stalemate. british journal of medical psychology, 34(4), 273–288. https://doi.org/10.1111/j.2044-8341.1962.tb00524.x guntrip, h. (1968). schizoid phenomena, object relations and the self. international universities press. guntrip, h. (1971). psychoanalytic theory, therapy and the self. basic books. hazell, j. (ed). (1994). personal relations therapy: the collected papers of h. j. s. guntrip. jason aronson. khan, m. m. r. (1963). the concept of cumulative trauma. the psychoanalytic study of the child, 18(1), 286–306. khan, m. m. r. (1974). the privacy of the self. hogarth press. kohon, g. (1986). the british school of psychoanalysis. yale university press. little, m. i. (1981). transference neurosis and transference psychosis. jason aronson. little, m. i. (1990). psychotic anxieties and containment: a personal record of an analysis with winnicott. jason aronson. moursund, j. p., & erskine, r. g. (2003). integrative psychotherapy: the art and science of relationship. brooks/cole-thomson. o’reilly-knapp, m. (2001). between two worlds: the encapsulated self. transactional analysis journal, 31(1), 44–54. https://doi.org/10.1177/036215370103100106 perls, f., hefferline, r., & goodman, p. (1951). gestalt therapy: excitement and growth in the human personality. julian press. stolorow, r., brandchaft, b., & atwood, g. (1987). psychoanalytic treatment: an intersubjective approach. the analytic press. sutherland, d. (1980). the british object relations theorists: balint, winnicott, fairbairn, guntrip. journal of the american psychoanalytic association, 28(4), 829–860. https://doi.org/10.1177/000306518002800404 suttie, i. d. (1988). the origins of love and hate. free association books. winnicott, d. w. (1965). the maturational processes and the facilitating environment: studies in the theory of emotional development. international universities press. winnicott, d. w. (1974). fear of breakdown. international review of psychoanalysis, 1, 103–107. international journal of integrative psychotherapy, vol. 11, 2020 28 international journal of integrative psychotherapy, vol. 11, 2020 28 international journal of integrative psychotherapy, vol. 6, 2015 81 book review by marye o’reilly-knapp relational patterns, therapeutic presence: concepts and practice of integrative psychotherapy by richard g. erskine published by karnac books: london, 2015 paperback, pages 366, isbn 13: 978-1-78220-190-8 in his latest book relational patterns, therapeutic presence: concepts and practice of integrative psychotherapy, richard erskine presents his theory and methods of integrative psychotherapy. as he signed a copy of the book richard said to me that i already knew what was in the book. it is true that there is lots i know about his theory and methods, and indeed i should. through countless seminars, residential workshops in kent, and many discussions with richard, as well as my work with clients and my own psychotherapy with him where i have “lived” integrative psychotherapy, i indeed know a lot. what is exciting and validating for me is that the same concepts that i was first introduced to over thirty-five years ago are still as valid today as they were back then they have stood the test of time. the focus on intraand inter-subjective contact, relational patterns, and therapeutic presence along with the four dimensions of human functioning affective, behavioral, cognitive, and physiological, form an integrative frame of reference. the psychological constructs of ego states, transference, and script, together with the methods of inquiry, attunement and involvement add to the framework of a therapeutic relationship. the integrating of the personality with the use of integration of psychotherapeutic theories, allows for a major goal of integrative psychotherapy to be realized – “ to use the therapist-client relationship – the ability to create full contact in the presentas a stepping stone to healthier relationships with other people and a satisfying sense of self.” (p. 22). richard’s life work has truly reflected his contributions to the field of psychotherapy. although the concepts are familiar to those who have read or studied integrative psychotherapy, this book provides us with essays that were developed over the years to expand our own knowledge base in integrative psychotherapy. for me in my professional growth what has been very important to me in my professional growth is to take ideas and to be able to use them in my work with clients. i do this by reading and re-reading, working and re-working information with my own thoughts. this book gives me the opportunity to learn new ideas and go back over more familiar ones. for instance, richard lists eight philosophical principles which “serve as the foundation” for his theory and methods “of a relationally focused psychotherapy.” as i wrote this, i re-read this international journal of integrative psychotherapy, vol. 6, 2015 82 section of the book. the five pages filled me with appreciation and gratitude for the privilege and honor it is for me to work with my clients. i gained a lot by reading and reflecting on the words found in the introduction to the book. whether a beginner, a trainee, or one who has many years in psychology and psychiatry, this book provides a compilation of theoretical concepts that provide an inter-subjective process of psychotherapy that is profoundly respectful and healing. the first chapter, integrative psychotherapy: theory, process, and relationship provides a wonderful summary of the theory and methods of integrative psychotherapy. richard also describes how his ideas first developed in the early seventies. in chapter two, a therapy of contact-in-relationship, inquiry and attunement are discussed more fully. the discussion of asking questions versus inquiry is very beneficial in identifying specifics for inquiry as a valuable therapeutic intervention. the examples given clarify the therapist’s role in expanding the client’s awareness and avoiding interruption of the discovery process. the “attunements” – affective cognitive, developmental, and rhythmic are considered in this chapter as well as attunement errors. the next chapter, attunement and involvement: therapeutic responses to relational needs, continues with attunement to the relational needs and the therapist responses to these needs. i found it was helpful to once again review the eight relational needs of ip. the second part of this chapter was on therapeutic involvement that centers on acknowledgement, validation, normalization, and presence. for me, fine-tuning my use of inquiry, attunement, and involvement has helped me be present with the client in his journey. in chapter four, psychotherapy of unconscious experience, a condensed version of freud, berne, gestalt therapy, rogers, reich, and kohut’s descriptions of the unconscious is distinguished by richard’s view of the unconscious as “ an expression of developmental and neurological processing of significant experiences.” (57). he goes on to differentiate between the forms of unconscious memory – preverbal, never verbalized, unacknowledged, non-memory, and avoided verbalization. as therapist, it is important to be able to delineate the differences between these forms, and this section gives some beneficial guidelines. a case study helped highlight how what was once unconscious became conscious. in dealing with the unconscious, other areas identified were the five pre-reflective patterns of self in relationship attachment styles, body language, relational needs, script beliefs, and introjections. for me, this chapter outlined the essentials for an in-depth psychotherapy while working with the unconscious. erksine’s four chapters on script, chapters 5 through 8 give a seamless presentation of what you need to know about the script system. titled “life international journal of integrative psychotherapy, vol. 6, 2015 83 scripts and attachment patterns: theoretical integration and therapeutic involvement”, chapter 5 describes life scripts. there is an overview of the literature after which attachment patterns are elaborated. i found this discussion of the five attachment patterns – secure and insecure (which involves anxious ambivalent, avoidant, disorganized, and isolated) to be summarized in a welldefined way. in the segment on “general considerations” and “therapeutic involvement” it was if i could hear richard’s voice as i read this part of the chapter. chapter 6 “life scripts: unconscious relational patterns and psychotherapeutic involvement” addresses the unconscious processes in life scripts, differences in explicit, declarative memory and implicit, sub-symbolic memory. this chapter reminds me of being on a river cruise i just took in december on the danube. we stopped at different ports and each place i learned something new and exciting. in the different parts (ports) of this chapter injunctions and decisions, cumulative mis-attunements, implicit memory, body script, introjection, transference – there were ideas for me to add to my knowledge base. this is exciting to me. the chapter ends with a case study that i found useful in demonstrating unconscious relational patterns. for the next chapter (chapter 7) “the script system: an unconscious organization of experience”, i must tell you i am biased. this is because i wrote this paper with richard in 2010. i remember our discussions on the phone regarding the manuscript. i also remember the times we took at kent to go over (and over and over) the text. the case study represents the components of the script system and therapeutic interventions. many of the candidates for iipa evaluation have told me that this paper was helpful for them. i learned a lot and i hope you do too as you read this section of the book. the final section on life script is chapter 8 “psychological functions of the life scripts.” the six dimensions of the psychological function of life scripts are listed as: self-regulation, compensation for relational needs, self-protection, orientation of self to others, insurance against potential disruptions and loss of relationships, and maintaining integrity. these six components are skillfully defined by richard and give us a valuable image of the script functions. two quotes, one on life script and the other on life script cures sum up this section: life script: “life scripts are a complex set of unconscious relational patterns based on physiological survival reactions, implicit experiential conclusions, explicit decisions, and/or self-regulating introjections, made under stress, at any developmental age, that inhibit spontaneity and limit flexibility in problem-solving, health maintenance and in relationship with people” (p.78). international journal of integrative psychotherapy, vol. 6, 2015 84 life script cure: “ … to do a thorough life script cure, it is necessary to provide a developmentally focused relational psychotherapy that integrates affective, behavioral, cognitive, and physiological dimensions of psychotherapy while paying particular attention to the client’s unconscious communication of subsymbolic and pre-symbolic relational experiences that are revealed through their style of self-regulation, core beliefs, metaphors, avoidance, stories and narrative style, and transference both with the psychotherapist and in everyday life”. (p.79). chapter nine, “integrating expressive methods in a relational psychotherapy” focuses on the concept of therapeutic involvement. richard discusses working within the transference/ countertransference matrix and also working with a second position of resolving intra-psychic conflicts and archaic decisions. specific approaches are given for you and me as therapists to be involved with the client. i especially found the transcript to be very useful because it addresses ways in which the therapist can be effective in dealing with such areas as acknowledgement, empathy, shame, body language, truth telling, therapeutic highlighting and the therapist’s responsibility for therapeutic errors. richard writes: “an effective, relationally focused integrative psychotherapy continually weaves the client’s and psychotherapist’s experiences of their relationship in the present moment with an exploration of the emotional and selfstabilizing results of past relationships in the client’s life” (p. 141). for me this chapter reflects our values as integrative psychotherapists and the essence of therapeutic involvement and commitment to the client’s welfare. in the next chapter, “bonding in relationship: a solution to violence?” the importance of relational needs as components of bonding and relationship are examined. when relational needs are not met over and over again the results may be depression and violence. working with “stanley” within the therapeutic relationship highlights the absence of connection with both mother and father and his distrust of others. his violent fantasies in his second and third year of psychotherapy along with the “author’s postscript” bring out important considerations in working with violence in the clinical setting. within chapter eleven, “a gestalt therapy approach to shame and selfrighteousness: theory and methods,” shame and self-righteousness are considered. both are defined as protections, where shame as the experience of an unaware, longed for hope for relationship and self-righteousness as the denial of the need for relationship place the concepts within a relational context. this is what makes the writings in this chapter so powerful and meaningful. it gives the framework to genuinely inquire within a therapeutic relationship and to work with a client’s humiliation and self-esteem issues. the last part of the chapter international journal of integrative psychotherapy, vol. 6, 2015 85 concentrates on psychotherapeutic interventions. one part i have used over and over is richard’s summary of “affect as transactional-relational …requiring a corresponding affect in resonance” (p.190): for sadness – compassion; with anger – to be taken seriously; with fearsecurity; for joypleasure. see the text for a detailed description of affect reciprocity as well as involvement for effective psychotherapy approaches to shame and self-righteousness. in chapter twelve, “the schizoid process” a consideration of the “fearladen affect state” (p. 195) richard refines ideas previously discussed by other theorists such as berne, fairbairn, goulding, guntrip and winnicott inform the reader of the schizoid process. for anyone working with a client who is in an indepth psychotherapy, i believe this chapter is essential reading because it reinforces the integrative psychotherapy methods necessary for working with the experiences of an emerging self. the next three sections are parts of a case study trilogy which appeared in the international journal of integrative psychotherapy in 2011. chapter thirteen “early affect confusion: the “borderline” between despair and rage” starts with a client’s request for therapy. a description of the first year with “theresa” profiles the “calm, consistent, dependable and validating “(p. 203) relationship needed for the therapist to maintain a therapeutic relationship with someone who is disorganized, terrified of connection and at the same time longing for contact. the next chapter, “balancing on the “borderline” of early affect-confusion” documents working with the client within the second and third years of therapy. the last chapter in this trilogy “relational healing of early affect-confusion” describes years four and five of psychotherapy. these three sections taken together are a remarkable account of the relational conflicts both within the client (intra-psychic) and within the therapeutic relationship (interpersonal). in this case study richard gives us a wonderful paradigm of his consistent attempts to understand his evident compassion for theresa and his sustainment of the therapeutic relationship. for me these chapters are a reminder of the honor it is to be trusted with a very precious part of the human being, the psyche. thank you, richard. the last six chapters of relational patterns, therapeutic presence: concepts and practice of integrative psychotherapy present additional areas for therapeutic consideration. chapter sixteen “introjection, psychic presence, and parent ego states: considerations for psychotherapy” presents a systematic account of works by freud, bruer, farirbairn, watkins, berne and others who worked with intra-psychic states of the ego. the exploration of the ego and states of the ego continues with a well-defined description that “parent ego states are an actual historical internalization of the personality of one’s own parent or other international journal of integrative psychotherapy, vol. 6, 2015 86 significant parental figures as perceived by the child at the time of introjection” (p. 238). next follows a thorough analysis of the four determinants necessary for the diagnosis of an ego state, and the correlation of the four to determine which ego state is active at the time. these four components are the behavioral, social, historical and phenomenological. a breakdown of the introjected parent ego state into active or intra-psychically influencing and the inclusion of the fantasy parent or “self-generated parent” are examined to further assist in differentiating ego states. the last part of the chapter explores treatment planning and what is needed for an in-depth psychotherapy of the parent ego state. in the next chapter “resolving intrapsychic conflict: psychotherapy of parent ego states”, co-authored with rebecca trautmann, a case study is presented. annotated comments regarding the process of psychotherapy are included in “anna’s” work. while reading this chapter i felt like i was actually present while anna spoke as her mother. the interpretations as the work progressed helped to understand the therapeutic process and to appreciate some of the tenets of integrative psychotherapy: genuine interest in the client’s experience, therapeutic inquiry, encouragement and support, ongoing contracting between client and therapist, the alleviation of intra-psychic conflict. both this chapter and the preceding one offer the clinician a comprehensive framework for working with the parent ego states. in chapter eighteen, “what do you say before you say goodbye? psychotherapy of grief”, the focus is on giving sorrow “words” as stated in the beginning quote by shakespeare and dealing with both the incomplete “hello” and “goodbye”. this section adds to the literature on grief and loss by dealing with clients who face major losses in their lives and the significance of intersubjective contact for the healing process. case examples clearly demonstrate the results of an interpersonal approach in dealing with loss and grief. methods such as “truth telling” and the “empty chair” are used as means to facilitate unfinished business and disavowed feelings. the ultimate purpose of psychotherapy of grief is an interactive psychotherapy that “restore[s] the individual’s capacity to have an honest and meaningful hello before engaging in a genuine goodbye” (p. 313). chapter nineteen, “nonverbal stories: the body in psychotherapy” centers on body sensations and affect in psychotherapy in order to construct “a verbal narrative that reflects the body’s story” (p. 319). body-oriented methods are discussed along with ethical considerations when doing bodywork. attention is given to a body oriented therapy without the use of touch while the next part takes into account healing touch. this is a powerful chapter in that it gives guidelines for therapeutic touch within a relational psychotherapy. integrative international journal of integrative psychotherapy, vol. 6, 2015 87 psychotherapy’s model “self-in-relationship system” outlines the domains of cognitive, affective, behavioral, and physiological – all significant and integral for full contact. this chapter takes into account the biological component and advances the information in previous writings in integrative psychotherapy on bodywork within a relational psychotherapy. the last chapter, chapter twenty “narcissism or the therapist’s error?” talks about a client who is seen for possible psychotherapy. “philip” was having a great deal of difficulty at work and was referred by the firm for at least two years of psychotherapy. a three-session evaluation is described. as i read the last chapter my initial reaction was to think that this was a strange place for this chapter – at the end of the book. as i thought more about this i realized that the last chapter ends like a lot of richard’s teachings end. the many times i have been with him and heard him lecture or in supervision he invites others into the experience by asking the question – what would you do? the reading of this book is certainly not the end for me. i will go back and re-read different parts. the writings are rich in theory and methods within a relational therapeutic process. as joshua zavin wrote in the forward to the book “ these articles are the product of a steadfast quest to keep developing his ideas on theory, clinical practice and human relationships.” this book is another of the many rich resources we inherit from richard erskine. author: marye o’reilly-knapp, phd, rn is a board certified clinical nurse specialist in psychiatric and mental health nursing, certified clinical transactional analyst, and certified group psychotherapist. she was a member of the professional development seminar in kent, connecticut, a founding member, and teaching and supervisory faculty member of the international integrative psychotherapy association. date of publication: 22.12.2015 alcoholism is such a common condition that therapists must be exposed to clients who suffer from it, whether the therapist is case studies in integrative psychotherapy – an opportunity for challenge and growth (editorial) gregor žvelc with great pleasure i announce the new issue of the international journal of integrative psychotherapy, which is dedicated to the exploration and discussion of an integrative case study written by richard g. erskine. richard erskine has written a thought provoking case study in three parts. in this issue we publish the first part of the case study titled: early affect-confusion: the “borderline” between despair and rage. the next two parts will be published in subsequent issues of the international journal of integrative psychotherapy. four respectable psychotherapists from different countries were asked to write responses to all three parts of erskine’s case study. they are: james allen (usa), grover e. criswell (usa), ray little (gb) and maša žvelc (slovenia). they were asked to write from the perspective as if they were the psychotherapist working with erskine’s client. they were invited to reflect on the following questions: if you would be working with the client, what would you have in mind regarding theory and practice? what would you do similarly and what perhaps differently? the responses of four psychotherapists are edited into one collective response to each part of erskine’s case study. richard erskine was then asked to write a response to each of the psychotherapist who commented on his case study. his responses are joined into the article titled treatment planning, pacing, and countertransference: perspectives on the psychotherapy of early affect-confusion. finally we publish a post-script written by marye o’reilly-knapp, co-editor of the international journal of integrative psychotherapy. she comments on all the discussion so far and makes conclusion to the first part of erskine’s case study. in the next issues of the international journal of integrative psychotherapy the discussion will continue and next two parts of the case study and their comments will be published. i hope that you will be as excited as i was when i was reading the case study and comments. i learned a lot from each of the authors and they challenged my international journal of integrative psychotherapy, vol. 3, no. 2, 2012 1 international journal of integrative psychotherapy, vol. 3, no. 2, 2012 2 theoretical thinking and practice. from discussions i learned that many diverse paths can be effective to understanding the treatment of clients and that none should be declared as ultimate ‘truth’. i think that the detailed case study approach and collegial discussion give us opportunity for challenge and growth as practitioners and also provide opportunity for development of the field of integrative psychotherapy as a whole. author: assist. prof. gregor žvelc, phd is clinical psychologist and doctor of psychology. he is international integrative psychotherapy trainer & supervisor (iipa). gregor is director of the institute for integrative psychotherapy and counseling in ljubljana, where he has a private practice and leads trainings in integrative psychotherapy and transactional analysis. he is co-editor of international journal of integrative psychotherapy. he can be reached at institute ipsa, stegne 7, 1000 ljubljana, slovenia. e-mail: gregor.zvelc@guest.arnes.si homepage: www.institut-ipsa.si date of publication: 25.12.2012 alcoholism is such a common condition that therapists must be exposed to clients who suffer from it, whether the therapist is case studies in integrative psychotherapy – part 2 (editorial) gregor žvelc in the first 2013 issue of international journal of integrative psychotherapy we continue exploration and discussion of integrative case study written by richard g. erskine. richard erskine has written a thought provoking case study in three parts. in the last issue of ijip we published the first part of the case study with responses from five psychotherapists from different countries. for the whole understanding of the case, please read also the first part of the case study published in 2012, no. 2. in this issue we publish the second and third part of the case study trilogy titled ‘balancing on the ‘borderline’ of early affect-confusion’ and ‘relational healing of early affect-confusion’. four integrative psychotherapists from different countries comment and discuss the case. they are: james allen (usa), grover e. criswell (usa), ray little (gb) and maša žvelc (slovenia). they were asked to write from the perspective as if they were the psychotherapist working with erskine’s client. they were invited to reflect on the following questions: if you would be working with the client, what would you have in mind regarding theory and practice? what would you do similarly and what perhaps differently? the responses of four psychotherapists are edited into collective response to second and third part of erskine’s case study. richard erskine was asked to write a response to each of the psychotherapist who commented on his case study. his responses are joined into two articles titled ‘phenomenological inquiry and self-functions in the transferencecountertransference milieu’ and ‘intrapsychic conflict, transference, and a healing relationship’. finally we publish two post-scripts written by marye o’reilly-knapp, co-editor of the international journal of integrative psychotherapy. she comments on all the discussion so far and makes conclusion to the second and third part of erskine’s case study. international journal of integrative psychotherapy, vol. 4, no.1, 2013 1 international journal of integrative psychotherapy, vol. 4, no.1, 2013 2 author: assist. prof. gregor žvelc, phd is clinical psychologist and doctor of psychology. he is international integrative psychotherapy trainer & supervisor (iipa). gregor is director of the institute for integrative psychotherapy and counseling in ljubljana, where he has a private practice and leads trainings in integrative psychotherapy and transactional analysis. he is co-editor of international journal of integrative psychotherapy. he can be reached at institute ipsa, stegne 7, 1000 ljubljana, slovenia. e-mail: gregor.zvelc@guest.arnes.si homepage: www.institut-ipsa.si date of publication: 6.5.2013 1 international journal of integrative psychotherapy, vol. 13, 2022 memory reconsolidation through emdr in an integrative psychotherapy: a case example john hallett abstract this article describes memory reconsolidation and how the author uses the concept to explain the success of a psychotherapy session using eye movement desensitization and reprocessing (emdr). a transcript of the session is provided to demonstrate how the author works in a relational way and to give a personal example of how memory reconsolidation occurs in everyday life. keywords: memory reconsolidation, integrative psychotherapy, relational therapy, emotional change, emdr, traumatic memory, implicit emotional learning bruce ecker’s book unlocking the emotional brain: eliminating symptoms at their roots using memory reconsolidation (ecker et al., 2012, 2015) provides a neurobiological explanation for how permanent emotional change occurs. the change is called memory reconsolidation, a process first discovered in neurobiological experiments on rats in the early 2000s (pedreira et al., 2004). it has been proposed that this process is the same mechanism by which humans are able to delete or erase the emotional component or meaning associated with traumatic emotional experiences. it is a type of neuroplasticity or synaptic change that can erase emotional learning and is based on “the brain’s adaptive process for updating existing learnings with new ones” (ecker et al., 2012, p. 26). numerous studies since the earlier work on animals have provided evidence that this process occurs in humans (forcato et al., 2007; hupbach, 2011; hupbach et al., 2007; hupbach et al., 2009). the impact of childhood emotional trauma has been discussed extensively in the psychotherapy literature. for example, as erskine (2015, 2021) wrote, our client’s traumas are present in adult life as childhood emotional reactions or cathexis of the child ego state, unconscious relational patterns, script beliefs, and fixated behavior patterns. ecker’s theory using memory reconsolidation provides an explanation of how these early childhood emotional traumas locked in memory can be changed or permanently altered in the process of psychotherapy. this article describes an example of this process, one that 2 international journal of integrative psychotherapy, vol. 13, 2022 occurred essentially in one session of eye movement desensitization and reprocessing (emdr) (shapiro, 2001). ecker et al. (2012) demonstrated how this process of memory reconsolidation can be facilitated through a variety of therapeutic techniques, including emdr (shapiro, 2001), two-chair or empty-chair dialogue (perls, 1969), and the developmental methods of deconfusion (erskine & moursund, 2011). however, for permanent change or memory reconsolidation to occur, two conditions must be met simultaneously. first, the client must be fully aware and reexperiencing—cognitively, affectively, and physically, all at the same time—a full experience of the early emotional trauma (erskine & mauriz-etxabe, 2016). in my work with clients, i determine this by watching their body gestures and listening to their descriptions of the memory and their internal experience, both emotionally and somatically. it has been demonstrated experimentally that the neural circuits that encode the experience of the memory are open for up to 5 hours following fully connecting with the memory (pedreira et al., 2002), and during that time they are available to be replaced by new emotional learning, to reach this point may take weeks, months, or even years as a client builds trust or a sense of secure attachment to the therapist. the process of fully connecting with an early memory can also occur spontaneously through the use of regression techniques, attuned inquiry, or in preparation for targeting a memory during emdr. the second condition for permanent emotional change is for the client to be presented with some new information that disconfirms the early emotional learning or conclusion during this time window. the new emotional learning can occur in a number of ways, all of which involve new knowledge or experiences that contradict or disconfirm the long-held emotional beliefs such as “i’m not good enough,” “i’m not lovable,” and/or “i’m stupid.” the new knowledge must have either “salient novelty,” which means a completely new perspective, or it must be a complete contradiction. the personal example and case presented later in this article will illustrate this. at this point, it is important to address the distinction between new cognitive/emotional learnings, which can help a person cope better in interactions with others and/or bring about a calmer internal life, and those that fundamentally erase early emotional learning. the former can be called additive learning, which brings new perspectives and leads to new behaviors, thus counteracting old learning. much of what we do as therapists is to provide additional emotional learning for clients, for example, teaching someone how to react to a partner in a calmer way. ecker et al. (2012, p. 16) referred to these as counteractive measures. however, that learning does not address the underlying unconscious reasons behind clients resorting under stress to old, dysfunctional patterns. as therapists, we see this again and again. the material for transformative, new emotional learning in a psychotherapy setting can be elicited in a number of ways. one is that it can be drawn from life experiences that the client has revealed to the therapist over time, an experience that because of cognitive 3 international journal of integrative psychotherapy, vol. 13, 2022 dissonance the client has never been aware of as emotionally significant. for example, a client with an “i’m worthless” script might have revealed to the therapist an accomplishment of which they are proud. another way is that the new learning can come from fantasy or visualization, a two-chair dialogue, or by bringing to awareness some aspects of the therapist/client relationship. to bring about permanent change, the disconfirming evidence must be accessed during the time the brain is open for memory reconsolidation. otherwise, new learning that the therapist tries to provide—such as “you weren’t responsible for being sexually abused”—will not be integrated and will remain as just a thought without a corresponding emotional component. helping a client find the key new learning necessary to erase the old belief can be a hit-and-miss process and might require a number of attempts over time until the key new or disconfirming information is discovered. before describing the process of memory reconsolidation in psychotherapy, i offer an example of how it can happen serendipitously through ordinary life experiences. the brain has the innate ability to heal from destabilizing or traumatic experiences if the right conditions are present. for example, i began losing my hair in my early twenties, an ongoing experience that was hugely upsetting for me. it affected my sense of attractiveness and induced feelings of embarrassment or shame, especially when someone remarked on my hair loss. “you are going bald” was a shame-inducing experience for me. at the time, i had developed a good relationship with a hair stylist to whom i had been going for several years. he was a little older than me, and i looked up to him. i had concluded that the only way for me to solve my hair loss problem was to get a hair piece, but it was very anxiety provoking to think of broaching the subject with my hair stylist. just thinking about putting the problem into words filled me with shame. finally, one day, in spite of my anxiety, i asked him about the possibility of getting a hair piece. i was fully in contact with my shame physiologically, emotionally, and cognitively, which are the three factors that constitute the first condition necessary for memory reconsolidation. when i posed my suggestion, the hair stylist’s immediate response was, “why would you want to do that? you look fine the way you are.” his answer was so unexpected, coming from someone i respected and looked up to, that it provided the second condition for memory reconsolidation. this salient novelty was new information or learning that completely contradicted what i believed to be true. my previous emotional learning was that i looked unattractive as a balding man and would never attract a desirable partner. my hair stylist’s response was a powerful, transformative experience for me that immediately and permanently changed my emotional reaction to baldness. would i still have preferred to have hair? yes. did i still have the same sense of wanting to hide the problem after this experience? no. i felt a new level of acceptance. in thinking about being bald after that, the new memory of my hair stylist’s response had replaced the shame attached to being bald. ecker developed a framework for organizing the therapeutic approach to facilitating change that will be familiar to therapists informed by integrative psychotherapy. however, 4 international journal of integrative psychotherapy, vol. 13, 2022 ecker’s framework offers new clarity. in summary, when a child experiences emotional trauma in relation to others or in the absence of necessary emotional experiences provided by caregivers, the child attempts to find a solution to that emotional problem. such solutions may be known as script decisions or coping strategies. in a slightly different formulation from that of an integrative psychotherapist—who might be seeing the client through a developmental or ego state lens, for example—ecker theoretical conception involves viewing the client’s current symptoms as the attempted solution to an early emotional problem. when we understand what the emotional problem is, then we can develop a clearer treatment plan, in this case using edmr. the case study presented here is from an eye movement desensitization and reprocessing (emdr) session that combined an empty-chair dialogue and fantasy/visualization to succinctly demonstrate the process of memory reconsolidation. at age 15, my client peter decided that he was responsible for the death of the family dog and her puppies (after his father had killed them) and concluded that he was a bad person. his father was a refugee who escaped to canada in the 1950s from a sovietcontrolled eastern block country. he was a traumatized, angry man who constantly criticized peter. in reaction to his father, peter’s script beliefs of “i’m a bad person” and “i’m responsible for the death of the dogs” ruled his life. what he called his “internal critic” (the term also used by his previous therapist) watched everything he did and was unrelenting in its criticism. peter lived in shame and was angry with himself because in 2 years of therapy with his previous therapist, he had made little progress in quieting his internal critic. in our first session, peter and i explored why being so self-critical might be necessary. he got in touch with the unconscious motivation behind his internal criticism and how it reflected his traumatic relationship with his father. this can be seen as an implicit emotional learning. the internal critic was necessary to make sure he never did anything bad again or made any mistakes. in our work, he was able, for the first time, to make sense of his internal experience, which relieved him of some of his shame and engendered a degree of self-compassion. peter was highly critical of himself because in spite of his previous therapist’s skill, his internal critic still made his life miserable. the former therapist, who did not practice emdr, had referred peter to me because she felt emdr would be helpful. in his first session with me, peter said that cognitive-behavioral therapy (cbt) had not made a difference with his internal critic nor had the many affirmations he repeated daily. to further his process of deshaming, i explained there was a reason he had not been able to erase those old beliefs or conclusions. peter said he felt they were hardwired, and i agreed that no amount of cbt was going to rewire the old learning in his brain. i explained the process of memory reconsolidation and how emdr can provide the necessary conditions for 5 international journal of integrative psychotherapy, vol. 13, 2022 permanent emotional change. he said then that for the first time, he had hope he could change. he left the session feeling excited about trying emdr. emdr is a therapy technique based on the adaptive information processing theory of francine shapiro (2001). it facilitates new emotional learning by stimulating both hemispheres of the brain. bilateral stimulation was originally done having clients move their eyes from one side to the other, hence the “eye movement” part of the name. however, over time it was discovered that bilateral audio stimulation (alternating tones in the ears) was effective as well as bilateral tapping on the body. the technique i have come to prefer for producing bilateral stimulation is tapping on the back of the client’s hands while the person holds them on their knees. based on my experience and results, i believe that sitting closely together provides a sense of being held, and i tap lightly at a pace similar to a regular hear beat. this provides a calming influence, especially when the client is highly emotionally and sensorily activated. clients experience this as intensely contactful both internally and externally. what the client reports being aware of involves metaprocessing of the memory, an essential part of the change process. in this regard, emdr is similar to mindful meditation, which is developing awareness of internal experience in an accepting manner. in the second session, i had peter retell his traumatic memory in as much detail as possible. this is my summary of what he said: it’s winter and cold; he’s 5 years old. he goes into the dog’s room and sees his father, then noticed the mother dog and six puppies all lying still on the floor. he sees some red and doesn’t understand what’s happened. the mother dog, whom he loves and can ride because she is so big, is staring with open eyes. he starts to cry and asks why they are like this. his father says he had to kill them because there is not enough food. apparently, there has not been any food for the family either for 2 days because they are so poor. peter confesses that when he was hungry he ate some of the dog’s dried food. “i stole their food.” his father blames him, hits him, and tells him to leave. peter has retained a sense of guilt and a conviction that “i’m a bad person” his entire life. this is clearly a pivotal memory in peter’s early life and the first time he recalls thinking he was bad. to fully reexperience this memory (which is called the target memory in emdr), i had peter come up with the image that captured the worst or most distressing part of the memory: “it is the mother dog’s open eyes.” in reexperiencing the memory, he feels pain in his chest and rates the level of the feeling on a scale from 1 to 10 at 11. the next step in emdr is to have the client get in touch with the negative cognition. to elicit this, i say to a client, “with these traumatic memories, there is always an irrational negative thought about ourselves, something we may know isn’t true but feels very true.” the one peter came up with was “it’s my fault.” as we were about to start processing the memory with emdr using bilateral tapping, it was clear he was in full contact with the 6 international journal of integrative psychotherapy, vol. 13, 2022 memory cognitively, affectively, and physiologically. the evidence was in his voice, his words. and the tears in his eyes. the following is a transcript of what we each said. after a set of tapping i stop, giving the choice to the client of opening or keeping their eyes closed as they give a short summary of what they were aware of during the tapping. peter kept his eyes closed (as most clients choose to do). each set of tapping was between 30 and 40 seconds long and is marked by the asterisks in the following text. this emdr session was about 40 minutes long. (t = therapist, p = peter) t: staying with that memory, just notice what you are feeling in your body, emotions, and thoughts as i tap. **** p: my father is yelling at me. **** p: i can’t bring them back. **** p: i want to scream at him. **** t: you can scream at him if it feels right. **** p: my body is tight. **** t: because you screamed at him or had to hold back? **** p: i didn’t scream at him. (here a choice would be to encourage the client to scream at him, but i don’t do that because peter is clearly not ready, and if he can’t do that after my encouragement, he might feel shame. he is processing well, and i feel no need to intervene at that point.) **** p: “why did you do it?” (to his father in a calm voice) 7 international journal of integrative psychotherapy, vol. 13, 2022 **** p: i see sorrow in his eyes; he had no choice. (although this might be considered using intellectualization as a defense, i think he is adding something that he has not been conscious of before.) **** p: we are talking (in his current imagination, which is part of the new learning occurring). **** p: my tightness is going down. (a good sign that i do not need to intervene in his process.) **** p: we’re still talking. **** p: what i did was inconsequential. (he has come to this on his own. in all probability, his previous therapist would have told him this when he recounted the memory, but new learning could not happen at that time if he was not in full contact with the neural circuits encoding the memory according to the process of memory reconsolidation. at this point in the processing, when he says this, it feels like an emotional shift. he has added some new information or awareness, which is a sign that significant new emotional learning is happening.) **** p: i’m sorry for my father having to deal with it on his own. **** t: see if he can tell you it wasn’t your fault. (here i chose to intervene as a way to gauge how much of an emotional shift is happening and to possibly deepen the work.) p: he’s reluctant to tell me. **** t: but you know that eating the dog food was inconsequential. 8 international journal of integrative psychotherapy, vol. 13, 2022 (i reiterate what he already knows. however, i knew there was a possibility he would go back to his shame in the next set of tapping.) **** p: he’s screaming it’s his fault. (the report that his father is screaming this surprises me. this must be a powerful cathartic emotional experience for peter.) **** p: he’s accepting responsibility. **** p: i’m cautiously hoping he acknowledges it and owns it. (it sounds like he’s not sure if his father really accepts responsibly or whether he can let go of his guilt.) **** p: it feels like a chain unwinding. (this is highly significant, and i have a resonating sense of something unwinding.) **** t: feel that unwinding in your body. **** p: i’m getting clarity on cause and effect. **** p: i don’t own it. **** p: i’m thinking of all the reasons i wasn’t responsible. (in a regular verbal session, i would ask him to list them all. however, with emdr, an intervention like that could derail his own process, which is going so well that i trust i don’t need to make this intervention.) **** p: i’m a good man. 9 international journal of integrative psychotherapy, vol. 13, 2022 (his response here confirms i made the right decision.) **** t: let yourself really feel that. **** p: embarrassment, being boastful. **** p: my catholic ideology. **** t: can you go back as your adult self and say to your 5-year-old self “you are a good boy”? (i purposely avoid any intervention regarding his embarrassment caused by his catholic upbringing and the sin of pride. instead, i pay attention to my instinct that bringing in adult awareness is going to be most helpful.) **** p: i tell him that and i hug him. (again my instinct was right, and there is emotion as he tells me.) **** p: i have pride in him. **** t: tell him that as he continues to grow up he will continue to be good and will be a good man. (i am repeating what he just said. my impression is the label “a good man” is accurate based on what he’s told me about himself as a father and husband and corroborated by his previous therapist. my intervention is to see if he can integrate his young and present self to see there is a continuum and to anchor the awareness.) **** p: i’m calming. **** p: i feel peaceful. 10 international journal of integrative psychotherapy, vol. 13, 2022 (i can tell he is getting close to a good place to stop the processing for that day, so i ask the following question.) **** t: where is your feeling level now on the 0-10 scale? **** p: 1. (this is in line with what i have observed since there has been such a significant shift in his voice and body since the beginning.) t: what is the most positive thought about yourself right now as you reflect on all of this? something will pop into your head, you don’t have to think about it. (this is the question i always pose at the end of a session, and every client has been able to articulate a positive thought, sometimes with the help of a few suggestions based on what i’ve heard them say in the processing. here i do a short tapping set of 10-12 seconds.) **** p: i’m honorable. (this is interesting because it’s not one i’ve heard before, but clearly it has real significance for him. this is so different from affirmations that clients repeat having read about them. this has arisen from deep inside him.) t: now i’m going use a different scale where 1 is completely false and 7 is completely true (the standard validity of cognition scale used in emdr). where do you put the belief that “i’m honorable”? (i tap for a few seconds). p: it’s 7. t: i’m going to tap again and perhaps it will get stronger. (i tap for a few seconds.) p: it’s a strong 7. t: when you feel ready, come back to the room and open your eyes. (he takes several minutes; and he looks different and calm.) p: i feel different (long pause). i’m not looking over my shoulder (long pause). i don’t have to justify myself (long pause). i feel this is a game changer. 11 international journal of integrative psychotherapy, vol. 13, 2022 i was flooded with happiness for peter because i was resonating with him and knew that he had undergone a fundamental change. to facilitate cognitive understanding, i explained to him what happened in terms of memory reconsolidation and how he was open to new emotional learning. i pointed out that the shift started when he said, “what i did was inconsequential,” and he replied, “i felt that.” i used my usual exercise for ending an emdr session. i ask him to feel “i’m honorable” in his body, to imagine standing, walking out of the office holding on to it, in the street, in his car, going home, and holding on to it the next day and at least until he came back the following week. when he returned for the next session, i was curious to find out if the memory reconsolidation had truly been transformational and the old emotional learning had been erased. he started by saying the week had been “unsettlingly good,” which made me think of the power of homeostasis, the purpose of which is the “biological imperative to remain the same, to stay with the familiar” (erskine, 2021 p. 15). something did not feel quite right about not looking over his shoulder, not having his internal critic constantly at him. in spite of that, what he mainly felt was “lightness, a sense of peace” and not “wondering if the other shoe was going to drop.” he felt he had “a clean canvas” to reimagine his life. he said the only other time in his life he had felt a sense of peace like that was when he completed an 85-kilometer bike race, but that feeling only lasted a couple of hours. he had only heard his internal critic a couple of times during the week, and it felt “like the equivalent of a mosquito bite.” he felt for the first time more in tune physically and emotionally. when i said we would do some more emdr processing to see if there was anything unfinished, he thought it was a good idea because he felt there was something but did not know what. the session lasted about 10 minutes. again, there was a 30to 40-second pause as i did tapping and peter processed his internal experience. t: what do you get when you go back to the memory. **** p: sympathy for father. **** p: calmness. **** p: it happened because the dogs were sick. **** p: i have no need to apologize. **** 12 international journal of integrative psychotherapy, vol. 13, 2022 t: where is your feeling level on the 0-10 scale? p: 1 to 2. **** p: i was supposed to take care of them. **** p: feeling a warmth in my core. (in spite of him saying he was supposed to take care of the dogs, something happened in his thoughts that led to feeling that warmth.) **** p: no need to apologize; you did what you were supposed to do (meaning he fed them as he was instructed). **** p: this is life. (this is a statement of acceptance, and i infer that he means death is a part of it.) **** p: i can only control me, not others **** p: i don’t accept responsibility for others and their actions. **** t: where is your feeling now on the scale? c: 0 t: take some time to scan your body and see if there is any remaining tension. **** p: no tension. i feel completely calm. t: what is the most positive thought about yourself right now? c: i’m proud of myself (without hesitation). i had peter go through a visualization of holding this now and in the future. following this he said, “this is the final piece.” he was quiet and clearly filled with joy. we still had 13 international journal of integrative psychotherapy, vol. 13, 2022 15 minutes left in the session, but he said he wanted to go home and hug his wife and kids. he felt no need to make another appointment, although i invited him to contact me if the need arose. he may continue couples therapy with the therapist who referred him to me. it can take many therapy sessions before the conditions arise for this kind of emotional transformation to occur. i believe there must be a solid, trusting client-therapist relationship both before and after the intense memory reconsolidation. in this case, although i only saw peter three times, he came with a positive transference based on his relationship with the referring therapist and what she had told him about my work with emdr. as described, in peter’s case, the emotional transformation happened during one session of emdr, but it could have occurred with empty-chair work or some other intervention. in addition, memory reconsolidation can take many sessions of emdr until the key to the crucial new learning occurs to delete the old emotional learning. although the process might appear almost magical, there is a predictable outcome if the criteria for memory reconsolidation are met: full internal contact with the early emotional learning and, at the same time, disconfirming evidence or information. in peter’s case, the new learning came from inside him, which was the knowledge that a 5-year-could not be responsible for the death of his dogs. in other cases, it might come from some new emotional knowledge or learning that the client has acquired through the relationship with the therapist, knowledge that contradicts the early emotional learning (e.g., feeling loved by and cared for by the therapist). memory reconsolidation in the context of a healing relational therapy is a powerful tool that guides the therapist in attuning to a client’s early emotional learning in order to facilitate the permanent erasure of the emotional component of a memory. memory reconsolidation speaks to me of our innate ability to heal from emotional trauma if we are presented with the right experience and/or a nonjudgmental and accepting relationship. notes on author john hallett is a psychologist in private practice in vancouver, british columbia, canada; a certified international integrative psychotherapy trainer and supervisor (ciipts), and a founding member of the international integrative psychotherapy association (iipa). he has over 45 years of experience and has presented workshops at most iipa conferences. e-mail: johnhallett@shaw.ca references ecker, b., ticic, r., & hulley, l. (2012). unlocking the emotional brain: eliminating symptoms at their roots using memory reconsolidation. routledge. mailto:johnhallett@shaw.ca 14 international journal of integrative psychotherapy, vol. 13, 2022 ecker, b., ticic, r., & hulley, l. (2015). a primer on memory reconsolidation. in m. dahlitz & g. hall (eds.), memory reconsolidation in psychotherapy (pp. 6–28). dahlitz media. (original work published 2013) erskine, r. g. (2015). relational patterns, therapeutic presence: concepts and practice of integrative psychotherapy. karnac. erskine, r. g. (2021). early affect confusion: relational psychotherapy for the borderline client. nscience publishing. erskine, r. g., & mauriz-etxabe, a. (2016). inference, re-experiencing, and regression: psychotherapy of child ego states. in richard g. erskine (ed.), transactional analysis in contemporary psychotherapy (pp. 139–159). karnac. erskine, r. g., & moursund, j. p. (2011). integrative psychotherapy in action. karnac. (original work published 1988) forcato, c., burgos, v. l., argibay, p. f., molina, v. a., pedreira, m. e., & maldonado, h. (2007). reconsolidation of declarative memory in humans. learning and memory, 14(4), 295–303. https://doi.org/10.1101/lm.486107 hupbach, a. (2011). the specific outcomes of reactivation-induced memory changes depend on the degree of competition between old and new information. frontiers of behavioral neuroscience, 5:33, 1–2. https://doi.org/10.3389/fnbeh.2011.00033 hupbach, a., gomez, r., hardt, o., & nadel, l. (2007). reconsolidation of episodic memory: a subtle reminder triggers integration of new information. learning and memory, 14, 47–53. hupbach, a., gomez, r., & nadel, l. (2009). episodic memory reconsolidation: updating or source confusion? memory, 17(5), 502–510. https://doi.org/10.1080/09658210902882399 pedreira, m. e., pérez-cuesta, l. m., & maldonado, h. (2002). reactivation and reconsolidation of long-term memory in the crab chasmagnathus: protein synthesis requirement and mediation by nmda-type glutamatergic receptors. journal of neuroscience, 22(18), 8305–8311. https://doi.org/10.1523/jneurosci.22-1808305.2002 pedreira, m. e., pérez-cuesta, l. m., & maldonado, h. (2004). mismatch between what is expected and what actually occurs triggers memory reconsolidation or extinction. learning and memory, 11(5), 579–585. https://doi.org/10.1101/lm.76904 perls, f. (1969). gestalt therapy verbatim. real people press. shapiro, f. (2001). eye movement desensitization and reprocessing: basic principles, protocols and procedures (2nd ed.). guilford. international journal of integrative psychotherapy, vol. 11, 2020 1 compassion, hope, and forgiveness in the therapeutic dialogue richard g. erskine12 abstract compassion, hope, and forgiveness in the therapeutic dialogue are essential aspects of a relationally focused integrative psychotherapy and are instrumental in healing the psychological wounds from neglect, stress, shame, and abuse. each concept is defined, examples are given, and therapy illustrations provided that link the three concepts. keywords: compassion, empathy, forgiveness, hope, integrative psychotherapy, presence, psychotherapy, relational psychotherapy, therapeutic dialogue ------------------------------------- compassion. the word conjures up images of jesus healing the sick and buddha’s suffering because others in the world were suffering from hunger or oppression. the word “compassion” comes from latin: “com,” which means “with,” and “passion,” which means “to suffer.” compassion thus means to suffer with the other, to suffer together. compassion involves both a physiological and an emotionally sensed experience 1 institute for integrative psychotherapy, vancouver, canada 2 deusto university, bilbao, spain international journal of integrative psychotherapy, vol. 11, 2020 2 of the suffering that others endure. it is a total sense of the other, a moving out of our own experience by being fully aware of the pain of others. compassion is selfless. it is about the welfare of others. it may involve putting the welfare of another person above our own—as when a hero jumps into cold water to rescue a stranger. in psychotherapy, compassion begins with ethics. we are compassionate when we practice our profession with a constant awareness of ethics. in my view, the most significant ethic of all is the commitment to our clients’ welfare. that is what guides us in all we do and say. all other ethics emerge from this central one, which involves our commitment to make our clients’ welfare most important in all of our actions. compassion is a central element in psychotherapy and what may have motived some of you to become psychotherapists. it is that felt sense of experiencing other people’s suffering and a simultaneous desire to relieve their pain, anguish, or loss. compassion is what motivates us to put our arm around individuals who are grieving. we want to comfort them, to alleviate their grief. compassion motivates us to attune to clients’ affect, rhythm, and relational needs, to fully connect with them. in my practice of psychotherapy, compassion emerges from the conviction that each person is of value in his or her unique way. carl rogers (1951) called this valuing of the other “unconditional positive regard” (p. 144). martin buber (1923/1958) described how this aspect of compassion is based on what he called an “i-thou relationship.” he used the biblical word “thou” to reflect the spiritual nature of a fully contactful relationship, one that is without preconceived notions of the other, that is built on continually discovering the other’s uniqueness, and that attends to the other’s affect and relational needs (erskine, moursund & trautmann, 1999). when we foster such a relationship, we are naturally empathic because empathy is based on compassion. although the words “compassion” and “empathy” are often used interchangeably in the english language, empathy usually refers to the emotional connection with a specific person, whereas compassion is often associated with a response to the suffering of all human beings. empathy refers to our ability to feel the emotions of another person, to experience those feelings as though they were our own. this is echoed in a saying attributed to native americans: “you cannot really know another unless you have walked a mile in his moccasins.” empathy is about being deeply connected to another person’s affect and experiencing what it is like to be in his or her skin. carl rogers (1951, 1975/1980), in defining the theory and practice of client-centered therapy, elaborated on this idea when he defined empathy as our capacity to feel the other person’s affect, international journal of integrative psychotherapy, vol. 11, 2020 3 such as sadness, fear, anger, or joy. psychoanalyst heinz kohut (1977), in writing about self psychology, referred to empathy as a form of listening to the other person’s phenomenological experience without any preconceived notion or judgment. for him, empathy was about wanting to understand others’ subjective experience without imposing his ideas on them. in psychotherapy, this kind of empathy occurs automatically if we have the attitude that “i know nothing about the other person’s experience, and so i must continually strive to understand the subjective meanings of his or her emotions and behaviors.” as psychotherapists, it is essential that we have both forms of empathy as described by rogers and kohut: to feel others’ affect and to strive to understand how they experience themselves. although empathy usually refers to the ability to feel the emotions of another as well as to understand his or her reasoning, compassion generally refers to the desire to help. this is the type of compassionate psychotherapy i described in beyond empathy: a therapy of contact-in-relationship (erskine et al., 1999) and in integrative psychotherapy: the art and science of relationship (moursund & erskine, 2004). we go beyond empathy when we attune ourselves to our clients. attunement is our yin to the client’s yang. affect attunement provides the necessary reciprocity that the other needs to feel emotionally whole. the important concept of reciprocity refers to the way others need something from us in response to their affect. here are four examples of reciprocity: • when our client is sad, we provide expressions of sensitivity, warmth, tenderness, and acceptance. • when our client is angry, we respond by taking what he or she says seriously. • when our client is afraid, we feel protective and may act protectively. • when our client is joyful, we meet him or her with our vitality and celebration. recently, i was typing up a transcript of the video of a therapy session and trying to describe the compassion, empathy, and attunement that the client required in order to heal from the emotional wounds of neglect and abuse. i realized that the words i was using only slightly conveyed my compassion and empathy because the most important component of compassion was in my nonverbal behavior: my sustained eye contact, the muscles of my face, my hand gestures, and the tone of my voice. all of these conveyed my full presence. therapeutic presence requires that we be fully with our clients’ experience as well as being there for them, decentered from ourselves. to be fully present, we make our own concerns not important. yet simultaneously we draw on all of our personal and professional experiences as a resource to further our attunement and international journal of integrative psychotherapy, vol. 11, 2020 4 connection with our clients. it is our presence and attunement that allows for an authentic person-to-person connection. our clients’ capacity to heal from the wounds of neglect, ridicule, or abuse directly depends on the quality of interpersonal contact and attunement that we provide. confronted by compassion one spring day, after returning from lunch, i discovered a women sitting on the stairs to my office. she was dressed in a rumpled skirt and blouse and appeared to be in her mid-fifties. her stringy gray hair hung over her flushed face, and her eyes were swollen from crying. i asked her if she needed anything, and she responded that she was waiting for the psychologist whose name was on the sign. i said i was that person and asked why she was waiting. she said that she was confused and needed to talk to someone who could help her. it was apparent that she was distressed, confused, and did not know how to phone for an appointment. i did not want to leave her crying on the stairs, but i also did not want to talk to her. the brief encounter was unsettling. i had intended to use the half hour before my next client to take a nap. yet the way the woman conveyed her anguish and confusion touched my heart, and i could not ignore her request to talk. i decided to give her a few minutes before my next client and perhaps refer her to a colleague. i asked her to step into the waiting area of the office and tell me why she wanted to see a psychologist. agatha rapidly told me fragments of an entangled story about her husband dying of pancreatic cancer, her wanting a divorce, her care of him during his painful illness, his physical abuse of her throughout their marriage, and her children’s anger at her for staying in the marriage. she punctuated each part of the story with “i’m so confused.” although i was empathic, i too was confused by the profusion of information as she went from one part of her story to another and back again. it was too much information too fast. it was difficult to stay attuned to her changing affect and discombobulated story. she continued to talk for the full 30 minutes until my next client arrived. unexpectedly, i was drawn to her emotion-filled story in some way i did not understand. as a result, i offered to see her the next day but added that we could only have six sessions because i would be leaving in seven weeks for europe. i knew it was not the time to begin a psychotherapy relationship with anyone, yet i spontaneously offered her the six sessions. later that day i wondered how i had become ensnared in such a countertransference trap. that evening i arranged to see a trusted colleague to talk about my encounter and how, against my better judgment, i had arranged for international journal of integrative psychotherapy, vol. 11, 2020 5 the six sessions. as i told the story, my eyes fill with tears. i talked about how i wanted to comfort the woman, even though we did not yet have a relationship. it seemed necessary to explore my countertransference. in our conversation, my colleague used the word “compassion” a few times to explain my intense reactions to the woman on the stairs. we talked about the meanings and significance of compassion as well as our professional commitment to the welfare of our clients. my colleague’s discussion of the concept of compassion opened a new awareness for me. that night i had an enlightening dream about protecting a woman from being physically attacked by a man. i was filled with a desire to protect and help. it was as though compassion had a deep hold on me. i had felt a similar sense of deep interpersonal connection several times in both my personal and professional life, but i had never thought of it as compassion—a deep desire to provide the other person with relief of his or her suffering. the next day agatha and i began our limited series of therapy sessions. i soon realized that i was again experiencing compassion via my intense affect attunement when she told me more details of her story. this was the beginning of a significant therapeutic relationship that eventually transformed her life. hope the word “hope” reminds me of a children’s book entitled the little engine that could (piper, 1930). “i think i can, i think i can, i think i can” was the motto of the little engine. some of you may know this story, as i do, from reading it over and over to your young children. in the story, the little engine was eventually able to climb the hill and finally exclaim: “i knew i could, i knew i could.” this story is a delightful way to teach children about the importance of hope. merriam-webster (n.d.) has two definitions of hope: first, “a desire with anticipation” and second, “desire accompanied by expectation of or belief in fulfillment.” i like the second definition because it is central to the process of psychotherapy. our clients come to us because they expect to change and grow and they are looking for some form of fulfillment. this is why transactional analysts often begin therapy with a clear contract defining clients’ expectations and how they will know when those goals have been fulfilled. hope is optimistic, a state of mind based on anticipation that something good will result and that events and circumstances in life will turn out well. one of my mother’s important teachings was about hope. when things were bleak and i was discouraged, she frequently said, “life always turns out, not necessary the way you expect, but it always turns out.” more than 70 years later, i realize how international journal of integrative psychotherapy, vol. 11, 2020 6 instrumental my mother’s message of hope has been in my life. her message has served to keep me enthusiastic and enjoying the adventure of life. several writers on psychotherapy have commented on the sense of hope. alfred adler saw hope as central in our mental health when he described the importance of goal seeking (ansbacher & ansbacher, 1956). he encouraged clients to make plans and find various way of making those plans come true. lawrence leshan (1994) described his research with people who were diagnosed with terminal cancer. he encouraged them to dream big, to make big plans for what they always wanted to do, and then to implement those plans. the patients who activated their dreams, who dared to follow their desires, lived from 2 to 5 years beyond their expected time of death (l. leshan, personal communication, 20 may 1993). donald winnicott (1964) saw hope in a child’s disruptive behavior, which he viewed as an unconscious desire to make an impact on the adults in the child’s life. if we expand on winnicott’s idea, perhaps our clients’ “resistance” reflects their desire to make an impact on us. what would happen in your therapy practice if you viewed your clients’ reluctance as an unconscious desire to influence you, to encourage you to see the world from their perspective? psychologist charles snyder (1994) described the connection between hope and mental will power. in my personal experience, hope emerges most strongly when there is a crisis because it is hope that opens me to new, creative options. my client may be despairing about the circumstances in his or her life, and in that moment of crisis i am often propelled to find some important way of connecting with that person. the crisis in our therapy relationship propels me forward with a new hope, with courage to experiment with different ways of our being together. hope offers us a challenge. it is much more than wishful thinking or passively longing for something to happen to us. true hope is realistic and must include real possibilities, with a clear plan about how to reach what is hoped for. an important aspect of psychotherapy includes helping clients to identify their aspirations and then to find the step-by-step ways to achieve their hoped for goals. however, psychotherapy may also involve helping the client to be realistic about what may never happen, for example, to let go of the illusion that someone else will change. if the loss of hope results in depression, then hope must be an essential element in psychotherapy. not only is it instrumental in recovery from the psychological effects of neglect, abuse, and humiliation, hope is central in all psychotherapy. it helps people recover from physical illness and may even prevent illness from developing in the first place because our beliefs and expectations can stimulate the body’s hormones to enhance recovery. alexander pope (n.d.) wrote about how people are blessed because “hope springs eternal in the human breast.” i think he meant that hope gives us a sense of liveliness filled with a desire to achieve something. it is hope that gives sparkle international journal of integrative psychotherapy, vol. 11, 2020 7 to our lives. this zest for life has been emphasized by sages for millennia. as st. paul said, “for we are saved by hope” (romans 8:24 king james version). all of the world’s religions emphasize hope as a necessary aspect of overcoming life’s drudgeries. agatha’s hidden hope over the first few weeks we met, agatha told me many of the details of how she had been “trapped in a disastrous marriage” with a husband who both physically and sexually abused her. she had finally gone through the arrangements for a divorce when her husband was diagnosed with pancreatic cancer. agatha gave up on the divorce and instead nursed him devotedly for the next 11 months while he continued to criticize and verbally abuse her. after he died, she had a “strange mixture of missing him” and being “free of the bastard.” she was confused by her “mixed-up feelings.” she described how over the years she had often wanted to murder her husband but was scared to because it would have had “a disastrous effect” on her two children. i discovered that i was the first person she had ever told about the abuse she had lived with for 33 years. she felt guilty about wanting to kill her husband and about the murderous fantasies she had from the time she was first pregnant. her self-criticism and guilt were intense. providing her with some relief from the intense internal criticism seemed important before we went further in our psychotherapy. i used the word “hope” to describe her fantasies of killing her husband: “hope to have some relief from the pain your husband repeatedly inflicted on you.” at first she did not understand and continued to feel guilty. in the following session she was again confused about why she had “wanted to kill him all these years and yet i carefully nursed him to the end.” again i described both her fantasies and actual caring behavior as hopeful, as “a way to have relief at a time when you did not have the internal resources to terminate a disastrous marriage.” she told me how she would “lie in bed imagining him dead … with a knife in his balls” and would fantasize getting a divorce “if i only had the money to do so and a place to go.” i explained how hope is often the unconscious motivation in people’s fantasies and how it provides us with some relief from discomfort. agatha began to think of her fantasies as a significant desire to be free of her abusive marriage and no longer as though something was evil in her. our conversations about the significance of hope helped her to realize that throughout her married life she had longed to return to university to finish what had international journal of integrative psychotherapy, vol. 11, 2020 8 been interrupted when she became pregnant. in our next session, she told me how she had begun to imagine finishing her university degree. as our sessions came to an end, she was not confused. she had spent several sessions telling me the details of her painful story, things she had never revealed to anyone. she was still embittered about her abusive marriage, still resentful about her children’s anger at her for staying in the marriage, but she was no longer selfcriticizing or feeling guilty. agatha was hopeful about returning to school. we decided together that we would continue our psychotherapy sessions when i returned in september. forgiveness forgiveness is letting go of resentment and finding an end to our angry reactions and bitterness toward someone who has offended or injured us. it is about freeing ourselves from the physical and mental pressure that occurs when we continue resenting someone. forgiveness frees us to move out of the past and into the present and future with a new and different perspective. resentment results from holding on to old angers; it involves living in the past. it is often accompanied by fantasies of getting even or withdrawing. resentment involves the fantasy that we hold some power over the other person, but in actuality it distracts from the disappointment and pain that occurs when there is a disruption in relationship. when we hold on to anger at someone, the body is stimulated to produce cortisol and adrenaline, two primary stress hormones that have a major effect on our behavior (cozolino, 2006; damasio, 1999). our body may then become addicted to living with an overproduction of stress hormones. this addiction is one reason some of our clients hold on to old resentments for many years, perhaps even after the resented person is dead. the prolonged release of stress hormones within the body often interferes with both physical and mental health. that is why forgiveness is so important in psychotherapy: it brings peace to both body and soul. with my clients, i find that the first step in forgiveness involves consciously deciding to let go of the resentment. the second step occurs when they examine their own behavior and attitude toward the resented person. i guide my clients into challenging themselves with the question, “how did i possibly contribute to the conflict?” answering this question involves soul searching, facing truths about ourselves, and examining our attitudes, fantasies, and behaviors toward the person we resent. this soul searching is a central part of the alcoholics anonymous 12-step program. the aa literature describes this step as “taking a searching and fearless moral inventory of ourselves.” international journal of integrative psychotherapy, vol. 11, 2020 9 some people think that forgiveness is about forgetting, that is, no longer remembering what occurred. but that is not the case. forgiving involves both being fully aware of what occurred and taking some responsibility for it. by responsibility, i do not mean self-blame but, rather, being soberly aware of my part in the conflict. forgiveness does not mean that we excuse the other person for what he or she did. that person is responsible for their behavior. but central in forgiveness is taking responsibility for what one believes and feels. forgiveness is based on our attitude toward the other person and one’s self. the third step in resolving resentment includes not only telling the truth to oneself, as in step two, but also telling the truth to an interested other. truth telling to an emotionally attuned other is essential in achieving forgiveness. when confessing, we not only hear our own words and explanations but also observe the facial expressions and hear the other’s tone of voice and words. such intersubjective communication often helps to calm resentment and restore internal peace. to help clients maintain an attitude of forgiveness and not lapse back into resentment, i try to convey the idea that at any moment we each do what we think is best given our limited perception of options. later we may realize that our choice of behavior was a poor one, but, at the moment, what we said and did often seems like the only choice. forgiveness does not mean that we have to reconcile with the other and make everything ok. it means letting go of the false idea that we have some control by remaining resentful. we can engage in the process of forgiveness even if we never talk to the other person again. forgiveness may take a long time. it is a process of self-awareness and learning that “this resentment and anger that i feel hurts me as much, or even more, than it hurts the other.” in a 1973 article entitled “six stages of treatment,” i described the last stage of therapy as forgiveness of others. after publication, i became concerned that some therapists might push clients into forgiving prematurely and their clients might merely adapt or that some people might push themselves to forgive before they were internally ready. for example, some clients are quick to say, “my parents did the best job they were capable of doing.” sometime this might be true, but sometimes it is not. the parents may have been drunk, intentionally critical, inflicted physical pain, or were sexually abusive. in such situations, forgiveness based on excusing the other is not transformative and growth producing. it is merely avoiding realizing and accepting the impact that the other had on the individual. international journal of integrative psychotherapy, vol. 11, 2020 10 resentment is killing me when we resumed our therapy sessions, agatha agreed she would come weekly until the end of may. she was excited about having enrolled in university in a special course designed to reorient older students who were returning to study. as our work evolved, she said she experienced my being supportive and how it gave her courage to rage at her husband’s many acts of abuse. at first it seemed important that i witness her intense rage and resentment. but as the months went on, agatha’s resentment not only did not dissipate but seemed to intensify. her anger was not an interpersonally contactful form of anger. she was just enraged and unaware of what she might have needed in a healthy marriage. whenever i could, i talked about the caring qualities that she had needed, and that were absent, in her marriage. periodically she ignored my opinions of what she needed and would again express her intense resentments. it was as though the rage and resentment were providing some form of selfstabilization. eventually, she began to cry about what had never occurred in her marriage and how her husband was not only abusive to her but neglectful of and abusive toward their two children. i talked to her about the tension i could see in her face and neck when she was resentful. she angrily said, “you want me to forgive the bastard, but i will never forgive him.” i explained that forgiveness was not about forgetting the abuse but about letting go of her husband’s influence over her and that as long as she remained resentful she was under his domination. she cried and said that she had always felt so controlled by him. as she wept, her whole body relaxed. the next session began by agatha saying, “my resentment is killing me. if i am going to survive i need to forget all the awful things he did. i need to make a new life for me.” we talked about the difference between forgetting versus not letting what occurred influence us any longer. over the next few sessions, we talked both about making a conscious decision to stop the resentments and various ways of “letting go.” we talked at length about agatha’s hurt and anger at her husband as well as her responsibility in provoking some of the physical fights that they had had. she concluded that she should have ended the relationship the first time he raped her, that she protected him and never told his family about the physical abuse or reported him to the police. she wept as she described how she spent “half a lifetime waiting for him to change.” she added, “now i am going to change. i am going to stop my hatred of him because this resentment is killing me. i will make a new life.” in the late winter, agatha met a man who attended the same university course. they quickly developed a respectful and caring relationship. she was excited about her “new life.” she then told me that she had a confession to make. she international journal of integrative psychotherapy, vol. 11, 2020 11 described how for a few years she had walked past my office twice a day and would look at the “psychologist” sign on the door and “hope.” she had tears in her eyes as she talked about crossing the street to look into my window so she could see what i looked like, hoping that i would be sympathetic, kind, and able to understand her and help her create a new life. she described the importance of expressing her anger and how i had never criticized her for her rage. she added that the most important thing was to let the anger go because the “resentment is killing me.” agatha had a sense of renewed hope that she said she had not felt since she was an adolescent. conclusion: compassion, hope, and forgiveness compassion, hope, and forgiveness are central in a relationally focused, integrative psychotherapy. these three areas are frequently in my mind when i carefully listen to my client’s narrative. i am continually monitoring my expressions of empathy and desire to be compassionate so that i am affectively attuned to the client’s internal experiences. i want to emotionally connect with my client but i am also cautious that my expressions of compassion not overwhelm the person by invoking more emotional stimuli than he or she can internally process. affect attunement is always a challenge because it requires a moment-by-moment balance of my affect in resonance with my client’s affect. i want to infuse my clients with a sense of hope, which is the antidote to despair because it provides direction and enthusiasm. yet i want to make sure that i am not offering hope as a panacea but that the hope we share together is realistic and vitalizing. hope, and the accompanying sense of well-being, is based on realizing that a fully lived life is a process of learning and growing. forgiveness is an important ingredient in a relationally based psychotherapy. i want to make sure that with my clients, any expressions of forgiveness come from a desire and readiness to let the emotionally consuming past be over. i do not want to suggest that they forgive before they are internally ready. the desire to forgive must come from their sense of hope to be relieved of the burden of resentment. forgiveness is transformative when the impetus for change is the result of clients’ realization that their resentment harms them more than anyone else. compassion, hope, and forgiveness: these three important elements of a psychotherapy relationship are instrumental in the healing of the psychological wounds from neglect, stress, shame, and abuse. international journal of integrative psychotherapy, vol. 11, 2020 12 acknowlegments portions of this article were presented by richard g. erskine as the keynote address entitled “compassion, hope, and forgiveness in the therapeutic dialogue” at the manchester institute for psychotherapy conference, 15–17 november 2019, manchester, united kingdom. references ansbacher, h. l., & ansbacher, r. r. (1956). the individual psychology of alfred adler. new york, ny: atheneum. buber, m. (1958). i and thou (r. g. smith, trans.). new york, ny: scribner. (original work published 1923 in german) cozolino, l. (2006). the neuroscience of human relationships: attachment and the developing social brain. new york, ny: norton. damasio, a. (1999). the feeling of what happens: body and emotion in the making of consciousness. new york, ny: harcourt brace. erskine, r. g. (1973). six stages of treatment. transactional analysis journal, 3(3), 17–18. doi:10.1177/036215377300300304 erskine, r. g., moursund, j. p., & trautmann, r. l. (1999). beyond empathy: a therapy of contact-in-relationship. philadelphia, pa: brunner/mazel. kohut, h. (1977). the restoration of the self. new york, ny: international universities press. leshan, l. (1994). cancer as a turning point: a handbook for people with cancer, their families, and health professionals. new york, ny: plume books. merriam-webster. (n.d.). merriam-webster.com dictionary. retrieved 13 june 2020 from https://www.merriam-webster.com/dictionary/hope moursund, j. p., & erskine, r. g. (2004). integrative psychotherapy: the art and science of relationship. pacific grove, ca: thomson brooks/cole. piper, w. (1930). the little engine that could. new york, ny: platt & munk. pope, a. (n.d). hope springs eternal. retrieved from https://www.brainyquote.com/quotes/alexander_pope_163156 rogers, c. r. (1951). client-centered therapy: its current practice, implications, and theory. boston, ma: houghton mifflin. rogers, c. r. (1980). empathic: an unappreciated way of being. in c. r. rogers, a way of being (pp. 137–163). boston, ma: houghton mifflin. (original work published 1975) snyder, c. d. (1994). the psychology of hope: you can get here from there. new york, ny: the free press. international journal of integrative psychotherapy, vol. 11, 2020 13 winnicott, d. w. (1964). the child, the family, and the outside world. london: pelican books. alcoholism is such a common condition that therapists must be exposed to clients who suffer from it, whether the therapist is shedding a heavy load leigh bettles abstract: this paper is a case study, presenting the work with a client who was referred to me for six counselling sessions. this case illustrates the effectiveness of using a relational therapy in short term therapy so that the client was able to move from a place of feeling stuck in her life. key words: case study; relational psychotherapy; short term therapy; integrative psychotherapy _______________________ azra was invited into the office where i would be assessing her needs and if counselling would be appropriate for her. i was aware that she was laden with bags, which as she walked in hid her very thin childlike frame. she put her bags to the side of the chair. azra, a young woman in her early twenties was living at home with her mother, younger sister and younger brother. she had been brought up as a muslim by her parents who were originally from pakistan. she was working as an environmental project officer. she had been signed off by her doctor for 6 weeks due to depression. even though she had put her bags to the side of the chair, the way that she slouched forward in the chair made me wonder how someone so small, was able to carry bags that seemed so heavy. she looked as though she was carrying a heavy burden. i could see that her problems were embodied in her physiology and that she was being weighed down. she told me how she was feeling low, had lost her appetite and was feeling tired all of the time. she had no interest in doing anything and was also over analyzing everything, which meant she was going through different situations in her mind but ending up stuck and unable to sort out how to go forward and then felt that she was going around in circles. she told me that she was not currently on any medication. she had attempted to take an overdose in october of last year, when the relationship with her boyfriend had broken down. she was no longer having thoughts of suicide and said that it was a reaction to her situation at the time. she was then referred to a psychiatrist who had assessed that she did not need long term psychiatric help; he recommended that she be referred for counselling. international journal of integrative psychotherapy, vol. 1, no. 2, 2010 48 she had still been seeing her boyfriend (joe) and was having a sexual relationship with him which she had instigated. she commented that she had felt that she needed some control in the relationship and this is how she felt she had it. i made a mental note that she had mentioned that she needed to feel in control. she told me that she knew this relationship was not good for her but she could not find the strength to leave him and didn’t understand why. i used historical and phenomenological inquiry to find out about her life history and what her experience had been, of growing up within her family. i was also looking out for any evidence of any script beliefs that she may have made at an earlier developmental age, which may be influencing her life now. she told me that she had felt lonely as a child. she spent a lot of time on her own in her room. her father was never around and when he was, she saw him being violent towards her mother. she remembered her parents as distant and that when they were together there was a lot of fighting and screaming. her mother was the kind of mother who was not outwardly affectionate. if azra fell over or was upset her mother would not respond. there was a lack of attunement from her mother. she would not give her daughter an encouraging smile or give her the eye contact, to let her know that she had someone there, caring for her and giving her the security that she needed. if azra came home from school with an a for an essay, her mother’s response would be to ask her why she had not got an a star. azra had not been able to make an impact on her mother and receive the praise she wanted for working hard and getting an a. because of her parent’s culture and religion they were unable to satisfy azra’s need to be valued and accepted for who she is. when azra did not conform to the beliefs that her parents had, she lost their love and respect. as a consequence of the lack of care and her parents inability to satisfy her developmental and relational needs she grew up thinking that her parents did not love her. she told me that she loved to go to school and if she worked hard the teachers would give her praise and encouragement, so by doing this the teachers compensated for the encouragement that she did not receive from her parents. i considered the fact that the care she had received as a child was inconsistent. she met joe when she was 19 years old. she fell in love with him but he was from a different culture and religion. she kept their relationship a secret because she knew that her family would not approve of her being with him. she then decided to tell her mother that she was seeing him. i inquired how she had come to the decision to tell her mother at that time. she told me that she had been thinking about it for weeks before. she said that she could have never made the decision on her own and that she talked to friends who told her that they thought her mother would understand and support her if she told her. she fantasised about telling her mother and that in her fantasy her mother reacted as her friends had told her they thought she would. she had gone through the fantasy so often that she thought that it could be a reality. it was a spur of the moment decision when she actually told her mother. the reality was that she told her and it led to a massive argument. azra felt and believed that she had the right to be with whom she wanted to be with and international journal of integrative psychotherapy, vol. 1, no. 2, 2010 49 wanted her mother to be able to accept her choice in partner but because of her religious beliefs her mother couldn’t accept that. her father, who at the time was living in the house next door, over heard the arguing and came to find out what was going on. azra was sitting on a bed in the bedroom, opposite her mother, sister, and brother when her father came in. when he found out what was going on, he hit azra. i inquired about azra’s response to her father hitting her. she told me that she had not responded when her father hit her. this was because it was normal for her to be hit by her father, when she did something wrong. it was evident that at some point she had made an implicit experiential conclusion that that was the way it was when she did something wrong, she thought that she deserved to be hit and so did not retaliate. her family also did not respond to her father’s behaviour which reinforced the conclusion that she had made. it seemed that this conclusion was made from the cumulative trauma, of her father hitting her as she grew up. when her father picked up a television and went to hit her with it, her brother stepped in and stopped him. as azra was telling me what had happened i felt shocked and angry that her family could not accept azra and let her live the life that she wanted. i inquired what azra was feeling, as there was no evidence of any emotion in her voice. she was not aware of feeling anything. it seemed that i was experiencing the feelings that she had needed to disavowal because they were so painful and hard to tolerate. she talked of how she ran to the bathroom where her father knocked the door down. the police were called and her father was charged with assault. he received a fine and a criminal record. azra told me that she hated him and she now denied the fact that he was her father. because he had threatened to kill her on more than one occasion the police classed it as an honour based crime and she was sent to a hostel in another city, for her safety. she hated it there and felt very alone. we had 5 more sessions and she told me that she would like to talk about the relationships with her family and joe and try to get a better understanding of them, so that she could deal with situations better in the future. i asked her if she had any questions and if she felt comfortable coming to talk to me again. i wanted to give her the opportunity to say if she was not happy about anything that we had talked about. we agreed to meet again at the same time the following week. in our next session i let azra take the lead. i wanted her to have a sense that she was in control of the sessions. she had already talked about a lack of control in her life and that she had needed to feel that she was in control in her relationship with her boyfriend. from when i first met azra, my intention was to build a safe working environment, where i could focus on her relational needs. her immediate needs seemed to be for security and self definition. from what she had told me it also seemed that relationships in her life had been inconsistent and she was aware of being judged by people, according to her beliefs and her behaviour. she talked about how she was angry at her mother not being able to cope on her own. her mother had not learned english; instead she had relied on her father for international journal of integrative psychotherapy, vol. 1, no. 2, 2010 50 all of her needs and had not thought that he would maybe not be around one day. i considered the fact that azra was now living in a different generation to her mother. she had received an english education where she was more likely to have been encouraged to ask questions when she did not agree with something. she had witnessed how things could be different and as a consequence was more likely to question rather than accept and conform, as her mother and other women had done in previous generations. she felt that if her mother had a terminal illness then she would be able to see the situation differently; she had seen that in situations where her mother was on her own, she was able to cope by getting other people to help her or by managing to deal with the situation herself. azra commented that she did not want to upset her mother. she was the only person that on her return from the hostel had stood by her, even though it was against her religion. tears welled up in her eyes as she told me that she thought that she had lost her mother for good and when her mother let her return, it was the first time that she had realised that her mother did love her. this went against the belief that she had grown up with and it was still hard for her to believe. she was constantly aware of looking for evidence in her mother’s behaviour to support the belief that she did now care. the fact that her mother now turned a blind eye to her relationship with joe was evidence that she cared. she felt that it was not her responsibility to look after her mother. as a result of this she felt angry at her mother. because she was suppressing her anger for fear of upsetting her mother, her anger was coming out in more aggressive ways, by her being snappy and irritable with everyone around her. this led her to feel guilty about her behaviour and although she did not want to look after her mother, she had the belief that she should be doing so. we looked at how she could express her anger in more healthy ways. we explored what she would like to be able to say to her mother and ways in which she could say what she wanted in a non-aggressive way. even if her mother was unable to acknowledge and respond to her anger the way that she wanted, it was important for her to be able to voice how she felt. we looked at the physiological signs of anger in her body so that she could withdraw earlier if she wanted to and also looked at exercises she could do as a constructive way to channel anger energy. azra recalled what it was like for her being all alone in the hostel. she remembered sitting on her bed feeling so alone. this is when she had tried to take an overdose of tablets. i was aware of slowing down the pace of our interactions to give her the chance to feel and express what she was feeling. she recalled feeling angry and confused. she then commented that she was angry at her mother for not being there for her. i commented that i could hear the anger in her voice as she told me her mother should have been there to look after her. she had felt that there was no one in the world that was there for her, and that she was totally on her own. as she talked of the emptiness that she had felt inside, i also had a sense of the emptiness that she was feeling. i wondered how such a young person could have survived such a traumatic series of events and international journal of integrative psychotherapy, vol. 1, no. 2, 2010 51 the intense feelings of loneliness that she had had to deal with after being cast from her family, friends and the culture that she had been bought up in. as i focused on azra, i was aware of wanting to comfort and reassure her, as i would have done with my own daughter if she had have been in that situation. i gently asked her what she thought she needed at that time. she said that she needed her mother to be there to look after her. i told her that if she had been my daughter i would have wanted to reassure her and i would have wanted to look after her. she could see how her mother wanting her to look after her, now made her feel angry. it was a juxtaposition as instead of having a feeling of satisfaction or pleasure from helping her mother, it was painful in that she remembered that her mother was not there for her when she needed her most. while writing some notes up after the session i seemed to have difficulty recalling the way in which azra described her feelings of loneliness. i also remembered that i had had intense feelings of loneliness as a child and my way to deal with those feelings was to dissociate from them and go into my head. i wondered if my countertransference reaction had been to withdraw into my head, during the session, as i had done as a child, which would explain my difficulty describing azra’s feelings. i made a note of this and took it to my next therapy session where we agreed that we would focus on and work through the feelings of loneliness that i had experienced as a child. when azra talked about joe i sensed a feeling of stuckness and that things could not change. she knew that their relationship could not develop as she would like, because his family and in particular his mother did not approve of her and would never accept her into the family. when azra had met his mother she had looked at azra in a way that had made her feel that she did not like her and that she was not what she had in her mind for her son. she had also made comments to her that had supported azra’s thoughts. azra felt anger towards her because of the way that she had judged her and had not even given her a chance. azra had a history of being judged by people so i was aware that there could be some transference going on in the room. i asked her if at any point she had felt judged by me. she said that she hadn’t, my thoughts were that she may have unconsciously introjected for example the way that joes mother or other people had judged her and may now be projecting that introjection onto me and be expecting me to judge her in a similar way. joe was unable to stand up to his family. i inquired why she thought she could not move on from him. she said that she thought it may be because she did not think that she could cope if she was on her own. she then immediately made the comment that she felt that she was on her own now anyway. it was as if she had not realised this before. she had not seen joe for a few months and she was doing alright. this realisation was an important turning point in our work and seemed to free azra from her place of stuckness and fear of being without joe. she could see that joe was allowing his mother to control his life and he could not stand up to her like she had done to her family for him. this made her international journal of integrative psychotherapy, vol. 1, no. 2, 2010 52 angry as she had given up everything for him but he would not do the same for her. he had also been someone who had encouraged her to do what she wanted and had also compensated for azra’s lack of parental encouragement. joe was getting on with his life and said that he would support her to do the same. by azra’s facial expression i could see that she was confused. he was telling her that she should move on and do what she needed to do but also he still wanted her to go and see him and he was also telling her that he loved her. she was feeling confused and that he was using her. she could now see that he knew how to manipulate her into being there when he needed her. she came to the conclusion that she did not want to be in a sexual relationship with him and that she did not want to go running to him when he wanted her to. she decided that she deserved someone who would be there for her and that she could have a future with. she realised that she had control in what she did and could put herself first (i was jumping for joy inside, because she was now taking control and putting herself first). she also admitted that she had a fantasy that he would one day drop everything and want to be with her. this fantasy was also keeping her from leaving him. azra had told me that when she was young she would fantasise a lot. her face seemed to lighten and she talked happily of how she would fantasise that she was adopted or that her mum remarried and she had a different father. she imagined a father that would take them out on trips and would be there doing things with the family and that there would be lots of happy times. i found that i was enjoying listening to the fun that she had with her imaginary family. this was a self regulating fantasy that took away the loneliness that she was feeling at the time. she invented a family that would accept her for who she was, take care of her and help her through the lonely times. she told me that she thought that she was about 5 years old when she had these fantasies. they could have been her pre-conceptual way to make sense of not having parents that were able to attune and respond to her relational needs. as a consequence of the fantasies she had built up a myth of what a mother and father should have been like. she told me that she had been brought up as a muslim, but did not have the beliefs that her family had, which had caused so much conflict between them. she talked about how she wanted her sister to accept her for who she was. her sister had not talked to her for the past 1 ½ years, because she did not agree with the way she had gone against their religion. i inquired about her relationship with her sister previously. it turned out that they had never agreed on anything and that if azra liked or believed in one thing her sister usually thought the opposite. it seemed unrealistic to expect her to change. azra concluded that rather than expecting her sister to change, she had to accept her for the way that she was. in the past her brother had stood up for her but she could see in him traits of her father that he had introjected and this made it hard for her to feel that she wanted to spend time with him. over the 6 sessions we were able to explore some of the relationships that she had with family members and by doing this and using the script system, international journal of integrative psychotherapy, vol. 1, no. 2, 2010 53 international journal of integrative psychotherapy, vol. 1, no. 2, 2010 54 we were able to explore the script belief that she could not cope on her own, implicit experiencal conclusions, and self regulating fantasies that were stopping her from moving on. over our time together i realised that azra’s physiology changed. she seemed stronger and more upright and her bags seemed lighter and did not seem to weight her down like they had on our first meeting. i had commented then on the heavy weight that she brought in with her. now she was carrying the bags with ease. it seemed that she had shed a heavy load. i contemplated on the fact that it felt that we had come a long way in the six sessions. i was reminded of the card that azra had given to me at the end of the last session. in the card she wrote: “thank you so much for your help and support over the last six weeks. i have come so far in such a short amount of time and i really don’t think i would have done it without your encouragement and support. i know it’s your job but still thank you”. the reason that we had been able to come so far was that we had been able to develop a good therapeutic relationship. by my being consistent, reliable and non judgmental we had built a basic trust and a mutual respect for each other. she had felt able to explore her difficulties and by doing so had felt supported and encouraged. i (like her teachers and joe) had also compensated for the support and encouragement that she had not received from her parents. also, i think azra was in a place where she was ready to and wanting to explore the things that we had talked about and wanted to be able to make changes in her life. it felt good that azra was able to express her gratitude for the work that we had done together. i expressed my appreciation for the card that she had given me and let her know that i would miss seeing her when we had finished. azra realised that she could be in control of her life, and put her needs first. she said that she had decided that she was fed up of feeling sorry for herself. azra started looking for a job in the city where she moved to, near her friends. she joined a muslim dating site, where she could meet someone that she would like and who her family would approve of. she admitted that the fantasy of joe giving up everything and being with her was still there but she was not letting it stop her moving forward. it felt that over the sessions she had grown stronger and she was more confident. my countertransference feelings were that i had been like a mother guiding her and helping her to see how she could move forward and now i was watching her leave home to make a life for herself and i felt sad to see her go. leigh bettles is a bacp accredited counsellor in peterborough, uk. she works in primary healthcare providing counselling for the nhs and also provides counselling for staff and students in a college setting. she has a long association with the cambridgeshire consultancy in counselling. she has a background in psychodynamic and cognitive therapy and is currently completing a two year integrative psychotherapy training programme with richard erskine. date of publication: 31.1.2011 alcoholism is such a common condition that therapists must be exposed to clients who suffer from it, whether the therapist is treatment planning, pacing, and countertransference: perspectives on the psychotherapy of early affect-confusion richard g. erskine abstract: this article is a rejoinder and elaboration on the article “early affectconfusion: the ‘borderline’ between despair and rage: part 1 of a case study trilogy” and addresses the distinction between personality style, pattern, and disorder. it describes the pacing of a time-limited psychotherapy, the use of phenomenological inquiry in resolving transferential enactments, and the psychological function of idealization. key words: psychological functions, personality style, personality pattern, personality disorder, phenomenological inquiry, pacing, time-limited therapy, transference, countertransference ______________________ it is a privilege to join each of my four esteemed colleagues -james allen, grover e. criswell, ray little, and maša žvelc -in this lively dialogue aimed at expanding our collective knowledge about psychotherapy. such a professional discussion provides an opportunity to engage in a meaningful discourse about therapeutic process, exchange theoretical concepts, and arrive at new understandings of clinical involvement. it is always possible to criticize any approach or method used by a therapist if the colleague merely addresses the clinical work from a different theoretical orientation or personal perspective than that used by the therapist or writer. however, each of our four colleagues were asked by the editors, gregor žvelc and marye o’reilly-knapp, to write their personal reactions to the trilogy on “early affect-confusion”, to address the clinical work from other theoretical perspectives, and to focus on what they would have done differently. the result international journal of integrative psychotherapy, vol. 3, no. 2, 2012 26 is this lively discussion. now, i have an additional privilege to write this rejoinder and invite you to engage in this dialogue with us. rejoinder to grover criswell grover criswell begins his discussion with three self-reflective questions. in my first session with theresa i had a version of his first question in mind: “inside of the explosive feelings is there any solidity in her personality structure?” midway through my first session i had two answers to this question: “yes” and “no”. theresa performed well in a difficult yet well-structured job. however, she seemed to lack internal solidity and personal resources when it came to interpersonal relationships. i decided that she did not have the internal solidity to handle varying points-of-view, potential confrontations, and the interpersonal intimacy that existed in my on-going therapy groups. because of this lack of internal solidity i decided to have three evaluation sessions before proceeding with a time-limited individual psychotherapy. grover, you were interested in knowing where in the course of treatment i decided to use the term “borderline”. although theresa met the categorical requirements for personality disorder in the dsm iv, i have not used the diagnostic term “borderline personality disorder” to describe her. a previous psychologist diagnosed her as “borderline psychotic” and a psychiatrist had told her that she had a “bi-polar disorder” that required medication. in this article i used the word “borderline” in two intentional ways: as a metaphor and as an analogy. “borderline” was used as a metaphor to symbolize theresa’s early affectconfusion and delicate balance between despair and rage. “borderline” was also used as an analogy to infer the intricate and adroit task i faced in fostering attitudinal and behavioral change, while keeping the transference just active enough so theresa’s unconscious story could unfold within the healing responsiveness of our therapeutic relationship. and, at the same time, protect her from my potential reactive countertransference – a countertransference that would reinforce her original self-regulating script beliefs and archaic ways of coping. i prefer to think of personality on a continuum from style, to pattern, to disorder. “style” refers to a general way in which the diagnostic characteristics may affect the client’s way of being in the world. a “style” may not be particularly problematic to an individual or to others except when the individual is under extreme stress and may revert to archaic patterns of self-stabilization. clients will reveal a personality style often later in the course of psychotherapy when they describe how they manage a crisis or a family reunion, through dreams or an envisioned future, and through subtle transferential enactments. international journal of integrative psychotherapy, vol. 3, no. 2, 2012 27 a personality “pattern” refers to a more problematic level of functioning on a dayby-day basis in relationship with others. an individual’s repetitive personality pattern is often more uncomfortable to family members and close associates than to the individual who often sees his or her own behavior as natural and ordinary. as disappointment, tiredness, or stress increases, they are likely to revert to archaic patterns of clinging, avoidance, disorganization, or isolation. personality “patterns” become evident early in psychotherapy through the client’s encoded stories, overt transferences enacted in both therapy and in daily life, and the physiological and affective response engendered in the psychotherapist. a personality “disorder” refers to the continual reliance on archaic methods of problem solving and being in relationship. an individual’s archaic form of selfreparation, self-stabilization, and coping is pervasive in nearly every relationship with people and in nearly every aspect of his or her life. clients with a personality disorder will often dramatically enact some element of their life script in their first and subsequent sessions. evidence of the severity of the script may be embedded in the client’s presenting problem, embodied in their physical gestures, and engendered in a strong physical and emotional reaction from the psychotherapist. theresa revealed her intense distress and confusion on the phone, in the first session, and certainly in subsequent sessions. rather than referring to such clients in the diagnostic terms of “borderline” or “borderline personality disorder”, i prefer to use the developmentally descriptive and caringly humanistic term early affect-confusion that describes the relational conflicts and overwhelming affect experienced early in life. theresa seemed to function well when i postponed her discussion of certain issues and limited her expression of emotions. i assumed that she had sufficient internal strength to understand her motivations and to make significant attitudinal and behavioral changes. therefore, i made the decision to see theresa in psychotherapy for only 7 months, from the beginning of october through may. it was precisely because of theresa’s degree of affect-confusion, the potential of perceiving me as either “cold” or rejecting, and her anticipation of not being understood that it seemed necessary to provide theresa with a sense of control by limiting the time of the psychotherapy. by setting a contract for only seven months we had an explicit agreement. she had my commitment for seven months – a counterbalance to the abrupt termination in previous psychotherapies. in addition, i knew that i would be out of the office for twelve weeks beginning in june and did not want to create a situation wherein she would feel abandoned by me. international journal of integrative psychotherapy, vol. 3, no. 2, 2012 28 such time-limited psychotherapy can be particularly effective in focusing on a specific problem, facilitating behavioral change, and in managing incidences of “acting out” what has not yet been resolved in the psychotherapy. time-limited psychotherapy contractually circumvents the client’s predictions of abandonment, provides time for a real therapeutic alliance to develop (if it is going to develop at all), and keeps the therapy focused on specific issues. once the therapeutic alliance is well established and there has been some success, the time frame of the psychotherapy can be extended. with an on-going psychotherapy the focus will primarily be on the transference-countertransference matrix to resolve the primal dramas of early childhood that are being lived out in the client’s interactions with the therapist and /or other people. at the end of may, as we were crystallizing what we had accomplished together, theresa seemed to accept that our therapy contract was at an end. she was pleased with what she had accomplished and was surprised when i offered her the opportunity to continue in september. when theresa voiced her fear of being too dependent on me i had no sense of her being angry. i think she was genuinely afraid of becoming dependent on me, and the potential of being humiliated and abandoned once again by someone on whom she had tried to rely for support, guidance, and protection. i think that it was because she experienced me as reliable and dependable that she was afraid – a juxtaposition reaction (erskine, 1993/1997). rejoinder to maša žvelc maša, thank you for your compliments about my gentle engagement, empathy, and respect for theresa’s needs, feelings, and modes of selfrestoration and self-stabilization. you wanted to know more about my feelings. an element of her was very enduring and evoked in me a sense of caring and protection – a responsive countertransference. alongside that sense of care and protection, i disliked her treatment of others, her aggressive attitude – a reactive countertransference. frequently i found myself in the position of wanting to make humiliating comments; i refrained. yes, on several occasions i experienced her as a “pain in the ass”. i did not feel a desire for revenge but on occasions i did want to push her away. after the sessions i was often glad that she was gone for another week. i kept what you refer to as “forbidden” experiences to myself. i either converted my reactions into a series of inquiries or used them to infer and understand the intrapsychic dynamics between the attitudes that she may have introjected and the needs of a neglected/abused child. i seldom thought of her during my private time. theresa was unlike the clients who are more self-centered and self-righteous whom i often find myself thinking international journal of integrative psychotherapy, vol. 3, no. 2, 2012 29 about between sessions – they appropriate my attention even when i do not want to think about them. i did make it a point to re-read my case notes before each session with theresa so that i would have a clear perspective on what was unfolding in the psychotherapy. i did not have fantasies or fears about her. i had a responsible position that i took seriously. theresa was coquettish, but in what i experienced as a very child-like way, not in a sexualized form. i have had clients who eroticized the therapeutic relationship in order to avoid the heart-to-heart intimacy that was possible. this was not what happened in theresa’s psychotherapy. as i provided attention and responsiveness to her current relational-needs her seductiveness waned. i did not focus on shame; attending to shame during this time-limited psychotherapy would have taken us away from theresa’s cognitive understanding of her behavior. if i had focused on theresa’s shame prior to developing a strong therapeutic alliance, we may have become immersed in her lifelong sense of worthlessness, an immense sadness, and her profound fear of abandonment because of who she is (erskine, 1994/1997). work with her sense of shame would have to wait until she had a secure and dependable relationship with me. my focus was on the original contract of helping her find constructive ways of being in relationships and countering her experience of “no one is there for me” and “no one understands me”. maša, thank you for pointing out an important series of therapeutic transactions that are often very effective in uncovering the internal dynamics in an aggressive transference. i have found it extremely useful to engage in a series of phenomenological and relational inquiries such as: “how do you expect me to respond when you shout at me?” “what were you feeling just before you shouted at me?” “how do you need me to respond to you?” these inquiries invite the client to explore internally, to feel, to remember, and to become aware of what they needed in important interpersonal encounters. i often use these inquires about the present relational moments in psychotherapy; they inevitably simulate affectively-laden memories of earlier relational disruptions. maša, you also point out that i explained to theresa that her feelings and reactions were valid but valid only in another time and context. such explanations are extremely helpful to the client in distinguishing the present from the past, to separate emotional memory from current feelings, and to facilitate her understanding of how the past can be relived in the present. this type of explanation is a momentary step outside the transference-countertransference matrix that typically distinguishes relational psychotherapy. yet, such an explanation is also relational; it provides the client with a cognitive understanding of archaic emotional experience and has the potential of providing a great deal of psychological relief. international journal of integrative psychotherapy, vol. 3, no. 2, 2012 30 our therapeutic relationship required that i help her build a safety net as she walked that emotional “borderline” between acknowledging her unmet needs and angrily attacking people. this required a multipart treatment approach: first, helping her cognitively understand her own emotions and behavior; second, teaching her how to engage in a relationally contactful anger; and, third, validation and normalization of her relational-needs. rejoinder to ray little ray, i liked the way you began your reaction paper by emphasizing that any case presentation is from the “therapist’s particular clinical perspective”. i would like to add that both the case presentation and how we respond to each other is also formed out of the each person’s autobiography – the theories, concepts, methods, individual proclivities, and ways of being-in-relationship that we each value. therefore, no two psychotherapists will ever do the exact same type of therapy. i am excited by your answers to the question: “how do you see this case differently than me and what would you have emphasized?” it was predictable that theresa would eventually perceive me as cold and critical of her, rejecting and demanding, like she experienced significant others in many previous relationships. i wanted to minimize that possibility during this timelimited psychotherapy and reserve the working through of the unconscious story being enacted in her aggressive transference until we had established a secure working alliance. in the first few months i was not certain that i wanted to continue with her after the seven-month period of contracted time. was this engendered reaction a resonance with her pre-symbolic and implicit memories or an attunement with introjected emotions of a significant other in her life? or both? your writings on psychotherapy theory would imply both of the above (little, 2006, 2011). in addition to the above-mentioned countertransference, i suspected that she might terminate the therapy at any time. therefore, i focused on what she needed in our immediate relationship. parallel to these two thoughts was the realization that a psychotherapist mindful of the intense emotionality and relational degradation that is part of early affect-confusion would not address the deep-seated affects of terror and pain entrenched in the aggressive transference until there is a well-established secure working alliance. ray, you picked up on the various forms of idealization that were evident in theresa’s story. i think of idealization, as in theresa’s situation, as an unconscious desperate call for acceptance by a stable, dependable, and protective other person. it reflects a normal developmental need to look up to and rely on parents, elders, teachers, and mentors. the relational-need for acceptance by a consistent, reliable, dependable other person is the normal international journal of integrative psychotherapy, vol. 3, no. 2, 2012 31 search for protection and guidance that is often manifested as an idealization of either the psychotherapist or another significant person. idealization frequently reveals a search for protection from one’s own escalation of affect or exaggeration of fantasies. in psychotherapy such idealization most often represents the search for protection from a controlling, humiliating parent ego state’s influence on the vulnerability of child ego states. i think these two concepts are what you mean by “an idealized needed relationship” and a “protective self-other relational unit”. in your article, “ego state units and resistance to change” (little, 2006), you clearly describe how various child and parent ego states are linked by affect into relational units – physiologically/affectively infused implicit memories of intolerable, traumatic experiences that become fixated as a child ego state with a corresponding introjection of a significant other. i agree with your statement, ray: “in general at the beginning of therapy i do not make historical inquiries. i stay with current affect, and wait for mention of childhood experiences that are connected with the present experience with me. in this way i have an affective understanding of the present moment through the client’s historical associations. my focus is on phenomenological inquiry.” this is the position i usually take with most clients and recommend to my trainees and supervisees. yet if cognitive mastery and behavioral control are necessary to establish a working relationship, as was the case with theresa and other clients who suffer from early affect-confusion, then it seems absolutely necessary that the client be able to distinguish the past from the present. please see my comments about this in my notes to maša. theresa did scoff at my attempts at empathy. i have found that such juxtaposition reactions are usually an indication of three factors: the existence of an avoidant or disorganized attachment pattern; an indication that the psychotherapy is proceeding too rapidly; an indication that the level of interpersonal contact is too rich or some combination of the three. the client is not able to tolerate the quality of contact and therefore acts as though she/he is pushing the psychotherapist away. in actuality the client may be pushing affect-laden implicit memories away. a client’s juxtaposition reaction can create a reactive-countertransferential trap if the psychotherapist is invested in creating intimacy and then has his or her attempts rejected. understanding the significance of juxtaposition reactions is an important aid in working with clients who suffer with early affect-confusion. with theresa i took her scoffing at my empathy as an indication that i was providing a therapy that was too intimate too quickly. it was my responsibility to slow the pace of the psychotherapy and/or dilute the affect intensity of our interpersonal contact. i did not put any emphasis on “her self-reliant defenses” but rather took the responsibility to pace the therapy at her rhythm of integration. the locus of international journal of integrative psychotherapy, vol. 3, no. 2, 2012 32 responsibility is with me, the psychotherapist, and not on defining the client as acting defensively: i think that this respectful position is the essence of a relational psychotherapy. ray, i did state that it was important that theresa “eliminate her aggression and fighting with people” as a preparatory stage in the psychotherapy. her conflicts with people constitute the transferences of everyday life. every conflict is an enactment of both her anger at and rejection from her mother. but, as long as she was involved in such current conflicts with coworkers and her boyfriend, all the therapy time would be absorbed by current extraneous events and we could not do the in-depth psychotherapy that was sorely needed. i certainly noted for further attention that theresa’s reporting of each of her current relational conflicts most likely represented an encoded story about her early life. ray, you end your commentary by saying “my approach would be to stay in the present moment, working with the past in the present and drawing the critical aspect to me.” this is certainly an important and necessary way in working with many clients. with theresa such interpersonal-contact was essential in the next stage of therapy once a secure therapeutic alliance was firmly established. as you read the ongoing case, there will be many instances of working within a relational context – in the present moment, with full interpersonal-contact. rejoinder to james allen jim, i was touched by your opening comment regarding the need of many people around the world to experience a healing therapeutic relationship. as a profession we need to develop a short-term psychotherapy that provides clients with many of the components of a healing relationship. perhaps a part of the solution lies in the moment-by-moment interpersonal-contact, respect, attunement, and validation that an involved psychotherapist can provide. as i began this therapy with theresa i expected that it would last only a few months and that i had to do my best to make our time together as productive as possible. that meant creating a respectful, caring, and involved relationship while helping her think about her feelings and behavior in order make a distinction between archaic experience and the current situation. jim, you say that the case study of theresa provides “a complexity that recent research in early child development and underlying neurophysiological activations inform.” i would like to hear more of your ideas and how you think about this “nuanced complexity”. you capture my experience in writing about this case when you say, “i became deeply aware of my dependence on international journal of integrative psychotherapy, vol. 3, no. 2, 2012 33 non-verbal communications and signals from the patient – shifts in the tone of voice, breathing, subtle distancing – and my own somatic resonance, and efforts to lift these from non-symbolic to verbalizable symbolic status. all this, of course, is very difficult to describe words”. as i re-read theresa’s case study many months later i am struck by how much i did not say and could not describe in words. theresa had a variety of gestures and distorting facial grimaces when describing her conflicts with her boyfriend and coworkers. these distorting body movements were uniquely different than when she was being coquettish or when we were problem-solving together. many of theresa’s gestures were pre-verbal, sub-symbolic, and implicit expressions of the distress of a little child. i am continually impressed in how the client’s unconscious early childhood story is embodied in the client’s current physiology. in writing this case study i only attended to those details that were obvious and provided only the information that communicated the general style of the therapy. i realize that there is so much more to tell. one of my failings, and perhaps you experience it as well, is the inability to attend to all that is emerging in any session. there is always so much is happening all at once: the ostensible story the client is telling; the relational experiences being revealed through the style of the client’s narrative; the primal dramas that are being lived out through the client’s behavior and transactions; what the client is unconsciously revealing about his or her relational history through gestures and physiological reactions; what is being engendered in me, either reciprocally or reactively; jim, i use the term “early affect-confusion” to describe the internal distress of a toddler age child. when caretakers are experienced as the only source of needs satisfaction and simultaneously as a source of danger, the child is left with disturbing confusion. there is often no one who notices the child’s distress, who provides safety, who helps the child express what he or she is feeling, and who helps make sense out of an emotionally overwhelming experience. this is what we psychotherapists do many years later in a relationally focused psychotherapy: identify and take the distress seriously; create security-in-relationship; provide an attuned responsiveness to affect expression; and, co-create language and concepts that provide new meanings. jim, you were curious as to why i found it important to have theresa look me in the eyes so that she could see that i was taking her anger seriously. to international journal of integrative psychotherapy, vol. 3, no. 2, 2012 34 some degree this was influenced by my attunement to her level of development, her affect, her sense of helplessness, and her core belief “no one is there for me”. she did not yet have the internal security and relational support to express her anger directly to a fantasized image of her father. i was concerned that she would become overwhelmed with helplessness and fear of rejection. she needed to express her anger in a way that provided her with a sense of making an impact on the other person. so instead of having her face an image of her father, i asked theresa to look me in the eye and express to me the intensity of her anger. a theoretical perspective was also in play: to make an impact on another person is an essential relational-need. it seemed important that theresa see my eyes and face as she clearly expressed what she did not like and observe the impact she made on me. if we did this work in fantasy, with an empty chair, she may never have had the sense of making an impact. in the following sessions we talked about how she felt when she could see the reactions in my eyes, my accepting her anger seriously, her new experience with a contactful anger, and how it was different from her habit of helplessly raging at people but never making the quality of impact she needed. theresa made many changes in the first year. her therapy shifted from blaming others to taking a small amount of responsibility for her behavior. she began to realize that her emotional states were child-like in origin and were an attempt to tell a desperate and very meaningful story. my feelings toward her were softer and more paternal. she was not acting out the relational conflicts that were so time-consuming and distracting from the in-depth psychotherapy. theresa was ready to terminate our time-limited therapy; she had gained insight and changed her behavior. yet, i thought it was time to offer theresa an on-going therapy to resolve the internalized relational disturbances that maintained her early affect-confusion. when making the offer that theresa continue the psychotherapy, i did realize that we may be engaged in a serious psychotherapy for a number of years. theresa was reluctant to engage in an in-depth psychotherapy because she was afraid to become dependent on me – a fear of repetition of the humiliation and rejection she had known throughout her childhood. thank you, grover, maša, ray, and jim, for your insights and thought-provoking questions. i look forward to our continuing dialogues as we discuss parts 2 and 3 of this trilogy on early affect-confusion. international journal of integrative psychotherapy, vol. 3, no. 2, 2012 35 international journal of integrative psychotherapy, vol. 3, no. 2, 2012 36 author: richard g. erskine, phd. is the training director at the institute for integrative psychotherapy. he writes extensively about various aspects of relational and integrative psychotherapy and conducts training programs and workshops in several countries. other articles are available on the website: www.integrativepsychotherapy.com references erskine, r. g. (1993). inquiry, attunement and involvement in the psychotherapy of dissociation. transactional analysis journal, 23,184-190. republished in theories and methods of an integrative transactional analysis: a volume of selected articles (pp.37-45). san francisco: ta press. erskine, r.g. (1994). shame and self-righteousness: transactional analysis perspectives and clinical interventions. transactional analysis journal, 24, 86-102. republished in theories and methods of an integrative transactional analysis: a volume of selected articles (pp.46-67). san francisco: ta press. little, r. (2006). ego state relational units and resistance to change . transactional analysis journal, 36, 7-19. little, r. (2011). impasse clarification within the transference -countertransference matrix. transactional analysis journal,41, 23-38. date of publication: 25.12.2012 international journal of integrative psychotherapy, vol. 8, 2017 1 relational methods and theories of intersubjectivity jose manuel martinez rodriguez abstract: the set of relational methods outlined by integrative psychotherapy provide a comprehensive guide for intersubjective treatment. research in child development has stressed the importance of intersubjectivity for the establishment of healthy reciprocal relationships. several models of psychotherapy have adopted an intersubjective approach to address relational problems. the relational methods of integrative psychotherapy put into practice many insights emanating from research regarding the origins of intersubjectivity in child development. this article focuses on meltzoff, moore, threvarthen, stern and rizzolatti´s theories about intersubjectivity and their relationship to the relational methods of integrative psychotherapy. meltzoff and moore´s studies of the development of intersubjectivity in childhood can be related to psychotherapeutic interventions at a clinical level based on the presence of an involved other. threvarthen and rizolatti´s research supports the need to resonate with other’s experience through self-experience, and stern´s theories are related to the inquiry about the other´s mind. such interventions contribute to building an intersubjective format in individual psychotherapy and may prove useful in helping people with early relational failures and the subsequent disruptions to the development of healthy intersubjective aspects of relationships. key words: integrative psychotherapy; intersubjectivity; relational psychotherapy; inquiry; attunement; involvement; individual psychotherapy international journal of integrative psychotherapy, vol. 8, 2017 2 introduction my work with children and adolescents with severe problems in communicating and engaging in reciprocal social interaction has led me to focus on the use of relational methods to help them improve their awareness of inner needs, urges, thoughts and feelings, and their consideration of other people needs. most of these children and adolescents lack proper development of their experience of a subjective self (stern, 1985) and are arrested at an experience of primary intersubjectivity (meltzoff & moore, 1994), thus requiring mostly external regulation to tolerate their affect. the use of relational methods helps them to improve in intersubjective relationality. keeping a focus on this kind of relationality occurs through the use of relational methods with adult clients suffering from early relational disruptions. therefore, it is fitting that we would apply this approach to younger clients as well. an intersubjective approach requires the therapist to be aware of his/her own experience and the way this influences what is happening in the therapeutic relationship. therapist involvement and intersubjectivity several researchers on child development (meltzoff & moore, 1977, 1994, 1998; trevarthen & hubley, 1978; trevarthen, 2004, 2005, 2011; stern, 1971, 1977, 1985; stern et al. 1985) have proposed different theories regarding the origin of intersubjectivity. although these authors hold significant differences, they share some similar ideas that are worth noting (beebe et al., 2003). one of the shared standing conclusions is that the presence of an involved other is a prerequisite for the development of innate intersubjective resources and is therefore a crucial component for our clinical practice with severe relational disruptions. as integrative psychotherapists, we pay attention to the quality of the therapeutic relationship in the present as a therapeutic tool (erskine & trautmann, 1996). in some ways, this may be understood as different from the neutrality expected in the past from psychodynamic therapists. for our purposes, neutrality could potentially reduce the new attachment within the therapeutic relationship (amini, 1996). for example, imitation of an “other” by babies is considered by meltzoff & moore (1977) an inchoate intersubjective relationship. they have proposed the idea of an innate relationality between self and other based on the perception and production of similarities. in early severe relational disruptions, we can observe the important role of subtle imitation in the therapeutic relationship as demonstrated in the following clinical vignette from my practice. international journal of integrative psychotherapy, vol. 8, 2017 3 paul came to my office with his parents who were looking for treatment for attention, communication and reciprocal interaction problems, previously diagnosed as autism when he was four years old. paul is now 9 years old and speaks in an affected and robotic way. he seems to be an adult. i observe the way he unconsciously imitates my gestures, for example, the way i am leaning my finger against my temple while i am listening to him. he is fascinated with dinosaurs. after watching films, he imitates their sounds, studies their movements and makes them during the therapy session. he puts his tongue out as a lizard and growls as a dinosaur. paul says, “i keep them in my brain and they help me do my exams. sometimes i chase them out because i don´t need them.” during the therapy session, he reaches out his hands to me and then“lends me” the soul of an anchilosaur. then i give it back with my hands. he picks it up and sucks it out as if it was a material substance. he seems to be possessed by the dinosaur while he is growling and moving like an animal in my office. then he tells me that the dinosaur has fallen asleep inside his body. paul is not interested in inventing stories about dinosaurs and playing with other children. he is instead fascinated with them and imitates them. he likes “becoming them.” i feel that as he is identifying with them, as he “absorbs” their qualities, his experience becomes regulated by the “souls of the animals.” it seems to me that this helps him experience a feeling of agency and power that reinforces his nuclear self (stern, 1985). he observes the coherence of their movements, their heaviness and strength. watching his imitations, i am able to build a proprioceptive representation of his experience and his need to build a feeling of coherence, agency and continuity. he teaches me during the sessions his need for imitating and i experience the proprioceptive other that he is for me. we relate through a primary inter-subjective experience. researchers meltoff and moore (1977, 1994, 1998) found that children 1221 days old were able to imitate the facial expressions of adults with their own facial expressions, obviously in the absence of any ability to see their own facial expressions. they concluded that neonates have the innate capacity to build representations from visual and proprioceptive information by means of an abstract, transmodal representational code, common to both sensorial modalities that allow the matching of both systems. they concluded that there is an innate ability to use intermodal equivalencies in human beings (meltzoff & moore, 1977, 1997). in addition, these authors have also shown that the capacity for imitation is already possible at 42 minutes after birth. thus, they say that pre-symbolic representations begin at birth (meltzoff, 1994, 1998), and are the origin of presymbolic intersubjectivity; the feeling state of the “self” as the child tries to coincide with the other in an intentional way. the neonate perceives correspondences international journal of integrative psychotherapy, vol. 8, 2017 4 between self and the other since the very moment of birth. these correspondences provide mother and child with a common language, and moments of intersubjective contact since the beginning of life. the baby accesses the other in a direct way through the self-proprioceptive perception of transmodal correspondences. each of the participants in the relationship can feel the other´s state by means of such correspondences a concept that is central in supporting the psychotherapeutic interventions and the relational methods in integrative psychotherapy. the client needs an involved other in order to begin this kind of mutual pre-symbolic exploration. neuroscientific research, in the form of functional neuro-imaging brain studies, has shown that two-month old babies have innate neurobiological devices that allow for an intersubjective relationship. these studies demonstrate that when these young babies see a person´s face communicating with him/her, the cortical areas known to respond in adults for face recognition are activated (tzouriomazoyer et al. 2002). in addition, some aspects of primary intersubjectivity in psychotherapy can be understood as a part of what is called projective identification (martínez, 2013). the following clinical observation from a therapeutic session with a client from my practice illustrates this: in the first interview with a client i notice, while she is speaking, the swaying and monotonous way she moves her shoulders and head. i also find remarkable her monotonous and rhythmic tone of voice. as i follow her movements i become aware that i am observing myself and that i am feeling her at a distance. it is like a light depersonalization experience. then she tells me: “one of the things that upsets me the most is feeling myself distant from people and finding me observing myself… people don´t notice it, but i think you are going to perceive it because it is happening right now…” attunement and intersubjectivity attunement to the experiences of a developing child provides another foundation on which to build an intersubjective world. trevarthen (1974, 1978, 1980, 2004, 2011), another researcher on child development, also supports an innate theory of intersubjectivity. much of trevarthen’s research (2005, 2011) is very relevant to psychotherapy practice and the creation of an intersubjective approach. his research suggests that people have an innate conversational mind since birth. trevarthen (2004, 2011) comments that human beings are born not as individuals but as social beings in search of other human beings willing to participate in reciprocal imitation and the mutual regulation of life activities. this international journal of integrative psychotherapy, vol. 8, 2017 5 theory is similar to fairbairn´s concept that human beings are born looking for relationships (fairbairn, 1952). trevarthen has shown that mother and baby behave in a rhythmic way, and adjust their rhythm and sequence of movements to advance together a dialogue without words, by means of alternating and synchronizing their movements and generating cycles of affirmation and understanding, of stimulation and response. throughout these cycles mother and child celebrate the fluctuations between effort and pleasure and share an affectionate comradeship. trevarthen (2005, 2011) makes a distinction between “primary intersubjectivity” and “secondary intersubjectivity.” the first is observed at birth and refers to the co-ordination of self and other based on shape, synchronicity and intensity correspondences, as we have seen in the case of paul. this form of primary inter-subjectivity is shown in the “proto-conversations” between baby and mother. secondary inter-subjectivity is developed from 9-12 months and is related to the co-ordination of self, other and an outside object, through a co-operative exchange of referential gestures about that object (trevarthen & hubley, 1978; hubley & trevarthen, 1979). this kind of secondary intersubjectivity is observed in the shared focus with our clients, as we can see in next clinical vignette. lewis is 14 years old and very fearful of being alone. he comes into my office with an object: a dog chain for two dogs. in the previous session, i asked him to bring an object and a story. he hasn´t written the story but has brought with him the object. at first i think it could be a way of self-definition that he still needs his mother. he tells me he has nine dogs. he uses the chain to walk a puppy and its mother. “the mother is very good … when she dies i will stuff it….” “it`s like a relative, all it needs to do is speak… it cares about me and loves me when i feel bad…. when i am sad, or upset or angry.... and also loves me when i`m happy…” i also have a three-legged dog that would die for my father…” lewis helps me to learn how important it is that someone respond to his need for inter-subjective attunement via an attuned relationship that helps him regulate his internal states someone who responds to him like the mother dog to her pup. this is the focus of interest that he shares with me, and the outside object that he wishes us to watch together. i also understand that it is very important for him to have someone so involved with him, that s/he would give his/her life for him. psychotherapy can be understood as a process of creating a new attachment relationship; one that is able to regulate affective homeostasis and the restructuring of implicit memories of early relational attachments (amini, 1996, gabbard, 2000, erskine, 2015). therefore, it is important that therapeutic international journal of integrative psychotherapy, vol. 8, 2017 6 interactions focus not only on symbolic language, but also on affective communication through body resonance, tone of voice and sensorial channels. from this point of view, we, as integrative therapists, focus not only on the explicit memories but also on the implicit memories (erskine, 2014), and the way they unconsciously organize and structure the procedural field of clients in their relationships. dialogues without words: a tale by cervantes dogs have been a symbol of friendship for centuries. they have been known to demonstrate that intense friendship at the graves of their dead owners, as documented in stories of dogs laying, pining next to their owners` graves, even at the risk of starving. clients who relate to puppies demonstrate some of the attunement they need, in the presence of difficulties with intersubjective relating to humans (stern, 1985). there is a tale by cervantes that makes possible a shared fantasy of most dog owners. this shared fantasy is that “all dogs need to do is speak” and that they are capable of intersubjectivity, even though they lack language. it is said that freud wanted to learn spanish so he could read “el coloquio de los perros,” one of the “novelas ejemplares” of miguel de cervantes (1613), written in valladolid. the story takes place in the ancient misericordia hospital of valladolid. in cervantes´ story, the two dogs cipión and berganza, are able to speak and dialogue for the first time one night. as they say, “in short we will show that we have some understanding and are able to write a speech.” “we do not only speak, but we speak making a speech, as if we are able to reason.” (cervantes, 1922, 2015, p. 225). cervantes used the model of dialogue to express this fantasy of inter-subjectivity with dogs. the form used to express the message, as well as the content, both fit. in their dialogue cipión tells berganza the need he has had for a long time ago to express events kept in his memory memories that the lack of language prevented him from expressing. “i always considered you cipión as discreet and a friend, and now more than ever, since you, as a friend of mine, want to tell me your events and know mine…” (cervantes, 1922, 2015, p. 227). cipión and berganza also talk at night. they can´t sleep, and as a consequence they can´t dream. perhaps dreams are an alternative route that the mind follows when it is impossible to process emotional and body experiences in an intersubjective context. during psychotherapy clients bring us their dreams, and in so doing, tell us some stories they can´t put into conscious language. international journal of integrative psychotherapy, vol. 8, 2017 7 in psychotherapy, we may engage in a kind of dialogue without words where movements, tone of voice, modulation, sitting next to the client, and/or staring, become a kind of dialogue without words, serving an important intersubjective and attachment function. this dialogue must be congruent with our words. in some cases, words are not needed to help clients to increase their intersubjective awareness and to get in touch with inner relational needs, especially the relational needs of security, validation, self-definition and initiation by another. attunement and regulation of affect a variety of studies have demonstrated that interactions in the first months of life between mother and child are similar to how attunement can be used as a relational method in psychotherapy. trevarthen (2004, 2011) contends that during shared behavior and games between mother and child there is a syntax of awareness and intentions in the body movements and in the voice. that syntax supports the learning of linguistic representations and the development of knowledge and skills before language acquisition. intersubjective co-ordination is produced through a temporal dimension of shapes and intensity. in psychotherapy, developmental attunement requires that we co-ordinate our verbal interventions, tone modulation and intensity of voice and movements with those of the client in a kind of syntax without words similar to that described between mother and baby by trevarthen (2004, 2011). rhythmic attunement requires that we coordinate with the physiological and emotional rhythm of the client. this allows us to hold early affective states in the context of a relationship. mackain, stern, goldfield, & moeller (1985, as cited in beebe, b., sorter, d., rustin, j, & knoblauch, s., 2003) have shown that nine-month-old babies who were separated from their mothers and then allowed to return, abandoned their protest immediately, but persisted in maintaining a serious mood. at that moment, they preferred to watch a sad face instead of a happy one, which is an example of the baby’s need for affective attunement. in similar ways, cognitive attunement allows us to understand a client´s way of processing and of building thoughts, and his/her own syntax of events. attunement to the relational needs for affective and cognitive understanding also contributes to the holding and regulation of early ego states, as described in transactional analysis. in the following clinical vignette, we can see the client´s need to be attuned to his characteristic style of processing affect and memories. thomas is 16 years old. he experiences an overwhelming rage in his relationships. in a previous session, he experienced alternating waves of irritability international journal of integrative psychotherapy, vol. 8, 2017 8 and rage following a rhythmic pulse while sharing traumatic memories that are besieging him. the therapeutic relationship has become a place where he can get in touch with over stimulant memories without acting out. in today´s session he feels bothered by these kinds of memories that he tells me one by one. i learn that if i make an intervention his rage and agitation will increase. he would feel bothered by me, as if i were another irritating stimulus. i feel that his need of an “other” that helps him to regulate his emotional state by listening in an attentive way, validating and holding, is much more important than the content. the process is the content. this kind of attentive listening helps him to relieve his internal overstimulation. step by step he starts in the session to recall more and more distant memories following the “rhythmic pulse” above mentioned. close to the end of the session he is beginning to connect with more positive memories like staying at his grandfather´s home. slowly his face is becoming sad. sadness is fighting against rage. “i had a good time there when i was a child… better than nowadays… when my grandfather took me to the swimming pool or to have a ride on a bicycle. when my grandfather saved a dog from drowning… i also miss when i hung out with my friends in the park… now my friends smoke cannabis and fight each other…” finally, he connects with a positive memory of his mother during the last summer at the beach. she was recording him while he rehearsed a gymnastic routine he had created. “i smother my friends like my mother does with me…” trevarthen (2004, 2011) has demonstrated the innate way that adults and infants co-ordinate their behavior, as if matched with pacemakers or neuronal watches, so that predictable cycles of behavior occur at an adagio rhythm, one movement every 700-800 milliseconds. trevarthen (2011) says that we directly feel how another´s movements are being regulated. therefore, intersubjectivity plays an important role both in upbringing and psychotherapy. we can say that we are born ready to link to the other through the intersubjective circuits of our brain. several neurobiological and neuroimaging studies show that the essence of the brain is deeply intersubjective (fuchs, 2004). some researchers state that mirror neurons could be seen as the “biological correlates” (wolf et al., 2001) of the correspondences described by meltzoff, trevarthen and stern (beebe et al. 2003). the mirror neurons have been proposed to be the substratum of intersubjective attunement. the italian researcher rizzolatti discovered that the electrodes implanted in the motor cortex of a monkey were activated while watching the researcher grab objects. rizzolatti and his colleagues concluded that there are kinds of motor-visual neurons in the premotor cortex which are activated both when a monkey carries a goal directed action and when the monkey simply watches the same action executed by another (rizzolatti et al., 1995; rizzolatti et al., 1996; rizzolatti & arbib, 1998; pally, 2000). international journal of integrative psychotherapy, vol. 8, 2017 9 the research noted above indicates the importance of developing therapeutic skills that enhance and maintain attunement to the client in the psychotherapeutic process. this is especially important with the modalities of body work, and is crucial in the treatment of people with early severe relational trauma, high levels of dissociation and/or disconnection from body experiences, often present in cases of physical and sexual abuse, and/or suicidal risk (martínez & fernández, 2013). in this next clinical vignette, that of a client who suffered sexual abuse in childhood, we can see the importance of attunement in clinical practice. in the last session before my vacation fritz comes to my office with a big bull mastiff which allegedly he couldn´t leave with anybody. he also asks me to allow the dog to stay with him in the room during the session. “he can`t stay in the waiting room while i am in the session because he`ll bark if he feels alone.” i feel surprised and remain pensive trying to understand the meaning of what is happening. after some thought, i think there might be something important to it and i grant his request. the dog is gasping for breath and almost agitated while his owner is quieter than ever. i think of the past of sexual abuse that fritz suffered for a long time in childhood committed by several adults. during the session, fritz talks about a part of himself he has felt for years as evil and deviant. now he experiences it more as an “innocent” part that was repeatedly sexually abused and “corrupted.” he wonders about the motivation of his abusers. during the session, i observe that the bull mastiff is becoming calmer, his transpiration and panting becoming less intense. at the same time, fritz´s stress increases. we talk about the function that abuse has for child abusers and its process of transmission from one generation to the other. at the same time, i become aware that bringing the dog with him is a way of showing me his “devil and furious” part, and also a way to express his fear of the therapeutic relationship and his need for protection. it is also a way of talking about his anger at “being alone” with his memories during my vacation. i also understand the way my client would have felt like a “pet” for his childhood abusers, a carnal object for the sake of them. he has also built ambivalent relationships where he in turn has abused others to calm himself. inquiry and intersubjectivity in my experience, inquiry helps those clients with reciprocal social interaction and intersubjective problems to acquire a sense of their own mind, as well as that of others. intersubjective inquiry moves the therapist out of an interpretive role, and places him in a role of curiosity, interest and respect for the other´s experience. erskine (1993, 1997, 2015) and erskine, moursund and international journal of integrative psychotherapy, vol. 8, 2017 10 trautmann (1999) have clearly described the function of inquiry as a way to help the person expand his/her awareness, rather than a way for the therapist to merely gain information. this author has also talked about the importance in the therapeutic process for the therapist to get beyond the idea that s/he “knows something” about the client, and the importance of continually renewing the cycle of inquiry during the therapy process. in this way, inquiry (erskine & trautmann, 1996) is used as a kind of dialogue to help increase the client’s own self awareness, as well as our awareness and understanding of the client. from my point of view, inquiry is an essential intervention that helps patients who are anchored to archaic experiences, to elaborate a theory of themselves through the mind of another, as postulated by baron-cohen, leslie, and frith (1985), fonagy & target (1997) and fonagy, gergely, jurist & target (2004). through the process of inquiry, they receive a mirroring of their own mind and of themselves as agents of thoughts, feelings, desires, needs, wants and expectations. for some clients, inquiry may be a unifying mirroring experience, as experienced through the ongoing genuine interest of the therapist who strives to understand him/her through an exploration of affective, cognitive, physical and behavioral experiences. stern (1985) postulates that intersubjectivity is fully present at the end of the first year of life, placing this later than meltzoff & moore, (1977, 1994, 1998) and trevarthen (2005, 2011). he proposes that between nine and twelve months the infant discovers that he has a mind, that others have a mind and that internal experience can be shared. he describes three types of intersubjectivity: shared attention, shared intention and shared affectivity – also known as “interaffectivity” or “affective attunement.” mental “self” and mental “other” at this time of development could be attuned or not, and thus affecting the opening of the field of a shared internal universe (stern, 1985). intersubjective inquiry implies a focus of shared attention, a shared will and an attunement to the client’s experience. the relationship itself and the factors that affect therapeutic experience also become the focus of intersubjective inquiry. one of my clients demonstrates his personal search for a relationship where mutual inquiry takes a main role. edgar is twelve years old. behind a gentle and delicate presence there is a great stress and shame that comes to the surface through his blushing cheeks. since he was three years old he has perceived himself living in two different dimensions at the same time. he talks with his parents, teachers or watches a film with his peers in one dimension. in the other he interacts at the same time with some characters, so he experiences two superimposed scenes. he sees all the time the characters of his second dimension international journal of integrative psychotherapy, vol. 8, 2017 11 and can keep simultaneous conversations with them and his real-life interlocutors. there is a character he calls “the master” that gives him advice on behaving properly, teaches him strategies to keep calm and helps him to sleep. “the master” and other characters want to prevent him from doing things wrong and give him rewards for good behavior. they want him to progress and become a better person. he feels they organize his mind and keep their memories in different files. he usually asks them questions about scientific issues that he doesn´t understand very well and which his parents do not know about. his characters give him an answer and, if needed, they call famous researchers like newton or einstein to teach him. he kept hidden the experience of his parallel world until some months ago. one day he brought to the session a drawing with two vectorial fields that meet at a black hole where they stop being separated surfaces. next to the drawing he has delineated a mathematical equation to explain the possibility of that confluence. the story of edgar makes me think about a misalignment with his parental figures and his sense of the impossibility in sharing some experiences, especially his belief that he is different and his compensatory wish to be someone important in science. through equations he tries to find a way to connect the two separate dimensions he experiences in his daily life. his father doesn´t understand the relational needs implicit in his fantasies and instead tries to show him the impossibility that he can understand particular scientific concepts at his age. this reinforces his belief of being different and not belonging. his father is a man with a practical, concrete stance in life, who is frightened of his son´s fantasies. in therapy i inquire about his fantasies, his feelings, and together, we look for their meaning in order to help him connect with his needs in the here and now. interestingly, stern (1985) doesn´t consider affective attunement as equivalent to empathy. instead he thinks it is an affective transaction by itself that doesn´t need to focus on empathic understanding. he believes affective attunement evolves through more elaborate forms of empathy, in which cognitive aspects play an important role. while attunement takes place mainly in an automatic and unconscious way, empathy requires the mediation of cognitive processes (basch, 1977). in integrative psychotherapy, the inquiry into another´s experience involves attunement and a developmental approach. this becomes a secure and protective frame for the person to get in contact with his/her thoughts, sensations, feelings, experiences and expectations and build a mental representation. fonagy and others (fonagy & target, 1997; fonagy, gergely, jurist & target (2004), have related mentalization to intersubjectivity and the ability to regulate emotions. international journal of integrative psychotherapy, vol. 8, 2017 12 hawkes (2011) describes that mentalization implies meaning making and metabolizing experiences. she thinks that secondary intersubjectivity implies the ability to build a representation of self as a person between others, instead of feeling like the center of the world, and that others are satellites. this also implies building a theory of the other’s mind and acceptance of that, instead of projecting and “reading other´s minds,” which she considers a failure in intersubjectivity (hawkes, 2011). conclusion relational methods in integrative psychotherapy put into clinical practice many of the insights derived from research about intersubjectivity in child development. meltzoff, moore, trevarthen, stern and rizzolatti´s research into the development of intersubjectivity in child development seems to be strongly related to, and support, the relational methods of integrative psychotherapy. in particular, meltzoff and moore´s studies are related to the need for the presence of an involved other to reach optimum intersubjectivity. the related subset of methods in integrative psychotherapy, such as acknowledgment, validation, normalization and presence, become important components in creating an intersubjective format in treatment. the need to attune to a client´s experience, as seen by trevarthen, is crucial to the development of primary intersubjectivity in early development and is an important part of relational methods. rizzolatti´s discovery of mirror neurons is the neurobiological foundation of empathy and attunement. stern´s description of the intersubjective self is linked to the infant´s discovery that he or she has a mind, and that other people also have minds. the subset of methods related to the process of inquiry in integrative psychotherapy, put into practice the need to understand the thoughts, feelings, behaviors and body reactions of the client as coming from a different mind. relational methods as a whole can be seen as a guide to intersubjective treatment, and are especially useful in helping clients suffering from early relational failures that have affected their intersubjective relating. author: josé manuel martínez, m.d., is a certified trainer/supervisor and certified integrative psychotherapist for the international integrative psychotherapy association (iipa) and a certified trainer/supervisor and transactional analyst for the international transactional analysis association (itaa) and european association for transactional analysis (eata). he serves as an associate international journal of integrative psychotherapy, vol. 8, 2017 13 professor of psychiatry in the psychiatry department at the school of medicine of the valladolid university. he works with children, adolescents and adults and is the director of the institute of transactional analysis and integrative psychotherapy (iatpi) in valladolid, spain. e-mail: inst.atpi@gmail.com references amini f., lewis t., lannon r., et al. (1996). affect, attachment, memory: contributions toward psychobiology integration. psychiatry, 59, 213–239. baron-cohen, leslie, and frith (1985): does the autistic child have a “theory of mind”? cognition, 21 (1985) 37–46. basch, m. (1977). developmental psychology and explanatory theory in psychoanalysis.the annual of psychoanalysis, 5: 229-263. beebe, b., sorter, d., rustin, j, & knoblauch, s. (2003). a comparison of meltzoff, trevarthen, and stern. psychoanalytic dialogues, 13, (6), 777-804. cervantes, m. (1922): novelas y teatro. madrid: instituto escuela. biblioteca literaria del estudiante. erskine, r. g. (1993). inquiry, attunement, and involvement in the psychotherapy of dissociation. transactional analysis journal, 23, 184-190. erskine, r.g. & trautmann, r.l. (1996). theories and methods of an integrative psychotherapy.transactional analysis journal, 26(4): 316-328. erskine r.g. (1997). theories and methods of an integrative transactional analysis: a volume of selected articles. san francisco: ta press. erskine r.g., moursund j.p. &trautmann r.l. (1999). beyond empathy: a therapy of contact-in-relationship. new york: routledge. erskine, r.g. (2014). nonverbal stories: the body in psychotherapy. international journal of integrative psychotherapy, 5, (1), 21-33. erskine, r.g. (2015): relational patterns, therapeutic presence. london: karnac fairbairn w.r.d. (1952). an object-relations theory of the personality. new york: basic books. fonagy, p. & target, m. (1997). attachment and reflective function: their role in self organization. development and psychopathology, 9, 670-700. fonagy, p., gergely, g. jurist. e. & target. m. (2004). affect regulation, mentalization and the development of the self. new york: other press. fuchs, th. (2004). neurobiology and psychotherapy: an emerging dialogue. current opinion in psychiatry, 17, 479–485. gabbard g.o. (2000). a neurobiologically informed perspective on psychotherapy. thebritish journal of psychiatry, 177, 117–122. international journal of integrative psychotherapy, vol. 8, 2017 14 hawkes, l. (2011). with you and me in mind: mentalization and transactional analysis. transactional analysis journal, 41, 3, 230-240. hubley, p., & trevarthen c. (1979). sharing a task in infancy. in i. uzgiris (ed.), social interaction during infancy: new directions for child development (pp. 57–80). san francisco: jossey-bass. martínez, j.m. (2013). transferencia y contratransferencia en los trastornos de la personalidad. revista de análisis transaccional, 2, 43-60. meltzoff, a.n. & moore, m.k. (1977). imitation of facial and manual gestures by human neonates.science, 198 (4312), 75-78. meltzoff, a.n. & moore, m.k. (1997). explaining facial imitation: a theoretical model. early development and parenting, 6, 179-192. meltzoff, a.n. & moore, m.k (1994). imitation, memory, and the representations of persons. infant behavior and development, 17, 83-99. meltzoff, a.n. & moore, m.k (1998). infant intersubjectivity: broadening the dialogue to include imitation, identity and intention. in s. braten. (ed.), intersubjective communication and emotion in early ontogeny, pp. 47-62, cambridge, uk: cambridge university press. pally, r. (2000): the mind-brain relationship. london: karnac books. rizzolatti, g., camarda, r., gallese, v & fogassi, l. (1995). premotor cortex and the recognition of motor actions. cognitive brain research,3, 131-141. rizzolatti, g., matelli, m., bettinardi, v, paulesu, e., perani, d. & fazio, r. (1996). localization of grasp representations in humans by pet 1. observation vs. execution. experimental brain research,111, 246-252. rizzolatti, g. & arbib, m. (1998). language within our grasp. trends in neuroscience, 21, 188-194. stern, d. (1971). a microanalysis of mother-infant interaction. journal of the american academy of child psychiatry, 19, 501-517. stern, d. (1977). the first relationship. cambridge, ma: harvard university ress. stern, d. (1985): the interpersonal world of the infant: a view from psychoanalysis and developmental psychology, pp. 145 y 151. new york: basic books. stern, d., hofer, l., haft, w. & dore, j. (1985): affect attunement: the sharing of feeling states between mother and infant by means of intermodal fluency. in: t field & n. fox (eds.) social perception in infants. norwood, n.j.: ablex. trevarthen, c. (1974). the psychobiology of speech development. neuroscience research program bulletin,12, 570-585. trevarthen, c. & hubley, p. (1978). secondary intersubjectivity: confidence, confiding and acts of meaning in the first year. in a. lock (ed.), action, international journal of integrative psychotherapy, vol. 8, 2017 15 gesture and symbol: the emergence of language, pp. 183–229. london: academic press. trevarthen, c. (1980): the foundations of intersubjectivity. in d. r. olson (ed.), the social foundations of language and thought, pp. 216-242. new york: norton. trevarthen, c. (2004). how infants learn how to mean. in m. tokoro & l. steels (eds.), a learning zone of one’s own (sony future of learning series), pp. 37–69). amsterdam: ios press. trevarthen, c. (2005). stepping away from the mirror: pride and shame in adventures of companionship. reflections on the nature and emotional needs of infant intersubjectivity. in c. s. carter, l. ahnert, et al. (eds.), attachment and bonding: a new synthesis. (dahlem workshop report 92), pp. 55–84. cambridge, ma: mit press. trevarthen, c. (2011): la psicobiología intersubjetiva del significado humano: el aprendizaje de la cultura depende del interés en el trabajo práctico cooperativo y del cariño por el gozoso arte de la buena compañía. clínica e investigación relacional, 5 (1), 17-33. tzourio-mazoyer, n., de schonen, s., crivello, r, reutter, b., aujard, & mazoyer, b. (2002). neural correlates of woman face processing by 2-month-old infants. neuroimage, 15, 454-461. wolf, n.s., gales, m.e., shane, e. & shane m. (2001): the developmental trajectory from amodal perception to empathy and communication: the role of mirror neurons in this process. psychoanalytic inquiry: a topical journal for mental health professionals, 1, 94-112. date of publication: 9.2.2018 http://www.tandfonline.com/toc/hpsi20/21/1 alcoholism is such a common condition that therapists must be exposed to clients who suffer from it, whether the therapist is post-script to part 1 of a case study trilogy marye o’reilly-knapp abstract: the case study by richard erskine, early affect-confusion: the borderline between despair and rage, is an in-depth, intensive analysis of early affect confusion and its impact on the client’s life. contributions offered by grover criswell, maša žvelc, ray little, and james allen further enrich the process by bringing their own unique perspective into the discussion. key words: integrative psychotherapy, supervision, case study ______________________ as i read the erskine’s case study i found myself immersed in the process. sometimes i experienced myself present in the therapy room as a witness to theresa’s unfolding narrative and richard’s mastery in using an involved relationship and the transference-countertransference milieu. the consuming intensity of theresa’s feelings were noted by the therapist as “transferentially expressing previous, and perhaps early, childhood relational conflicts”. the focus on relationship, use of a phenomenological inquiry with an emphasis on the here-and-now, and attention to: emotional stabilization, interruptions of contact with self and others, unmet wants and needs, moment-tomoment experiences between client and therapist, support for behavioral changes/behavioral management all resonated throughout the first part of the case presentation. rather than a focus on a diagnosis and pathology, erskine uses the term “borderline” within a relational framework. thus, rather than a focus on treatment of a disease, the whole of theresa’s personhood is highlighted and given attention. the borderline, “between intense neediness and rage, despair and self-reliance, impulsivity and manipulation” frames her intense psychological struggles. conflicts are met within the therapeutic dialogue where “i-ness” and “otherness” (winnicott, 1971) are co-created. as i followed the dialogue, two models of integrative psychotherapy came to mind: the self-in-relationship model and the script system. the first, the self-inrelationship model, brought to mind a relational system where theresa’s feelings, thoughts, behaviors and body sensations were addressed. a few international journal of integrative psychotherapy, vol. 3, no. 2, 2012 37 examples include: “i inquired repeatedly about theresa’s internal experiences and the meanings she made ….”; “the desperate emptiness in [theresa’s] relationships”; “[i]encouraged her to stay with her body sensations and emerging affect”. this model conceptualizes organization of a person – affect, cognition, behavior, and bodyand how these components effect the organization of self and relationships with others. the second model, the script system, identifies unconscious relational patterns and serves as a mechanism to identify core beliefs, needs and feelings repressed at the time of script decisions, observable behaviors, reported internal experiences, old emotional memories and current events (o’reilly-knapp & erskine, 2010). i found myself tracking the observations and responses made by richard and theresa. repeatedly, rather than taking a historical perspective, a phenomenological inquiry disclosed core beliefs, decisions and conclusions, and present-day reactions were reiterated: “fighting and pushing people away”; “depressed and fearing abandonment”; “blaming others and self-criticism”; “confusion about how others treated her”; “relational needs thwarted”; “fights”; “no one is there for me”; “no one understands me”; something’s wrong with me”; “i’m unlovable”. the case provided me with an opportunity to go back, review and re-assess my beginning years in integrative psychotherapy and to add to this knowledge base. i was transported as i ended part i of the case study trilogy. then i had the privilege to go to the responses. i felt an eagerness as i began. i was struck by the integrity of each one of the responders in their beginning statements: we need to remember what we know is fragmentary. grover criswell. i highly respect the author’s deep and gentle engagement, empathy and respect toward underlying needs, feelings, and defenses. maša žvelc. i think when it is when considering a case study by another therapist to hold in mind that the presentation of the client is from that therapist’s particular clinical perspective. ray little. once again, i am impressed by the usefulness of this framework in directing therapeutic interventions. james allen. each one addressed the importance of therapeutic engagement and the presence of the therapist. the thought-provoking comments and questions continued throughout the responses. i have taken a few of their responses to consider here. self-reflective questions by grover criswell considered the strengths of theresa, the level of her disturbance and what her role is in relationships. he also addresses the term “borderline”. in her response, maša žvelc noted an appreciation for “gentle engagement, empathy, and respect toward underlying needs, feelings, and defenses”. she also identified areas that were “skillful and useful”: cognitive attunement; individual versus group therapy; the “internal supervisor” of the therapist; and meaning-making. questions related to countertransference were also raised. ray little wondered about theresa’s ego state relational units (little) and “to consider if this woman lives and functions international journal of integrative psychotherapy, vol. 3, no. 2, 2012 38 in a split internal world, and whether her relational units are dissociated from each other”. he gives serious consideration to the transferencecountertransference process. in his response jim allen talked about his own dependence on non-verbal communications and somatic resonance. he skillfully identified a need “to lift these non-symbolic to verbalize symbolic status …. very difficult to describe in words”. the rejoinder by richard erskine followed and addressed each of the four responders. only a segment of the responses will be discussed in this section. to gain a full appreciation of the replies, treatment planning, pacing, and countertransference: perspectives in the psychotherapy of early affect confusion must be read. following are segments of richard erskine’s reactions to the retorts by his colleagues: use of “borderline”; time-limited psychotherapy; transference/countertransference; and idealization. use of “borderline”. “borderline” was used as a metaphor to represent theresa’s early affect confusion and her struggle to relieve her confusion in dealing with her thoughts, feelings, and behaviors. an elaboration of personality on a continuum, from style, to pattern, to disorder, illustrated the differences in the persona. at the extreme level of disorder, erskine uses “developmentally descriptive and caringly humanistic term early affect confusion” rather than borderline personality disorder. (see text for full discussion of this continuum.) the continuum may assist the clinician in differentiating issues to be encountered. time-limited psychotherapy. working with theresa for seven months, a timelimited psychotherapy is considered by erskine to be “particularly effective in focusing on a specific problem, facilitating behavioral change, and in managing incidences of ‘acting out’ what has not been resolved in the psychotherapy”. in james allen’s comments, i resonated with his “twinge of sadness” due to current economic conditions and his poignant question as to how treatment can be preserved “even if shortened or condensed”. transference/copuntertransference. a secure working alliance was essential working with theresa’s aggressive transference. to reiterate, the goals of therapy in seven months was to resolve her fear of abandonment and find constructive ways to be in relationship with her boyfriend. the next part, if theresa was to return to therapy was to do an in-depth psychotherapy and deal with archaic fixations. it is no surprise that she found the therapist “not doing the right therapy”, “unattuned”, “a failure at validation”. to her frequent attacks, the response was to “remain fully present and sensitive to what she unconsciously needed”. an account of the responsive versus a reactive transference was interesting “an element in her was very enduring and evoked in me a sense of caring and protection – a responsive countertransference… alongside that care and protection, i disliked her treatment of others, her aggressive attitude – a reactive countertransference.” international journal of integrative psychotherapy, vol. 3, no. 2, 2012 39 international journal of integrative psychotherapy, vol. 3, no. 2, 2012 40 attention to transference allows the therapist to look for the projections, the unmet developmental needs, and the defenses the client uses to stabilize and protect. a sensitivity to the transference and also to one’s own reactions (countertransference) is a powerful source for therapeutic assessment and interventions. in concluding, erskine in his case study describes a comprehensive therapeutic process and then invites colleague contributions. this is a wonderful way to enter into the therapeutic session. it is also a model for learning and for tapping into the minds of others. the specific interventions and rational, the accounts of the therapist’s descriptions of his internal experiences, as well as the notable questions and areas presented by the responders were invaluable, both in bringing out specifics and in enhancing our understanding for appropriate therapeutic interventions. rejoinders to the responders by richard erskine contributed to the interchange by bringing the exchange full circle. what an exciting and informative course this has been for me as the reader! a special thank you to richard erskine, grover criswell, maša žvelc, ray little, and james allen for providing me and the readers of this journal an opportunity to be involved in your dialogue. i look forward to the next two parts of the case study. author: marye o’reilly-knapp, rn, phd is a psychotherapist in private practice in nj. in june 2010 she retired from widener university school of nursing and was awarded emerita status. she continues to write and teach. marye is a teaching and supervisor faculty of the international integrative psychotherapy association. references o’reilly-knapp, m. & erskine, r.g. (2011). the script system: an unconscious organization of experience. in: r.g.erskine (ed.), life scripts: a transactional analysis of unconscious relational patterns. london: karnac books. winnicott, d.w. (1971). playing and reality. new york: basic books.   date of publication: 26.12.2012 alcoholism is such a common condition that therapists must be exposed to clients who suffer from it, whether the therapist is post-script to part 2 of a case study trilogy marye o’reilly-knapp abstract: author comments on the case study ‘balancing on the “borderline” of early affect-confusion’, written by richard erskine and responses to his article written by ray little, grover criswell, james allen and maša žvelc. key words: integrative psychotherapy, supervision, case study ______________________ in part 2 of the case study, balancing on the “borderline” of early affectconfusion, an in-depth psychotherapy was undertaken. the contract included: resolution of theresa’s early affect confusion; how archaic conflicts effected conflicts in her relationships in the present; and to “find alternative ways of stabilizing herself other than raging or demanding attention for her helplessness”. what began as few memories in theresa’s childhood progressed to more awareness within the therapeutic relationship. the methods of a phenomenological and historical inquiry, attunement to theresa’s affect, her developmental levels, and relational needs, and the process of involvement that included acknowledgement, validation, and normalization of her attempts to resolve conflicts in her childhood were evident in richard’s interactions with theresa. a few illustrations of the methods of inquiry, attunement, and involvement that appear in this case study follow. you may notice that under inquiry i have included “here-and-now” inquiry since this is a critical component in integrative psychotherapy. in his responses, richard uses the term “relational inquiry”. inquiry – phenomenological inquiry -“i regularly inquired about her body sensations and what she was feeling” historical inquiry “she was now able to talk about her teen-age years..”; “with each exploration she began to remember humiliating school situations and eventually her mother’s constant barrage of criticisms and ridiculing comments”. international journal of integrative psychotherapy, vol. 4, no. 1, 2013 28 here-and-now inquiry – “inquiring how she perceived the intricacies of our relationship was a practice that i continued to do at those potentially transforming points in almost every session”. attunement – “talked about her developmental needs”; “inquire[d] as to how she experienced my transactions”; “sensitively inquired”. involvement – “i explained that it was normal for a child to believe his or her mother…”; “validating and normalizing her ager at her mother’s criticisms”. in the replies, ray little reminds the reader of managing boundaries. he goes on to address the ‘opening’ up of memories and the possibility of retraumatization. his remarks on the here-and-now and his statements on the transferencecountertransference matrix furthered the dialogue. for a more comprehensive discussion of impasse clarification, the reader is referred to little’s (2011) article. grover criswell continues his scrutiny of the case study with the discussion of the therapeutic relationship as an “interactional laboratory”, of the significance of positive transference, the “timing” of interpretations, and the psychodynamic issues related to interruptions of therapy. the points made by james allen included a summary of theresa’s previous work. he also drew attention to the importance of admitting to our patients when errors are made. he referred to the work of schore and how the sympathetic nervous system is stimulated when shame results from parental misattunement. and he stated that he “would have done more work with the internalized other”. with the last of the responders, maša žvelc noted theresa’s progress. she observed the process of phenomenological inquiry and the “sensitivity,” “respect”, and “nurturance” provided by the therapist. her statement that in this second part of the case study there were “no signs of uncovering and verbalizing transference countertransference” will be addressed in richard erskine’s responses to his colleagues. the title, ‘phenomenolgical inquiry and self-functions in the transferencecountertransference milieu’ reflects richard’s responses. an examination of phenomenological inquiry continued in the rejoinder to ray little. also, the responses included: the “present moment”; the “us” in working with memories related to trauma; and negative transference as “an unconscious call for help”. responses to grover criswell involved a discussion of the building of a working alliance with theresa and the importance of phenomenological inquiry. noted was richard’s appreciation of grover’s description of “interpretation” and his account of the essence of a relational and integrative psychotherapy. discussion of the summer recess also took place. comments to james allen involved an expansion on early development and relational needs and self-regulating processes. questions, such as “something was missing”, by maša žvelc were appreciated. richard states that this is “an important asset in discovering what is international journal of integrative psychotherapy, vol. 4, no. 1, 2013 29 international journal of integrative psychotherapy, vol. 4, no. 1, 2013 30 not being talked about in the psychotherapy”. these questions also represent “your curious mind and capacity to discover the untalked about, an essential quality for doing in-depth psychotherapy”. a lengthy discussion addressed richard’s work with theresa within the transference-countertransference milieu. in concluding this part of the post –script, i want to note three thoughts that came to me as i read part 2 of the case study: the reluctance to talk, therapeutic errors, and juxtaposition reactions. all three are predictable and will inevitably emerge in the therapeutic relationship. reluctance to talk about childhood is a way theresa and other clients facing “the unthought known” (bollas,1987) present with such statements as “i don’t have any memories”, “i don’t know”. also there may not be words (preverbal) or the words were never expressed or validated by another person. within the intensity of the therapeutic relationship, it is inevitable (guistolese, 1997) that there will be errors and misunderstandings. these misattunements were recognized by the therapist: “it was important in our relationship that i acknowledged my errors and took responsibility for how my behavior affected her.” it is also unavoidable that juxtaposition reactions will occur. not only is theresa bringing the unconscious to conscious levels, she is encountering a sense of herself in the present that is new and different from what she believes and feels herself to be. at this point, she is a stranger to herself. it has been a privilege for me to be a part of this process. i have deep respect for the five who have contributed to this dialogue and i unreservedly anticipate part 3 of the case study. author: marye o’reilly-knapp, rn, phd is a psychotherapist in private practice in nj. in june 2010 she retired from widener university school of nursing and was awarded emerita status. she continues to write and teach. marye is a teaching and supervisor faculty of the international integrative psychotherapy association. references bollas, c. (1987). the shadow of the object: psychoanalysis of the unthought known”. new york columbia university press. guistolese, p. (1997). failures in the therapeutic relationship: inevitable and necessary? transactional analysis journal, 4, 284-288. little,r. (2011). impasse clarification within the transference-countertransference matrix. ransactional analysis journal, 41, 23-38. date of publication: 6.5.2013 international journal of integrative psychotherapy, vol. 12, 2021 75 my mother’s voice: psychotherapy of introjection: part 5 of a 5part case study of the psychotherapy of the schizoid process richard g. erskine1 abstract this article is the last in a five-part series subtitled “case study of the psychotherapy of the schizoid process.” an emphasis on the concept and methods of introjection concludes this case study of a schizoid client’s 4-year psychotherapy. the article demonstrates how the therapeutic relationship was used to quiet the client’s constantly criticizing internal voice. it illustrates the method of treating introjection by engaging the introjected voice in actual therapy, as if the voice were an actual client. keywords: internal criticism, internal voice, introjection, integrative psychotherapy, relational psychotherapy, therapeutic relationship, countertransference, schizoid, schizoid process, case study what a liberation to realize that the “voice in my head” is not who i am. “who am i, then?” the one who sees that. — eckhart tolle, 2005, a new earth when allan returned in september to begin his fourth year of our work together, i wanted to make sure that he was in agreement with changing the focus of our psychotherapy over the next few months to attend to the introjection of his mother’s personality. i intended to begin by talking about how the therapy would be different and getting a clear agreement about the purpose and direction of the work. 1 institute for integrative psychotherapy; deusto university international journal of integrative psychotherapy, vol. 12, 2021 76 however, my plan was temporarily diverted by allan’s enthusiasm. like a young boy, he was excited to show me his photos. he talked about discovering a new camping area and his excursion with the hiking club. he appeared to need both my interest and patience and seemed almost joyful when i responded with curiosity about his adventures. in response to several inquiries about his inner experience, allan described being lonely at night when he was with his hiking group. he realized that he often withdrew when the others were sharing personal stories. he recounted, “i felt stuck. i didn’t know how to join in the conversation, and then i was empty in my stomach. i wanted to join in but i could hear my mother’s voice saying ‘no one wants to hear you’ and ‘you are a bother.’ ” he described how on most of the trip, “i just felt useless as a person. oh, i could be a part of the group by doing most of the cooking and cleaning up, but i just knew that i should not speak, certainly not speak about myself.” i remembered that the previous spring allan had used similar words when describing the “mother voice in my head.” he ended the session with “i wish you had been there to teach me how to talk to people.” with those words, i presumed that allan was feeling some degree of attachment to and support from me. if my supposition was correct, it was time to talk to the introjected voice of his mother. although i often spot opportunities early in a client’s psychotherapy to address an introjected voice or attitude, i prefer to postpone conducting therapy with an introjected parent until the client has a solid bond with me. i am mindful that the client’s loyalty to internalized parents may be stronger than the emotional bond with me. in the next session, we reviewed the gains allan had made as a result of the previous 3 years of psychotherapy. he added that he had returned to psychotherapy to “get rid of my mother’s criticism of me. her words paralyze me.” this led to my introducing the concept of introjection and how we might proceed (erskine & moursund, 1988/2011). i explained that introjection was an unconscious, self-protective identification with the thoughts, feeling, attitudes, and behaviors of a significant other person and how it occurs when a child’s physical and/or relational needs are repeatedly left unsatisfied. i explained how a child fills the void of relational neglect by internalizing the features of the person on whom they are dependent (perls et al., 1951). by using his own experience and stories of other people, i provided allan with some illustrations of how the introjected voices, attitudes, and criticisms often returned, years later, as an internal voice, one that repeats the criticisms that the person heard earlier in life and dictates what to feel and how to behave. (see international journal of integrative psychotherapy, vol. 12, 2021 77 chapters 16 and 17 in erskine, 2015, for an explanation of the theory and methods of the psychotherapy of introjection.) allan and i talked about our psychotherapy contract and how to proceed. we discussed how he could alter or stop the therapy process if it did not fit for him and how the therapy of “the mother in his head” fit into the work we had done about shame, his withdrawing to his internal private place, and his lonely search for someone to love him. allan and i created some drawings to illustrate the dynamic internal interplay of his relational needs, introjected criticism, shame, and withdrawal from relationships. these provided allan with visual images of his intrapsychic process and explained what we were doing in our work. although he was nervous about what he would discover, he said, “let’s do it. it can’t feel any worse than how i’ve already felt.” he sighed and withdrew into himself for a few minutes. when he was present again, he said, “help me get rid of her.” i explained that i would have a therapeutic interview with his mother, just as though she were my actual client. “but,” i added, “you are my client. my commitment is to you. at times it may seem that i am empathetic with your mother, but keep in mind that my responsibility and investment is with you.” allan nodded and smiled. i described that in some sessions i would spend between 10 and 20 minutes talking to his internalized mother, and then the remainder of the session would be devoted to helping him make sense of what had occurred in my dialogue with her. in the next session, allan’s internal anxiety was high. he brought several of his photos and used most of the time telling me stories of how he had composed the pictures. in the last 15 minutes, we were able to talk about his worry that i was going to “interfere somehow, upset things, something will go wrong.” i interpreted his comments and accompanying anxiety as an indication that his mother was already internally active and invading our therapy space, just as the memories of her criticisms invaded his internal space. he said that he knew his mother would be “furious with him for talking about her.” i responded, “i have no intention of talking about your mother. i will talk directly to her, the mother in your head.” by then it was the second week in october. allan was nervous and deflected the conversation to the hike he would take the coming weekend. after 10 minutes, i interrupted and reminded him about our agreement. i asked allan to sit in a different chair, and as he was about to do so, i asked him to pause, close his eyes, and then sit like his mother would sit. allan looked at me and said, “what will i do with her purse? she always has a purse.” i said, “do exactly what your mother does.” as allan slowly sat in the chair, he clutched his arms across his chest as international journal of integrative psychotherapy, vol. 12, 2021 78 though he were tightly holding a handbag. his left leg began to jitter, and his body was tense. i wondered if allan was displaying his own emotions or the body reactions of his mother. i wanted allan’s internalized mother to feel at ease, so i began with a warm welcome, just as though she were a new client. i told her that i needed help in working with her depressed son, that he had been withdrawn and without friends but that he was now changing his life. i told her that she was the person most likely to be able to help. she reluctantly agreed and then said, “he won’t change. he was always incorrigible. he’s just a loner. no wonder he’s depressed. as a kid he sat in his room all the time watching tv.” her voice was cold and condemning. it was my goal to warm her to our cooperative task by having her talk about herself. when i asked her name, she first gave me her married name and then reluctantly gave me permission to call her “henrietta.” as allan sat on the chair with his eyes closed, i asked the “henrietta” ego state where she was from and who was in her original family. she hesitantly told me that she grew up in a wealthy suburb of new york city, was the oldest child, and that she had two younger sisters whom she had always disliked. when henrietta said “disliked,” there was a tone of disgust in her voice. i suspected she was in competition with her sisters. as i inquired, she told me that as an adolescent, she could not wait to be “out of the house and on my own.” she bitterly described her parents as “demanding” that she be “proper” but that they spoiled her two younger sisters. she described deciding in early adolescence “to be independent and not need anything from anyone.” she quickly added that she was lucky to have a daughter who was not like her own sisters, who was “considerate” and “always an easy child,” unlike allan, who was “a problem to be controlled.” as henrietta spoke, i found myself wanting to recoil from her bitter tone. i could identify with allan’s attempts to hide from her in his room. after 15 minutes with “henrietta,” i indicated for allan to resume his usual place on the sofa and asked him what he was experiencing. he said that he had a sudden clarity that his mother “was always playing a role. she won’t tell you the truth. she is just being nice to impress you.” he went on to say that his mother had always been “extremely jealous” of her sisters and that she “always criticized people behind their backs.” i asked what it was like to live with a mother who had those personality traits. his response was, “i learned to live alone in the same house. the only thing i admired about her was that she was a good cook.” allan then spontaneously contrasted his mother’s attitude toward him with his description of my “accepting and understanding way of being.” immediately he was quiet and turned inward; eventually he spoke about how his life would have been international journal of integrative psychotherapy, vol. 12, 2021 79 different if he had had a parent like me. allan’s idealizing words touched a tenderness in me as i realized that this type of idealization was an unconscious desire for protection from an introjected mother who treated him as “a problem to be controlled.” if i was to be therapeutically responsive to him, i would have to provide a stabilizing protection against his mother’s potential lies and caustic tone. i privately renewed my commitment to be with and for allan. what i provided for him was intangible: my interest, compassion, validation, and presence, in essence, a relationship that was uniquely different from what he had experienced with his mother. in the next session, allan wanted to talk about possible changes in his job. but after 10 minutes on the job topic, i asked if i could again talk to henrietta for 20 minutes. i tried asking her about her marriage, but she responded with tangential stories that hid much more than they revealed. in each story, she told me how she was impressed with herself or, conversely, how she was not appreciated, even maligned, by various people. instead of empathically listening, i changed the focus of our conversation and asked about allan’s infancy. on this topic she was more forthcoming: “when he was a baby he would spit up my milk as i tried to breastfeed him. even on special formula he was colicky, except if my husband was home. robert could calm the boy and put him to sleep, but with me he just screamed and threw his arms and legs in the air. he would stiffen up when i tried to put him to sleep. the best thing i did was to let him cry himself to sleep. that took a few weeks, but he finally calmed down.” as she described all this, i again felt a big emptiness in my stomach. just as in the previous session, i wanted to distance myself from her. i was not scared, but i certainly did not like being with her. i was struck by the intensity of my identifying countertransference; my uncomfortable body sensations and emotional reactions were fundamental in my empathy for allan. i could only imagine the emotional distress he had endured while living with his mother. i was reminded of fraiburg’s (1982) descriptions of emotionally distressed infants and how they flail their arms and legs or stiffen their body to signal that they are experiencing a relational disruption. even though i was resonating with what allan probably experienced as an infant, i was also curious about henrietta’s story. as i inquired about her feelings when caring for her infant son, she said in a theatrical voice, “he never loved me, never from the start.” i responded empathically while she told several examples about being “disappointed” at having “a boy child.” while she elaborated on this story, international journal of integrative psychotherapy, vol. 12, 2021 80 my compassion was centered on allan. i wanted to protect him. my countertransference, both identifying and responsive, guided me in how to respond empathically to allan during the concluding 20 minutes of our session. allan began the next session with amazement at how “my mother’s voice poured out of me so easily,” and then he added, “but now i know that the problem is her, not me. i don’t remember her saying those things, but i know it’s true. i was never wanted or loved by my mother.” we spent most of the session with allan recounting stories of his mother’s criticisms and his loneliness in his preadolescent years. he provided a verbal portrait of his mother when he said, “i now realize that she was always self-absorbed. i did not exist. i have always lived in my private wilderness. my only salvation was to be alone.” after 30 minutes, allan had had enough of our exploration into his past, and it looked like he was going into withdrawal. preemptively, i asked about what had been happening during the week. he told me about his concern that the company he worked for was merging with another firm. he did not know whether to continue with the new firm or take early retirement. as he was leaving the session, he requested that we have time in some sessions to discuss his future. i wondered if this was a sign that allan was reorganizing internally or if he was distracting himself from the work we were currently doing. in several subsequent sessions, i continued talking to allan’s introjected mother. when i asked about allan’s early childhood, school years, and adolescence, her typical, emotionless answer was, “he was quiet. he preferred to be alone.” once, when i asked about allan’s toddler years, henrietta said, “i had to always tell him ‘no.’ he liked to get into things.” i asked if he ever caused trouble, and she answered: “well, no, but that’s only because i controlled him. i never wanted him to be wild. i didn’t want another child. my daughter was all i wanted, she was easy to handle. and i didn’t need another male in my life, and certainly not a pigheaded one like my father. thank god my husband was always away; he worked a lot. when he was home he had no interest in being with me [a 1-minute pause]. he died in a car accident when allan was almost 5. i don’t like this interview. i never talk about him. he’s gone and it’s over [another 1-minute pause]. the police said he killed himself [pause]. i had my daughter. until she met her second husband, she was always there for me, not like allan, who preferred to be alone.” after that conversation with henrietta, allan was quiet for several minutes. he propped his elbows on his knees and covered his face with his hands. his posture gave the appearance of defeat. when he finally looked up at me, he said that his international journal of integrative psychotherapy, vol. 12, 2021 81 stomach hurt. “i’m sad, but i can’t cry. it’s just the emptiness i always feel, but this time it’s in my chest as well. i know that she never loved me.” he described how he longed to be loved but felt “great fear that i will be invaded and controlled. i don’t like being touched.” i reminded allan of the times he walked the streets of new york city late at night, watching women and lamenting, “can you love me?” we discussed how allan’s fantasy of being loved provided an illusion of safety; he searched for someone who would be tender, patient, and a companion, and he added, “with no possibility of being criticized or controlled.” in the following two sessions, allan did not want me to talk to the “henrietta” part of him. he shuddered as he spoke about hearing the tone of his mother’s voice. in the first of those two sessions he said, “what i am remembering now is the sound of her, not so much her words, but the sound of her being disgusted with me. often i don’t hear her exact words, just her sneering tone. when i hear that tone, i know i must hide.” we began the next session by talking about how his self-criticism was an effective distractor from remembering the sound of his mother. in both sessions he seemed to require time to withdraw to his private place while i watched over him. after each withdrawal, he told me more memories of his family life. the next weeks were similar. sometimes allan did not want to talk, but he was not withdrawing to his private place. rather, he kept his eyes on me, watching my face, breathing, and physical gestures. a couple of times he was surprised that i did not “go away.” when i asked what he was sensing in his body during those sessions, he said that he had a lot of muscle tension, stomach pain, and had been biting his lips. together we hypothesized that these physiological reactions were presymbolic physiological memories stimulated by my conversation with his introjected mother. i presumed that allan was quite young, partially regressed, possibly to toddler or preschool age. i was concerned he might have reached an emotional level at which he could not absorb more awareness of the neglect and trauma he had experienced. i watched his pattern of breathing; when it became more rapid and shallow, i assumed that he was close to becoming emotionally overstimulated. when i had that concern, i paused for a while and then changed the focus of our attention to his school-age years when he might have explicit memories. allan talked about several occasions when his mother castigated him. the details of his story changed depending on what he was remembering, but the themes remained the same. allan arrived early one day, distraught by a dream. his face looked flushed as he stumbled over the words to describe his intense body reactions and the dream international journal of integrative psychotherapy, vol. 12, 2021 82 content. we spent the next several minutes with him focusing on the tight places in his body, breathing into the tension, and finding sounds that reflected what he felt. after several minutes focused on his body, allan was able to verbally sketch the dream: “i am camping with my hiking group. it gets dark and suddenly no one is there. i was scared and searched for them. without them, i was terrified of falling off a nearby cliff. i try to run, but all is black. i hear a grizzly bear growling. i know that she will devour me. i cried out, but no one is there to help me. i woke up at the sound of my own weeping. i have never cried like that before in my life.” after a long pause, allan asked me to help him understand his dream. i began with, “allan, you have cried like that before.” he looked astonished. after a moment’s pause, i said, “several weeks ago your mother told me how she let you cry yourself to sleep when you were just an infant. i imagine that you must have wept intensely many times before you learned to be quiet.” his eyes filled with tears. he was quiet for a while, then he asked if i had more to say. i was concerned about having enough time to process the meanings of the dream, so i chose to explain the least problematic part of the dream and save the more malignant part for early in another session. “you have recently made personal connections with some of the people in your hiking group. perhaps you are more secure when they are with you. in the dream you were scared when you could not find them. i think that part of the dream reflects a desire to be connected to people.” allan nodded his head but said nothing. in a following session, allan and i returned to deciphering the dream. i proposed, “in the dream you were without security and all was black. that is how it is for an infant who is left all alone to cry himself to sleep. you must have been terrified.” allan added, “not only when i was a baby. my mother never comforted me. i have always been alone.” we were both silent for several minutes before we discussed the significance of what we had both said. when he was ready to hear more, i added, “perhaps the grizzly bear represents your mother. you have implied that ‘she’ is quite ferocious. your mother must have been terrifying to you when you were a baby and young boy.” i paused between each sentence so that allan had time to evaluate the significance of my words. we returned to understanding the dream again the next week. i pointed out that when he had originally told me the dream a couple of weeks before, he had described the grizzly bear as a “she.” allan was quick to add, “the essence of me was devoured by my mother’s criticisms of me. she was a real grizzly bear.” i continued, “you may have been crying for help long before you could understand criticism. at that early age, you could not possibly understand what you know now, international journal of integrative psychotherapy, vol. 12, 2021 83 but you could feel the absence of affection and protection in the cells of your body. i imagine that you cried until you just gave up on having any human connection.” after a pause, allan offered his understanding: “i spend a lot of time observing and photographing wild animals. with the animals there is no personal connection, we just inhabit the same area. that is how i learned to live, no connections.” i interpreted that particular dream, which came at that point in our work, as his mental coalescence and concretization of the implicit and procedural memories that had been emerging in our time together. we spent a few minutes each week talking at the beginning of each session about allan’s employment situation before we went on to consider what he understood from the work we had done in the previous sessions. some weeks i reserved 10 or 15 minutes to interview his internalized mother. after each session with henrietta, allan and i would talk about his mother’s behavior and how he had coped with her coldness and criticism. as henrietta’s criticisms of allan continued, i used each derogatory comment she made about allan to ask her about her childhood. eventually she talked about her early school years, the secret alcoholism of her parents, contempt for her father, and the emotional neglect she felt as a child. as i listened, i tried to be empathic, but she remained emotionally hidden. the only apparent emotions were disgust and anger. in one intense session, she remembered being about 11 or 12 years old and coming to the conclusion that “no one loves me” and “i will be independent and not need anyone.” in a later session i explored the latter decision, and through a series of phenomenological inquiries she revealed that she wanted her children to be protected by “their independence, not needing anybody.” as i questioned her about her criticism of allan, she confessed that she was teaching him “to manage for himself.” i was empathic with her need to be “independent from my alcoholic parents” but challenged how she forced her children to be like her. i talked to her about her emotional neglect of her son and how it resulted in his being depressed and without friends. i thought it was time to coalesce the work we had been doing, so i began the next session by inviting henrietta to speak. i empathically reviewed with her the stories she had told about her childhood, marriage, and, importantly, allan’s infancy and school-age years. i was both gentle and confrontive when i described how her behavior had been extremely detrimental to allan, that he was not a bad child, that he needed her affection, and that her behavior toward him was abusive. i emphasized how lonely and confused allan was in reaction to all of her criticisms. international journal of integrative psychotherapy, vol. 12, 2021 84 at first she tried to defend her behavior. i interrupted her justifications by focusing on the effects of her criticisms. i told her how allan had suffered loneliness and uncertainty all his life, that he was in emotional pain, and that he needed her to take responsibility for how she had affected him. i then asked henrietta to imagine allan sitting on the couch and to talk to him. she began by trying to explain why she had never been emotionally close to him. i confronted her attempt to minimize the significance of her impact on allan and encouraged her to “be honest with yourself.” she began to cry and said, “i never wanted to hurt you, allan. i only wanted you to be independent.” she then told allan that she had been unhappy in her marriage and wanted out but then discovered that she was pregnant. “i know i blamed you, allan, but it was not your fault. i was angry at your father.” she told allan how she longed to be independent from her husband just as she had longed to be free of her family. she disclosed that she did not love her husband but then felt guilty when “he killed himself by smashing the car into a tree.” she cried as she said, “you were a lovely boy, energetic, but i stopped you.” i then pointed out that she had criticized him from the time he was a small boy until he was a grown man. henrietta responded, “i should never have done that. i was just so angry at your father, and then guilty. i criticized you, i did it a lot, but inside i was criticizing myself.” following henrietta’s confession, i asked allan to sit on the couch and face the empty chair. i encouraged him to respond to henrietta. at first he had difficulty speaking, and then he blurted out his anger at how she had always criticized him. “you blamed me for your crazy troubles. i had nothing to do with your marriage, and i never deserved your criticisms. you are the one who should be criticized for your cruelty, for making me always be afraid of you and other people. your words hurt me.” then he wept as his body relaxed into the couch. in sessions that followed, allan and i went over each conversation i had had with his introjected mother. he talked about how her coldness and criticism had permeated his life. he went into detail about his mother’s voice being “consistent and insistent.” we again examined how his self-criticisms had been a way to block out his mother’s voice. i talked about “the loyalty of a little boy” and how he had stayed attached to his mother by disavowing his anger and believing her definitions of him. allan was happy that he seldom heard her critical voice in his head now, but he talked about how he was still inhibited with people at work and in his hiking club. we discussed various strategies about how to connect with people. international journal of integrative psychotherapy, vol. 12, 2021 85 allan was now worried about his current life. two events were impending: he had an offer to sell his apartment for a large amount of money, and his company was in the process of merging with another firm. he was in a quandary. he could remain employed or he could take early retirement and leave the firm with a payout equivalent to 5 years of his salary. he had been in the same job for 28 years, and, although he had advanced within the firm, he was not sure what his position would be in the new company. additionally, allan was uncertain about selling his apartment because he had lived in the place all his life. he had no idea where to go or what he would do if he retired. the time in our sessions was increasingly absorbed with his concerns about his current life. i wondered if allan’s concerns were a way of deflecting from the work we had been doing or the result of life’s circumstances and the opening of a new chapter in allan’s life. in two sessions we discussed each of these possibilities. in the second session he seemed content when he said, “i’ve changed inside. my body is more relaxed. every night i’m busy with my photography work. the voice of my mother is mostly quiet. when i do hear her nasty comments, i tell myself ‘that is just the memory of a bitter women’ and ‘she cannot control my life anymore.’ if the job and apartment both work out, i want to move out of this city. i’ve spent 55 years in one place. i will have enough money to buy a house and photography studio. i saw a place for sale in vermont that i might buy. i am going this weekend to see if it will work for me.” we had three more sessions, during which allan and i reviewed the work that we had done during each year. he shared his vision of a future life as a photographer in a rural, mountain town. in each session he cried as he expressed his gratitude for the quality of our relationship. during those final sessions, i was sad and glad: glad that allan was creating a new life and sad to be saying good-bye to both the man and the neglected little boy, both of whom i had come to love. conclusion the conclusion of a long case study such as this usually includes a recap of the salient events in the psychotherapy, the discoveries made during the process, and the intricacies of the therapeutic work. however, in this study, i will let the therapeutic narrative speak for itself. my view is that the healing of cumulative neglect (as epitomized in allan’s early life) occurs through the psychotherapist’s sustained attunement to the client’s affect, unique rhythm, and level of development (erskine et al., 1999). international journal of integrative psychotherapy, vol. 12, 2021 86 as i look back on the 4 years of allan’s psychotherapy, i am reminded of modic and žvelc’s (2015) analysis of clients’ experiences in integrative psychotherapy. their research identified which aspects of the therapeutic relationship were most helpful. they found six: (1) the therapist’s empathy and attunement, (2) the therapist’s acceptance, (3) the match between the client and the therapist, (4) feelings of trust and safety, (5) a feeling of connection, and (6) the experience of a new quality in relationship. in reflecting on what was central in my relationship with allan over the 4 years of his psychotherapy, i was aware of working from a relational (moursund & erskine, 2003) and developmental perspective (erskine, 2019). this perspective is similar to how bowlby (1969, 1973, 1980) defined the qualities of relationship that facilitate a child developing an internal sense of security. in summarizing bowlby’s three volumes, the french psychoanalyst didier anzieu (1993) listed bowlby’s five criteria that are essential in an infant forming a secure bond with the maternal person, the foundation on which all later development rests (erikson, 1950). these criteria include: • the exchange of smiles • the solidity of holding and handling • the warmth of the embrace • the softness of touch • the interaction of sensorial, kinesthetic, and postural signs during breastfeeding and maternal caretaking anzieu added his own sixth criteria: “synchronization of rhythms.” these six criteria, each necessary for an infant to develop both internal stability and relational security, are evident in this case study of allan’s psychotherapy. they are the essential ingredients in the psychotherapy of any client who uses the schizoid process to stabilize and regulate emotions and the distress of unmet relational needs (erskine, 1998). in reviewing allan’s psychotherapy, i want to emphasize the dimensions that led to a fundamental change in allan’s life: • throughout the psychotherapy, i wanted allan to see a gleam in my eyes that reflected my unswerving interest in his stories, a resolute acceptance of who he was, and my appreciation of his uniqueness. • i was committed to establishing a relationship with allan that was authentic, reliable, and consistent. international journal of integrative psychotherapy, vol. 12, 2021 87 • i strove to provide a “warm embrace” through my continued presence and to create a relaxed, attentive atmosphere in which allan was free to be fully himself. • the softness of my voice, the cadence of my speech, and the respect in the way i talked to allan provided a therapeutic contrast to his mother’s criticizing words and harsh tone. • my continual attention to allan’s body gestures, muscle tensions, and his tendency to avoid interpersonal contact provided clues as to when i was attuned to his affect and level of development and when i was not. • when allan told stories, i listened with curiosity. i waited quietly when he withdrew into his private place and was mindful not to hurry him into interpersonal contact. i remained patiently present. attunement to allan’s rhythm was essential in healing the relational disruptions that permeated his early life. references anzieu, d. (1993). autistic phenomena and the skin ego. psychoanalytic inquiry, 13(1), 42–48. https://doi.org/10.1080/07351699309533921 bowlby, j. (1969). attachment. volume 1 of attachment and loss. basic books. bowlby, j. (1973). separation: anxiety and anger. volume 2 of attachment and loss. basic books. bowlby, j. (1980). loss: sadness and depression. volume 3 of attachment and loss. basic books. erikson, e. (1950). childhood and society. norton. erskine, r. g. (1998). attunement and involvement: therapeutic responses to relational needs. international journal of psychotherapy, 3(3), 235–244. erskine, r. g. (2015). relational patterns, therapeutic presence: concepts and practice of integrative psychotherapy. karnac books. erskine, r. g. (2019). child development in integrative psychotherapy: erik erikson’s first three stages. international journal of integrative psychotherapy, 10, 11–34. erskine, r. g., & moursund, j. p. (2011). integrative psychotherapy in action. karnac books. (original work published 1988) international journal of integrative psychotherapy, vol. 12, 2021 88 erskine, r. g., moursund, j. p., & trautmann, r. l. (1999). beyond empathy: a therapy of contact-in-relationship. brunner/mazel. fraiberg, s. (1982). pathological defenses in infancy. the psychoanalytic quarterly, 51(4), 612–635. https://doi.org/10.1080/21674086.1982.11927012 modic, k. u., & žvelc, g. (2015). helpful aspects of the therapeutic relationship in integrative psychotherapy. international journal of integrative psychotherapy, 6, 1–25. https://www.integrative-journal.com/index.php/ijip/article/view/103 moursund, j. p., & erskine, r. g. (2003). integrative psychotherapy: the art and science of relationship. brooks/cole-thomson learning. perls, f., hefferline, r., & goodman, p. (1951). gestalt therapy: excitement and growth in the human personality. julian press. tolle, e. (2005). a new earth: awakening to your life’s purpose. dutton. https://www.azquotes.com/quotes/topics/voices-in-my-head.html international journal of integrative psychotherapy, vol. 10, 2019 1 developmentally based, relationally focused integrative psychotherapy: eight essential points richard g. erskine abstract this closing keynote address was delivered at the international integrative psychotherapy association’s 9th biennial conference, 19-23 march 2019 in montpellier, france. it describes the history and eight essential points of a developmentally based, relationally focused integrative psychotherapy. therapeutic presence is the concept that unites each of the essential points, which include: the centrality of relationship, awareness of phases of child development, current enactment of the past, attending to the person’s body and unconscious relational patterns, the use of child therapy methods with adults, the understanding provided by the theories of ego states, and facilitating change only after the individual has an understanding of the function of his or her behavior. keywords: integrative psychotherapy, relational psychotherapy, relationship, presence, child development, enactments, unconscious patterns, ego states, paradoxical theory of change, history of integrative psychotherapy ------------------------------------- the development of integrative psychotherapy has been an exciting journey of discovery and sharing. during these past 50 years, it has been my goal to learn new ideas, experiment, and improve the concepts and methods that i was using at any particular time in my own maturation as a therapist. it was never my goal to create a unique school of psychotherapy. originally, the term integrative international journal of integrative psychotherapy, vol. 10, 2019 2 psychotherapy was the name i used to describe two aspects of how i practiced psychotherapy. the first was the integration of various psychotherapy theories that formed a new synthesis for understanding relationships and the reparation of ruptures in significant relationships. the second, and more important, reflects the internal integration within the client—of affect, physiology, and cognition—so that behavior is, by choice, in the current context and not stimulated by fear, compliance, or conditioning. both of these aspects describe how i think about psychotherapy and what i actually do with clients. i first used the term integrative psychotherapy in september 1972 when i was assigned a class of advanced master’s students and doctoral candidates in clinical psychology, counseling psychology, and special education at the university of illinois. at that time, i was excited about transactional analysis. i approached my dean with the idea of teaching ta. he said, “no, ta is just pop psychology.” a couple of days later i offered to teach gestalt therapy. i was intrigued with the dynamic ways change could occur with gestalt methods. again the dean said, “no.” other faculty members discouraged me from teaching family systems therapy. i was faced with a dilemma because many of the students had already taken courses with professors who were specialists in behavior therapy, client-centered therapy, neo-freudian therapy, and group therapy. at that time, i was in supervision with a psychoanalyst, dr. herman eisen, a retired university professor. i described my dilemma to him and he quietly answered, “teach your own personal integration.” this led us to several discussions about how i actually practiced psychotherapy. he invited me to describe each therapeutic transaction, my thoughts about the clients just before i made an intervention, my degree of personal involvement in the therapy, and my overall understanding of psychotherapy. he repeatedly asked me to put what i did into my own language. i detailed to dr. eisen how i often began by inviting the client to become aware of the tensions in his or her body. then the work would focus on the client’s affect before moving on to his or her thoughts and memories. i described how i would explore with clients what they believed about themselves, others, and their quality of life. for many clients, their body, affect, cognition, memories, fantasies, and behaviors all seemed to be a part of a cybernetic system. i talked about how i encouraged behavior change but only after the client had full awareness and expression of his or her affect and cognitive awareness about his or her core beliefs. international journal of integrative psychotherapy, vol. 10, 2019 3 dr. eisen encouraged me to teach what i was describing to him but not to use the jargon of ta or any school of therapy. he stimulated me to teach each aspect of therapy as part of an internal-relational system. i began the course by teaching what i called the “abc’s of effective psychotherapy” (erskine, 1975). i talked about how personal growth and change require an integration of affect, cognition, and behavior. later in the course i introduced the concept and methods of body awareness (erskine, 1980; erskine & trautmann, 1993) and the cybernetic theory of internal systems. (erskine & zalcman, 1979). i called what i was teaching integrative psychotherapy. the definition of integrative psychotherapy that i have used since 1972 includes two parts. first, the simple definition is “the integrative [in integrative psychotherapy] … refers to the integration of theory, the bringing together of affective, cognitive, behavioral, physiological, and systems approaches to psychotherapy” (erskine & moursund, 1988, p. 40). integrative psychotherapy takes into account many views of human functioning: psychodynamic, client centered, cognitive-behavioral, systems therapy, child play therapy, gestalt therapy, body therapy, transactional analysis, and both object relations and intersubjective psychoanalysis. each provides a valid explanation for behavior, and each is enhanced when integrated with the others. this integration of theories has become a popular understanding, and sometimes misunderstanding, of integrative psychotherapy. many people now use the term integrative psychotherapy to describe an eclectic mix of theories, concepts, and methods. for a set of theories and methods to be consistent and truly integrative, it must have unifying factors. in the way i practice psychotherapy and teach integrative psychotherapy, the concept of relationship provides one of the central unifying factors. relationship is the core of all involvement with our clients. integrative psychotherapy begins with the premise that humans are born relationship seeking, and we remain interdependent throughout life (erskine & trautmann, 1996; fairbairn, 1952). we each have a variety of relational needs that require involvement with significant others for those needs to be fulfilled (erskine, moursund, & trautmann, 1999). these various concepts of psychotherapy are used within a perspective of human development in which each phase of life presents heightened developmental tasks, need sensitivities, crises, and opportunities for new learning. international journal of integrative psychotherapy, vol. 10, 2019 4 however, the primary meaning of the “integrative” in integrative psychotherapy refers to the process of integrating the personality, the facilitating of an internal integration within a person: [it involves] helping the client to assimilate and harmonize the contents of his or her ego states, relax the defense mechanisms, relinquish the script, and reengage the world with full contact. it is the process of making whole: taking disowned, unaware, unresolved aspects of the ego and making them part of a cohesive self. through integration it becomes possible for people to have the courage to face each moment openly and freshly, without the protection of a preformed opinion, position, attitude, or expectation. (erskine & moursund, 1988, p. 40) for me, the process of defining and refining the philosophy, theories, and methods of a developmentally based, relationally focused integrative psychotherapy has been the journey of a lifetime (erskine, 2013, 2015; erskine & moursund, 1988; erskine et al, 1999; moursund & erskine, 2003). i do not have a specific goal regarding the future of integrative psychotherapy. but i do hope that as members of the international integrative psychotherapy association and as individual trainers and supervisors we will always be flexible in how we teach and supervise, that we will be open to new ideas and experiential methods, and that we will be solid in our therapeutic commitment and integrity. while experimenting with new ideas and methods, we need to maintain both our relational philosophy and the developmental core. if we waver from these two core concepts, we lose the cohesion of our various theories and will be in danger of creating merely an eclectic mix of theories. the significance of relationship and early development are unifying factors in integrative psychotherapy, and its future development is up to all of you! i have invested more than 5 decades in studying and practicing this wonderful profession of psychotherapy. there is much i still do not know. i remain busy learning, reading, discussing, rereading, and assimilating various psychotherapy concepts. often in learning a new concept or method, i first imitate what someone else has done, then over time i change what i am doing to fit the person or situation, and then i reevaluate the concept or method. eventually, i make the theory or method my own. these therapeutic experiences have international journal of integrative psychotherapy, vol. 10, 2019 5 influenced and coalesced my therapeutic practices, and i have condensed these concepts into a few essential points. essential points recently, i evaluated the therapy i was doing in a series of intensive 5-day therapy groups. as an outcome, i delineated several points that i think are essential in creating an effective integrative psychotherapy that is developmentally based and relationally focused. there are certainly more than eight points, but these are the ones that are central in the way i currently think about and practice psychotherapy. i hope that my outlining these points will provide the stimulus for you to explore, experiment, and develop your own ideas and methods and thereby actively contribute to the future refinement of integrative psychotherapy. first, relationship is central. as integrative psychotherapists, we need to maintain and refine our person-centered perspective, which respects the inherent value of each person. this includes a nonpathological attitude about all people, an attitude that is both normative and validating. it is our therapeutic responsibility to find ways to value all clients, even if we do not understand their behavior or what motivates them. we manifest an attitude of unconditional positive regard (rogers, 1951) when we treat all of our clients with kindness, provide them with options and choices, create security, and accept them as they present themselves rather than looking for a possible ulterior agenda. psychotherapy is an intersubjective process when based on a foundation of unconditional positive regard or what martin buber (1958/1984) called the “i-thou” relationship. as integrative psychotherapists, we realize that healing of the psychological wounds of neglect and trauma occurs through sustained therapeutic contact. we also recognize the therapeutic effectiveness of consistent phenomenological inquiry as well as the effectiveness of an intersubjective, person-to-person, honest interchange that conveys respect, choice, and integrity. such therapeutic contact is provided through the therapist’s commitment to the client’s welfare and attunement with the person’s rhythm, affect, cognition, and level of development. as integrative psychotherapists, we maintain sensitivity to our clients’ relational needs throughout each stage of life. we recognize the importance of the person having choice and full, contactful self-expression. with attunement, we can create a relationship that is qualitatively and therapeutically responsive to both the international journal of integrative psychotherapy, vol. 10, 2019 6 client’s relational needs that were unsatisfied earlier in life as well as his or her current relational needs (erskine et al., 1999). second, our relationally focused integrative psychotherapy is distinctly developmentally based. the research on child development and the observational writings of child psychologists provide us with a variety of understandings about how children grow and learn, about how at each developmental age they accommodate themselves to, and compensate for, relational disruptions and the resulting internal distress. if we are to do an in-depth integrative psychotherapy, it is essential that we work from a developmental perspective. i always wonder what childhood story is unconsciously being revealed via my client’s body posture and movements, emotional expressions, and repetitive behaviors. i am continually using developmental images that provide me with a glimpse into the person’s life as a child. to create a developmental image, i assemble bits and pieces of information about my client’s childhood and speculate about the possibility that he or she was once a neglected baby, or a controlled and criticized preschool child, or a school age child under stress, or a teenager who lacked family support and care. developmental images are only hypotheses, but they are valuable in forming our use of both phenomenological and historical inquiry. such empathic inquiry, in turn, shapes our therapeutic involvement in a unique way with each person. developmental images provide a powerful form of interpersonal connectedness with our clients’ childhood experiences. yet the potential for nontherapeutic countertransference exists. that is why it is necessary for each of us to have an in-depth psychotherapy of our own so that we can distinguish our own experiences from our clients’ childhood experiences. third, as integrative psychotherapists, we are aware that the present provides a window to the past. we are always working in the now because unresolved conflicts and losses from the past are continually reenacted in the present. it is crucial that we observe our client’s behaviors in order to decipher what primal dramas of early childhood are possibly being lived out in their transactions with us as well as with other people. the client’s behaviors often reveal a story of emotional abandonment, neglect, abuse, or ridicule. early childhood deprivations of attunement may be revealed in the client’s expression of fear, rage, emotional numbness, or despair. the person’s manner of escalation of, or immunization to, emotions often reflects the age at which trauma or profound neglect occurred. the past is lived out in our client’s current lives. international journal of integrative psychotherapy, vol. 10, 2019 7 fourth, as integrative psychotherapists, we need to maintain our therapeutic focus on the client’s body. all experience—particularly if it occurs early in life or is affectively overwhelming—is stored in the amygdala and the limbic system of the brain as affect as well as visceral and physiological sensations without symbolization and language. instead of memory being conscious through thought and internal symbolizations, experiences are expressed in the interplay of affect and body as visceral and somatic sensations. our bodies remember the neglects, losses, and traumas of the past even if we cannot visually or verbally recall the events (cozolino, 2006; damasio, 1999; reich, 1945; van der kolk, 1994). the past is often embodied in the client’s physiology and lived again through current body sensations, gestures, and muscle tension. it is our task, as psychotherapists, to work sensitively and respectfully with the person’s bodily gestures, movements, internal images, and emotional expressions to stimulate and enhance the client’s sense of visceral arousal and awareness so that he or she has a new physiologicalaffective-relational experience. such sensitivity and respectfulness requires us to be attentive to the possibility of overstimulation and retraumatization and in such cases to take ameliorative action. the narrative of the body is a special language with form, structure, and meaning. through a body-centered relational psychotherapy we are able to decode the stories entrenched in our client’s affect and embodied in their physiology (erskine, 2014). fifth, as integrative psychotherapists we need to be sensitive to our clients’ unconscious relational patterns. early attachment dynamics are expressed in emotional responses, internal thought processes, decision making, and styles of interpersonal communication as well as through their script beliefs and attachment styles. clients’ script beliefs reflect early relational patterns that are not only embodied in their physiology and enacted in their behavior but also encoded in stories and metaphors as well as being envisioned in their fantasies, hopes, and dreams. we need to appreciate how script beliefs formed in childhood shape current thoughts, fantasies, and behaviors and how current behaviors, fantasies, and thoughts reinforce script beliefs. these script beliefs are based on implicit experiential conclusions that may have been formed from real experience during several developmental stages (erskine, 2015). sixth, as integrative psychotherapists we may use the concepts and methods of child therapy with some adult clients. we can create a child-sensitive psychotherapy that is responsive to the physiological, affective, imaginative, and verbal communications of the client’s “internal child.” such child-sensitive therapy provides the psychotherapist with empathic and reparative responses to the ways international journal of integrative psychotherapy, vol. 10, 2019 8 our adult client’s internal child is expressing his or her confusion, distress, agony, contentment, or joy. by thinking in a child-centered way, we can create a therapy that goes beyond verbal dialogue, one that makes use of imaginative enactments, play, drawing and art, music, and/or movement and dance. seventh, as integrative psychotherapists, we make use of the concept of ego states because it provides theoretical understandings about how the sense of self can be fragmented into separate identities. each fragmentation of a sense of self represents a desperate archaic attempt to self-stabilize and self-regulate in order to manage or compensate for previous failures in significant relationships. eric berne’s (1961) original model of ego states provides a way to understand both our clients’ intrapsychic distress and the nature of their transactions with others. john watkins’s (watkins & watkins, 1997) model of ego states helps us to understand how each ego state epitomizes cumulative neglect or trauma. my own model depicts the internal dynamics between a vital and vulnerable self, a social self, introjection, and an internal, self-created critic (erskine, 1999). each of these ego state models informs our understanding of our clients’ internal dynamics and helps us choose our therapeutic interventions. eighth, as integrative psychotherapists, we make use of the paradoxical theory of change and the significance of being with a person. we use our knowledge that the more change is the focus of our therapeutic practice, the more an individual will unconsciously maintain previously formed modes of behavior (beisser, 1971). we facilitate our clients’ understanding and appreciation of the psychological functions of their behaviors, repetitive feelings, or obsessions before attending to behavioral change. change in behavior is often integral to an effective psychotherapy but an emphasis on changing behavior distracts clients from awareness of their phenomenological experiences, the homeostatic functions of their behaviors, and the opportunity to freely choose how to live life. conclusion these eight essential points represent how i currently practice integrative psychotherapy. i hope they will provide a blueprint for the future maturation of our theories and methods of a developmentally based, relationally focused integrative psychotherapy. these points become meaningful only when they are imbued with our full presence as therapists. presence refers to our internal sense of being with and for the client, commitment to the client’s welfare, and the ability to put our own needs and desires into the background while remaining emotionally responsive to international journal of integrative psychotherapy, vol. 10, 2019 9 all that occurs in the relationship. presence expresses an “i-thou” relationship—a quality of relationship that heals. author: richard g. erskine, institute for integrative psychotherapy, vancouver, canada, & deusto university, bilbao, spain references beisser, a. (1971). the paradoxical theory of change. in j. dagan & i. l. shepherd (eds.), gestalt therapy now: theory, techniques, applications (pp. 77–80). new york, ny: harper & row. berne, e. (1961). transactional analysis in psychotherapy: a systematic individual and social psychiatry. new york, ny: grove press. buber, m. (1984). i and thou. ®. g. smith, trans.). new york, ny: scribner. (original work published 1958) cozolino, l. (2006). the neuroscience of human relationships: attachment and the developing social brain. new york, ny: norton. damasio, a. (1999). the feeling of what happens: body and emotion in the making of consciousness. new york, ny: harcourt brace. erskine, r. g. (1975). the abc’s of effective psychotherapy. transactional analysis journal, 5(2), 163–165. doi:10.1177/036215377500500218 erskine, r. g. (1980). script cure: behavioral, intrapsychic and physiological. transactional analysis journal, 10, 102–106. doi:10.1177/036215378001000205 erskine, r. g. (1999, 20 august). the schizoid process [opening address]. international transactional analysis association conference, san francisco, ca. erskine, r. g. (2013). vulnerability, authenticity, and inter-subjective contact: philosophical principles of integrative psychotherapy. international journal of integrative psychotherapy, 4(2), 1–9. erskine, r. g. (2014). nonverbal stories: the body in psychotherapy. international journal of integrative psychotherapy, 5(1), 21–33. erskine, r. g. (2015). relational patterns, therapeutic presence: concepts and practice of integrative psychotherapy. london: karnac books. international journal of integrative psychotherapy, vol. 10, 2019 10 erskine, r. g., & moursund, j. p. (1988). integrative psychotherapy in action. newbury park, ca: sage publications. erskine, r. g., moursund, j. p., & trautmann, r. l. (1999). beyond empathy: a therapy of contact-in-relationship. new york, ny: brunner/mazel. erskine, r. g., & trautmann, r. l. (1993). the process of integrative psychotherapy. in b. loria (ed.), the boardwalk papers: selections from the 1993 eastern regional transactional analysis association conference (pp. 1– 26). madison, wi: omnipress. erskine, r. g., & trautmann, r. l. (1996). methods of an integrative psychotherapy. transactional analysis journal, 26, 316–328. doi:10.1177/036215379602600410 erskine, r. g., & zalcman, m. j. (1979). the racket system: a model for racket analysis. transactional analysis journal, 9, 51–59. doi:10.1177/036215377900900112 fairbairn, w. r. d. (1952). an object-relations theory of the personality. new york, ny: basic books. moursund, j. p., & erskine, r. g. (2003). integrative psychotherapy: the art and science of relationship. pacific grove, ca: brooks/cole-thomson learning. reich, w. (1945). character analysis. new york, ny: farrar, strauss & giroux. rogers, c. r. (1951). client-centered therapy: its current practice, implications, and theory. boston, ma: houghton mifflin. van der kolk, b. a. (1994). the body keeps the score: memory and evolving psychobiology of posttraumatic stress. harvard review of psychiatry 1, 253–265. doi:10.3109/10673229409017088 watkins, j. g., & watkins, h. h. (1997). ego states: theory and therapy. new york, ny: norton. (original work published 1967) alcoholism is such a common condition that therapists must be exposed to clients who suffer from it, whether the therapist is regarding developmental perspectives brigitte rota abstract: this case study presents the work with frederic and how a bridge is being built between his current problems and an understanding about how his identity was built. the case study presents a dialogue with the client and therapist in the therapeutic relationship. transference, countertransference issues are discussed along with inquiry, attunement, and involvement in the therapeutic journey “we are making together”. ____________________________ frederic is 41 years old and lives with his companion. he has a 2 year old boy. he is a choreographer, a composer and a dancer. he has conceived a “numeric dance” and with a technician, he has invented movement sensors, plates that are placed on the body that are recording body movements and transmitting them to a computer that is translating them into sounds, sounds that the dancer can listen to, thus hearing what his body is creating. “i am connecting to the intensity of the inner movement. i am liberating the bodies where there is no shell. first connection with movement sensors, i am attempting to create a dialogue between the body and the music, thus making it body music. the sound is born through the movement. finding the instinct. totally connected to oneself. the song of the body.” i am amazed. by his creativity, by this extraordinary setup of body sensors he is inventing. i will use this notion of body sensors and shift it to emotional sensors. when frederic says “i am connecting to the intensity of the inner movement”, i am myself in contact with the starting movement of integrative psychotherapy that he conceives as a creative step, loaded with the hope “of being connected with the other” and i perceive, as if by anticipation, the despair. like the famous man who is writing in prose without knowing it, frederic is practicing integrative psychotherapy without knowing it. frederick came to therapy one year ago because he felt he was in a situation of failure with a group of dancers in a show he had created, a feeling that this situation is repeating itself. “i’m living too badly. i want to understand where this has its roots; i want to scrape the bottom of the drawers to defuse what i’m loaded with. i have trouble making myself understood, getting what i want. i’m keeping a low profile and then i give up. i’m working with wild cats (the dancers). i have hatred; i didn’t manage to win the respect of the people with whom i am working.” listening to him as he talks about what he is experiencing at the moment, i’m wondering what he’s talking about. and whom he’s talking about, and how he is international journal of integrative psychotherapy, vol. 1, no. 1, 2010 33 speaking to me about his history. “my dream is to find someone who would talk on my behalf, using the words i have in my head, who would tell about the unfair things i have experienced and who would take a stance for me. i am outside of everything, without a tribe to welcome me.” i understand what kind of therapist he wants me to be for him, and he gives indications about the treatment plan that needs to be constructed while shedding light on his wounds. frederic is the only son of his parents. he has a half sister he doesn’t know, a daughter from his father’s first marriage. he presents her as “paranoid” who has been hospitalised in a psychiatric hospital on several occasions. frederic severed the link to his father one year ago, in order “to catch breath. i can’t deal with the violence that has been inflicted”. his father is in the army; he was a mercenary during the war in algeria. frederic describes him as being violent, abrupt, discounting, and never satisfied. and he presents his mother as being without emotional echo, unwelcoming, without emotional sensors to sense his emotional reality. he describes himself as a child locked in its own world, a world defined by loneliness and isolation, a bit like a flower that closes when it’s touched, or the eyes of a snail. without knowing it, he invites me to be careful, and tells me how important it is to stick to his own rhythm. his world is a world of science fiction, of planes, of models and planets. a world of dreams and loneliness. he lived in an apartment complex in a working class neighbourhood of paris and in the power struggles he found a code, at last, and attempted to hide his sensitivity with his snail’s eyes. it was a code one had to decipher, to integrate, that was making contact possible and was giving access to the other: “to lower the eyes when you come across someone you don’t know. respecting authority. in a code of violence.” frederic speaks freely about his current suffering or about his history after the age of 16 “i’ve started to exist when i was 16”. when i’m exploring on the phenomenological level, example his feelings or his body sensations, he cuts the contact by talking about something else, or by laughing. the meanders of his thoughts in which frederic stays in a current dialectic of his trouble with relationships are like attempts to cling to something that is known and manageable. he also cuts the contact with laughter. laughing is used in order not to feel; laughing interrupts the contact with himself and with me. i chose not to confront him and to accept his frame of reference thus also accepting his defence system, in order to form an alliance. in the proximity with little frederic, his laughter hurts me. no hurry. being there. with what i know. with what he can’t know about his own experience. every time i mention the relationship to his mother, frederic answers me with the neighbourhood. as if the neighbourhood had had a maternal function that was giving an access code to communication. even when it is violent, this code gives access to the other person. “i built my identity when i was 16. i started to exist in the street. with dance. i needed to be a member of a tribe, i needed to belong.” i hear: looking for access codes, attempting to make sense, looking for stimulation and contact. looking for another, for relationship, for family. frederic gives an indication of what has been missing during the first 16 years of his life: “i started to exist with dance, that is creating movement, connexion, that is articulating the body and stimulating the senses. music is setting the rhythm. a rhythm that is carrying and structuring the movement. and that is creating a link to oneself and to the other.” international journal of integrative psychotherapy, vol. 1, no. 1, 2010 34 and in my head i’m thinking of winnicotts concepts of holding and handling; the music as a good enough mother that is creating stimulation, rhythm and movement. my comment bemuses him and we decide on a contracting dynamic to help him bring to consciousness what previously was unconscious, and to explore his phenomenological experience when he’s talking about his current problems. we are building a bridge between: today and his history his body sensations, his emotions, his behaviour and his thoughts; we have to construct together the story of the first 16 years of his life in order for him to own the missing parts. i offer him the space to create this missing story. and thus the missing relationship with another who is present and caring for his experience. this dynamic aims to give sense, to bring matter to the self, to the self that has been missed. and to the self that is missing, to the interruptions in contact with his inner truth, to his confusion and his wounds. body sensations. at the body level, frederick feels pain. he feels that he was born when he was 16 through the movement of dance, feeling that he belonged to a tribe. stimulation of the body, awakening of the senses. initiating life in contact. dead stimulation in the relationship to his mother. affect. affect is repressed or expressed in an exaggerated way. it’s the expression of a disavowal, a way of freezing emotionally. behavior. on the level of behaviour he mobilizes his energy to create, thus hoping to create a connexion to the other. in his childhood, frederic talks about his need to create objects, models and other devices to struggle against anguish. the articulation between thought and behaviour seems to be the favourite area in his personal and interpersonal dynamics. “ the hope of my life is to meet someone who would hear what i need. i’ve always been afraid of my increasing frustration and violence, i’m afraid of destroying. so i’ve decided to be stronger than my own violence, to be smarter (than whom?). i’m letting myself being treated like a doormat, the other one doesn’t take me seriously because i’m afraid i could escalate into violence”. because his anger didn’t make an impact on the other. “it contaminates my potency and part of me surrenders. it’s like a gap in a leaking ball. i so much would like someone to understand what i’m experiencing. i feel like a helpless chick that is complaining, that is exaggerating, that is overdoing things. my mother kept telling me that i was overdoing things, that things weren’t so bad, that what i was experiencing wasn’t important. it was unimportant. she certainly said that to protect me, to reassure me. and what are you thinking today? she didn’t give me any importance, no value. i hate myself for being like that, i feel guilty, and i feel like an alien. and what did you conclude? that she was right, and i was messing around. instead of… tell me mum that it’s not me who is messing around, but that it is you. it was a necessity for the child to believe there was something wrong about him. it’s a necessity for him to believe that and to convince himself of that. it prevents him international journal of integrative psychotherapy, vol. 1, no. 1, 2010 35 from feeling the rage against his mother, and his helplessness to change what is wrong with her.” during the last performance of his show, in a youth club that is not very adapted to the constraints of his staging, the spectators come and go, not very respectful of the show. “i felt violated, disfigured, ashamed. i am my creation. i’m asking the dancers to stage what is in my head, what i feel. they don’t understand and they don’t go to the end of the work”. i understand that frederic entrusts the dancers with his heart, expecting them to grasp what he is experiencing inside and to connect with him. like a good enough mother would do. the champollion mother who is deciphering, decoding the sense of what her baby gives her to know. a mother who lets herself experience the connection, feeling and offering an adequate response. he stages (behaviour), thinks about was he is staging, and entrusts to the dancers as maternal substitutes his emotions and his hope for connection. i can feel frederic’s despair, his quest, the sense of this quest on an existential level, this baby looking for arms, for adequate responses, for attention that would focus on the reality of its being. and while i let myself experience this desperate quest i let myself cry while connecting to the very small frederic. i feel compassion for this small boy. (me) “i’m touched and moved. i measure the sense of your words and your involvement in your shows. you are expecting a very special connexion to another who would capture what you feel, what you experience. what the small frederic missed mostly. what all children need to live, and to feel that they exist in the connexion to another who is present, stable, available.” frederic is surprised. i ask him what he is feeling when he sees me touched. “it’s a technique. a professional skill to let oneself be touched. to let oneself be touched is not something one learns, it’s a human availability to receive the pain of another person.” faced with the defensive reaction of frederic, i’m realizing what he is projecting onto me: uninvolved, neglecting, unconcerned parent neglected child the client will project onto the therapist the same realities as those he has regarding his inner parents. attunement to a sensitive and connected other and to his own history is something unthinkable, unrepresented in frederick’s frame of reference. the risk of a connection is too big and it would let the pain caused by what was missing emerge (we are talking here about the pain of juxtaposition): “i’m too afraid of what i need the most. it brings me down.” he comes furious, livid, to the following session. he says he’s being mistreated, not considered, and disavowed by a colleague for whom he has composed a piece of music: “i don’t feel that i exist. international journal of integrative psychotherapy, vol. 1, no. 1, 2010 36 your anger means that you need something that you don’t get from this person. i’m afraid that the other doesn’t take into consideration what i feel. what you need is being taken into consideration. and when you are afraid that it won’t happen, what are you telling yourself? i can’t imagine that i will obtain reparation or consideration. (laughs) that’s not possible. this looks like the conclusion of an old story. yes, it seems so. it’s always been like this. what might the little frederic feel when he doesn’t receive consideration for what he feels and he needs it? he feels furious, livid, and that he doesn’t exist. what are you feeling right now? hurt, i feel sad.” in the following session he says he has contacted his colleague. “i don’t feel understood, i’m shutting down, i’m withdrawing feeling heart sick, like when i was small. where are you withdrawing to? into my world. and what is little frederic’s world like? it’s a science fiction world. i need to build things, models, planes that could take me to another planet. where there would be someone who would show consideration for little frederic’s feelings. (laughter). i’m mad that i’m still there. at the same point. i gave a lot hoping that one day… one day… i would find security, a permanent dynamic, that the emptiness would fill up. instead i’m not peaceful; i have no trust in myself.i gave a lot, my trust, the best i have, i have smoothed the edges, i’ve kept my feelings to myself, i’ve answered to their demands (the dancers’). always wondering: have i brought the answer he was waiting for? am i as expected? it has cost me a lot to try to do it right. and it is unbearable, i am feeling helpless. desperate.” it is easy for me to shift the expression of what the grownup frederic feels now to the little frederic. while listening to him, i represent the child to myself, a small man smoothing the edges, keeping his feelings to himself between a mother “ taking good care of my food and clothes”, who has been living in a convent, who is considering her life as a sacrifice, and a dad who is either absent or violent. i imagine with pain this little boy in his world of dreams and hope. and suffering. “i’ve made all the efforts in the world to gain the dancers’ respect. i am resentful. who are you talking about?” i understand that he is talking about the dancers and i hear the transferential shift dancers/daddy/mummy. “ you’ve hurt me too much. you? the dancers, my parents. since i was a young boy, i’ve been trying to find the access code to my mother. there isn’t any. it gives me the creeps. i don’t know why international journal of integrative psychotherapy, vol. 1, no. 1, 2010 37 i’m thinking of this right now (laughter). some time ago i saw the movie a.i. (artificial intelligence) by s. spielberg (laughter). strange that i think of that now (laughter).” i ask frederic to tell me the story of that little boy, the hero of the movie. while he tells me, frederic is shifting between laughter, moments of silence, moments where he says, “it’s crazy what this little boy did, and all for nothing”, moments during which he seems touched and in pain. he is restless on his seat and he punctuates his sentences with “this is crazy, what a waste!” i punctuate his sentences with “an abandoned child looking desperately for a connexion to its mother and that is wandering about in a world full of danger in order to become an exceptional child: worthy of its mother’s love.” i hurry to buy the dvd of the movie and i let myself enter the triangulation between frederic, david (the movie’s hero) and me. in the movie, humans share their daily life with very sophisticated robots called mecas as in mechanics. a prototype of a child robot is programmed to devote an unconditional love to its parents. the child robot is sent to a foster family. the legitimate child of the family is in a deep coma and kept in ice. it eventually returns to the family and there trouble begins for david, the child robot. david desperately seeks the connection to a mother who doesn’t understand his attempts and decides to abandon him. david understands that something is the matter with him and he wants to find the blue fairy that will change him into a genuine boy, thus making it possible for his mother to love him. the blue fairy comes from the story of pinocchio mummy used to tell him (before the return of the legitimate son). he begins the quest for this fairy, meets a love meca (played by jude law, there i crack… jude law as love meca!) so, together they go to consult dr. know, the doctor who knows everything to find the whereabouts of the blue fairy who has answers to everything. the blue fairy exists in just one place at the end of the world where the lions are crying. that’s where dreams are born… then my mummy will come to tuck me in and she will tell me stories, she will sing for me because i’m exceptional, unique. there will never be anyone like me, she’ll cuddle me and will tell me a 100 times a day that she loves me… at the end of the story we stay silent. my eyes are filled with tears, and frederic cries inside. during the next session: “there’s never been a true connection between my mother and me how do you experience this child that is deprived from the connection to its mother? i don’t what kind of music would you write to represent it? what kind of music would capture what this child is experiencing? a music that would talk about the need for arms. about arms that are reaching out and that don’t find anything. nothing in front of them. the tunes would not be right, they’d be out of synch, hurting the hear, an endless note, like long stretched threads corresponding to a note. it’s as if the note was stretching into the infinite. the note will stop when the small one is exhausted. out of despair. what do you feel in your body? tight and in your heart? sad. i see myself crying. international journal of integrative psychotherapy, vol. 1, no. 1, 2010 38 how old are you when you see yourself crying? small. i was a depressed child when i was 6-7 years old. i was skinny, i didn’t eat, i was fainting. i think it was because of the fear. how are you cutting the connection? in order to cut yourself from the fear?” at this moment frederic feels pain in his hip. the same pain that was preventing him from walking when he was small. (laughter) “it’s funny, i haven’t felt this pain since i was a child, it’s incredible.” (laughter). he leaves the session limping, shaking with laughter. this pain is a language. this body memory tells about something traumatic, without words and without being able to verify its contents. in terms of process, this body memory erupts as a means to cut off the emotion. in the following session frederic is desperate. “i don’t believe in myself anymore. my time has passed. i couldn’t or didn’t know how to exploit the right people at the right time. i depleted all my resources in order to keep existing. it’s as if i was experiencing an end of the world. it’s like when i was 11-12 years old, i was already afraid of the void. i feel lonely. and when you feel lonely, what is the colour of the world? the world is grey, the sky is grey, i’m looking out of the window, there’s nothing. i’m alone and there is no noise. i’m in anguish to leave my bubble to go to school or to music school. i remember, when i was 7-8 years old, i was afraid of death. death is there, present. i’m going to die, to disappear. i can’t go to any other place; i can’t run away from time. i’m locked up in this process. as if i was a prisoner of the planet earth, i see the blue earth, there’s only me, a small point, there’s no one. no one ‘s there, there’s no other place to go, it’s as if one was a prisoner and no one else is on the planet earth. i understand it makes you feel like dying. it’s like an end of the world. at night, if i called mummy because i was thirsty or i needed to pee, the monster that was living in our flat could hear me. so i kept quiet, or i called her very softly. i was afraid of the darkness, because he could see me while i couldn’t see him, so i switched on the lights to see him. and no one there to hear the fear of that little boy who believes there’s a monster living in the flat. no one to look under the bed, to open the closets with him. no one to protect this child and to comfort him. all alone on the planet. to get out of my nightmares i used to switch from black and white to colour, i invented myself a disney world, as if i was pulling the curtain of a theatre, hop, and it was gone. it was a smart move to invent this curtain, to put some colour to get a grip on your anxiety. by lack of anyone. i have trouble imagining that it could be otherwise. i often have the impression that i’m exaggerating. i’m not the only one who experiences this; i have to move on, as my mother used to say. i am moved by this small one who is struggling on his own against a monster and his fear of darkness. who feels he’s dying from fear, which is living on a grey planet. alone. like a small dot on the planet where there is nobody else. who doesn’t feel he exists as a person. because he is without relationship.” we stayed silent. without words. without laughter. just there. international journal of integrative psychotherapy, vol. 1, no. 1, 2010 39 international journal of integrative psychotherapy, vol. 1, no. 1, 2010 40 and here we are, in this journey together we are building step by step. the impression that one is exaggerating is a desperate attempt to minimise or trivialise what one feels: it’s a way of cutting contact with oneself. i suppose that this kind of emotional avoidance can also represent an attempt to conform to the discourse of his mother in order to make contact, using unconscious defensive identification. i understand this process as a self-soothing system and as a way to smother his feelings and/or the intensity of it. the analysis of transference “i am alone in the world, no one can understand what i’m experiencing, no one can give an answer to my need for consideration. you can’t do anything for me”, and of my counter transference is a valuable source of information allowing us to make sense of what is occurring in the therapeutic relationship. when in my countertransference i am communicating to frederic what is happening in me, the impact of his story on me, when i’m transposing what he’s telling me about his problems with the dancers to the world of the little boy, he is surprised in his awareness here and now. it is as if this communication was creating a space and time allowing him to begin to be in contact with himself. it’s a relational process that can act as an anticipatory projection of my availability to welcome him. i am using what i am feeling in my heart and in my thoughts; i am formulating hypotheses while keeping my own sense of a distinct self. i am using the contact with myself to make contact with frederic, as an emotional base to reconnect the self. the function of this attunement is to facilitate the integration of feelings, of emotions, of physiological sensations in order to integrate the unconscious to the conscious. through my sustained presence and contact, the cumulative trauma caused by the lack of satisfaction of needs can be addressed and treated in the relationship. the objective is to support the complete regression that will make it possible for the child to develop a sense of self. brigitte rota is a clinical psychologist and psychotherapist. she is a trainer and supervisor of the international integrative psychotherapy association. she supervises professionals in psychotherapy, health and education fields and uses body meditation and arts to foster change in the therapeutic process. she works in marseille, france. alcoholism is such a common condition that therapists must be exposed to clients who suffer from it, whether the therapist is the integrative psychotherapy scale for assessment of therapist’s activity gregor žvelc abstract: the article describes a new assessment instrument for measuring the activities of an integrative psychotherapist. the first part of the instrument is concerned with establishing and maintaining a therapeutic alliance, and includes the competencies of forming an effective empathic bond, contracting and dealing with ruptures in the alliance. the second part focuses on the methods of integrative psychotherapy, and includes competencies of effective inquiry, attunement, involvement and the use of therapeutic interventions. the scale also includes scales which inform about the philosophy of the therapist and his dealing with transference / countertransference. the scale is currently in the preliminary phase of development and further research is needed to examine the usefulness, validity and reliability of the scale. _______________________ while training future integrative psychotherapists at our institute for integrative psychotherapy and counselling in ljubljana, we have become increasingly interested in how to assess the practical work of our trainees. although there exist different scales for measuring the work of a psychotherapist, as of yet we have no assessment tool within the integrative relational approach developed by erskine, moursund and trautmann (1999). therefore, the integrative psychotherapy scale for assessment of therapist’s activity (ipsata) was developed in order to assess a psychotherapist according to the methodological frame of integrative psychotherapy. such a scale shows the potential of being used for different purposes: 1) assessment of the trainee 2) supervision of the psychotherapist’s work 3) self-supervision 4) research purposes. international journal of integrative psychotherapy, vol. 1, no. 2, 2010 1 the scale consists of four main parts: 1) establishing and maintaining the therapeutic alliance 2) methods of integrative psychotherapy 3) additional scales for understanding the therapist’s work 4) overall rating. establishing and maintaining the therapeutic alliance this part of the scale assesses the therapist's capacity to establish and maintain a therapeutic alliance, which is a very important factor in psychotherapy. many researchers have explored the effectiveness of different kinds of therapies, yet over the years, they have come to similar conclusions. firstly, no particular treatment is more effective than any other and secondly, the therapeutic alliance is an essential integrative variable (evans & gilbert, 2005). bordin (1979) suggested that a good alliance is a prerequisite for change in all forms of psychotherapy. furthermore, the alliance consists of three interdependent components: • client and therapist agreement on goals of treatment • client and therapist agreement on how to achieve the goals (agreement on tasks) • the bond between the therapist and the client (bordin, 1979). the strength of the alliance depends on the degree of agreement between the client and the therapist regarding the tasks and the goals of therapy, as well as on the quality of the relational bond between them. additionally, safran and muran (2000, 2003) emphasize the importance of mutual agreement on treatment tasks and goals, and highlight the critical role of ongoing negotiation and mutual accommodation. establishing and maintaining a therapeutic alliance is a common factor in all psychotherapy approaches. the integrative psychotherapy scale for assessment of therapist’s activity includes three significant competencies which are important for the therapeutic alliance: 1) the empathic bond – assess the therapist’s capacity for empathic responding which is crucial for developing contact between the client and the therapist. such therapist is able to show the capacity for decentering from his own experience in order to understand the client's phenomenological world. 2) contracting – in integrative psychotherapy, the agreement between the client and the therapist regarding the tasks and the goals of therapy is conceptualized as contracting. for an integrative psychotherapist, process contracts, which negotiate the direction of the treatment and international journal of integrative psychotherapy, vol. 1, no. 2, 2010 2 determine which interventions are used on an ongoing basis, are of particular importance. consequently, contracting is an ongoing process rather than a singular act in the initial stages of therapy. 3) dealing with ruptures in the alliance – this competency includes the awareness of a rupture in the therapeutic alliance and an effective way of disembedding from the enactment that is taking place. the therapist can effectively deal with the rupture either implicitly (by changing the style of interaction) or explicitly (by acknowledging his part in the interaction and metacommunicating about the interaction which is taking place). methods of integrative psychotherapy erskine and trautmann (1996) describe three main methods of relational integrative psychotherapy: inquiry, attunement and involvement. with the help of inquiry, attunement and involvement, the therapist provides a relationship that allows and invites the client to become increasingly contactful (internally and externally), to dissolve the defences and to recover the parts of self that have been lost from awareness. the ipsata assesses the following competencies: 1) inquiry involves respectful exploration of the client's phenomenological experience. the therapist asks the client to reveal to him his subjective perspective; in doing so, the client becomes increasingly aware of his relational needs, feelings, behaviour and thoughts (erskine et al., 1999). the therapist invites the client to search for answers, to think in new ways and to explore new avenues of awareness. for an effective inquiry, there is no expectation that the client will come to some predetermined goal or insight (erskine et al., 1999). inquiry promotes awarenes and increases internal and external contact. the ipsata differentiates inquiry from other forms of questioning processes which focus more on data and wherein a therapist has a predetermined goal and directs the client in a certain direction. 2) attunement erskine and trautmann (1993/1997) describe attunement as a two-part process: 'the sense of being fully aware of the other person's sensations, needs, or feelings and the communication of that awareness to the other person.' (p. 90). attunement goes beyond empathy – it provides a reciprocal affect and/or resonating response. effective attunement also requires that the therapist simultaneously remains aware of the boundary between client and therapist. with the help of attunement, the therapist gently moves through the client's defences and makes contact with the client's long-forgotten split off parts of the self. the international journal of integrative psychotherapy, vol. 1, no. 2, 2010 3 therapist can be attuned to a wide variety of client behaviours and experiences, but especially to his rhythm, nature of affect, cognition, developmental level of psychological functioning and relational needs. effective attunement is not just concerned with the immediate experience of the client. what is even more important is that the therapist is attuned to the unaware and denied aspects of the client. with effective attunement, the split off parts of the client are accessed and brought into awareness and experience. 3) involvement involvement means that the therapist is willing to be affected by what happens in the relationship with the client (erskine et al., 1999). therapeutic involvement includes acknowledgment, validation, normalization, and presence. with acknowledgment, the therapist demonstrates that he is aware of what the client is feeling and experiencing. validation is the acknowledgment of the significance of the client’s experience. it communicates to the client that his affects are related to something significant in his experience. normalization depathologises the clients’ definition of their internal experiences or their coping mechanisms. in this manner, the therapist communicates to the client that his experience is a normal, and not pathological or defensive reaction. presence means that the therapist ‘is there’ for and with the client, i.e. the therapist is committed to the client's welfare. the goal of involvement is to dissolve the defences which interfere with the satisfaction of current needs and which prevent full contact with self and others in the here and now. involvement promotes new relational experiences which invite the client out of his old repetitive patterns. 4) therapeutic interventions an integrative psychotherapist uses a variety of interventions which promote integration of affect, cognition, behavior, physiology and spiritual dimensions of the client (erskine, & trautmann, 1993/1997). interventions are used within the frame of the main methods of inquiry, attunement and involvement. the therapist checks the impact of interventions on the client on an ongoing basis. relational epistemological stance and the use of transference / countertransference the ipsata includes additional scales which are not intended to assess the therapist’s work. their role is to facilitate further understanding of the therapist's work, his work philosophy and the use of transference and countertransference. as it is difficult to assess these issues based on an individual therapy transcript, they are used more in terms of providing additional information and clarification. these three scales are rather general and may be refined in the future for more clarity and differentiation. international journal of integrative psychotherapy, vol. 1, no. 2, 2010 4 1) relational epistemological stance integrative psychotherapy is based on the relational paradigm of psychotherapy which states that the client and the therapist form a system of mutual influence (žvelc & žvelc, 2003). an integrative psychotherapist is aware of the mutuality in a therapeutic relationship, and of his/her own contribution to this relationship. he/she acknowledges that the client and the therapist present a system of reciprocal influence and that neither of them possesses the 'objective' truth. 2) working with/within transference/countertransference an integrative psychotherapist works with or within the transference /countertransference matrix. effective work with/within transference may promote insight and/or new relational experiences which invite the client out of his script. in integrative psychotherapy, the therapist may use his countertransference experience during a therapy session, either directly or indirectly, and through careful self-disclosure. conclusion the integrative psychotherapy scale for assessment of therapist’s activity was developed in order to assess the work of an integrative psychotherapist. it includes the fundamental competencies of the integrative psychotherapist. the scale is currently in the preliminary phase of development. the use of the scale by different trainers, supervisors and psychotherapists will demonstrate its potential applicability and, hopefully, provide changes and refinements. research is needed to examine the validity and reliability of the scale. gregor žvelc, phd is clinical psychologist and doctor of psychology. he is international integrative psychotherapy trainer & supervisor (iipa). gregor is director of the institute for integrative psychotherapy and counseling in ljubljana, where he has a private practice and leads trainings in transactional analysis and integrative psychotherapy. he is co-editor of international journal of integrative psychotherapy. he can be reached at institute ipsa, stegne 7, 1000 ljubljana, slovenia. e-mail: gregor.zvelc@guest.arnes.si homepage: www.institut-ipsa.si international journal of integrative psychotherapy, vol. 1, no. 2, 2010 5 mailto:gregor.zvelc@guest.arnes.si http://www.institut-ipsa.si/ references bordin, e. (1979). the generalizability of the psychoanalytic concept of the working alliance. psychotherapy: theory, research, and practice, 16, 152-260. erskine, r., & trautmann, r.l. (1993/1997). the process of integrative psychotherapy. in r. erskine (ed.), theories and methods of an integrative transactional analysis. (pp. 79-95). san francisco: ta press erskine, r. g., & trautmann, r. l. (1996). methods of an integrative transactional analysis. transactional analysis journal, 26, 316-328. erskine, r. g., moursund, j. p. & trautmann, r. l. (1999). beyond empathy. a therapy of contact-in-relationship. philadelphia: brunner/mazel. erskine, r. & moursund, j.p. (2004). integrative psychotherapy. the art and science of relationship. pacific grove: thomson. brooks/cole. evans, k. r. & gilbert, m. c. (2005). an introduction to integrative psychotherapy. london: palgrave macmillan. safran, j. d. & muran, j. k. (2000). negotiating the therapeutic alliance. new york: the guilford press. safran, j. d. (2003). the relational turn, the therapeutic alliance and psychotherapy research. strange bedfellows or postmodern marriage? contemporary psychoanalysis, 39, 449-474. žvelc, g., & žvelc, m. (in press). integrativna psihoterapija. [integrative psychotherapy] in m. žvelc, m. možina, & j. bohak (eds.), psihoterapija. [psychotherapy]. ljubljana: institute ipsa. international journal of integrative psychotherapy, vol. 1, no. 2, 2010 6 appendix the integrative psychotherapy scale for assessment of therapist’s activity (žvelc, 2010) date: _______ initials of the psychotherapist: _____ initials of the assessor: _____ assessment is based on: a) tape of a therapy session b) transcript of a therapy c) observation of a live therapy during psychotherapeutic training. instructions for the assessor: the ipsata includes the list of competencies of an integrative psychotherapist. based on your observation, please mark the number in front of the description of a certain competency: 1 – poor or no sign of competency 2 – some signs of competency 3 – satisfactory (good) competency 4 – excellent competency. part 1: establishing and maintaining the therapeutic alliance a. the empathic bond 1 – little or no empathic connection. the therapist did not understand the client on explicit and implicit (non-verbal) levels. 2 – the therapist was able to reflect back on what was explicitly said, but failed to resonate with the client on affective level. 3 – empathic connection was evident. the therapist was able to understand the client's internal reality on both verbal and non-verbal levels. the therapist demonstrated a good capacity for listening and empathy. 4 – excellent empathic skills. the therapist was able to effectively communicate to the client what he had empathically grasped, both on verbal and non-verbal level (e.g. tone of voice, gesticulation). he was able to decenter from his own experience so as to understand the client's phenomenological world. international journal of integrative psychotherapy, vol. 1, no. 2, 2010 7 b. contracting 1 – there was an obvious disagreement between the client and the therapist in terms of goals and treatment direction. the therapist failed to address this and did not make an appropriate contract. 2 – there was no explicit sign of diagreement between the client and the therapist in terms of goals, treatment direction and the methods used. however, the therapist was too directive and 'pushy', leading the client towards his own (i.e. the therapist's) agenda. 3 – there was a clear agreement between the client and the therapist regarding the goals of the session, treatment direction and the interventions used. the therapist used process contracts to negotiate the treatment direction and the interventions used on an ongoing basis. 4 – the therapist expertly used process contracts. he neither led, nor followed the client. there was a marked balance between leading and following the client, combined with an ongoing process of negotiation between the client and the therapist on both implicit and explicit levels. c. dealing with ruptures in the alliance 1 – the therapist showed no awareness of a rupture in the therapeutic alliance. enactment took place and the therapist did not reflect upon it. 2 – the therapist was aware of a rupture in the alliance, but his attempts to disembed were not effective (for example: he did not take responsibilty for his part, did not change his style of interaction). 3 – the therapist was aware of a rupture and effectively initiated disembedding (either implicitly by changing his style of interaction or explicitly). 4 – the therapist demonstrated an excellent capacity to deal with ruptures. the process of dealing with the ruptures promoted insight and provided new relational experiences. examples of behavior: the therapist acknowledged his part in the interaction, he apologised, metacommunicated about interaction that was taking place, etc. this code is used also if no rupture occurred. international journal of integrative psychotherapy, vol. 1, no. 2, 2010 8 part 2: methods of integrative psychotherapy a. inquiry 1 – the therapist did not use inquiry. he was more focused on facts and gathering data than on the client's process of getting to answer. the therapist had a predetermined goal and directed the client in this direction (closed questions, investigatory style). 2 – the therapist used inquiry and was focused on the client's process. however, inquiry was evident only on one level (e.g. cognitive) and did not promote awareness or contact with self and others. 3 – the therapist effectively used inquiry on both non-verbal and verbal levels. he showed no expectation that the client ought to come to some predetermined goal or insight. inquiry was connected to effective attunement and involvement. however, the client did not seem to discover anything new about himself. 4 contactful quality of inquiry. inquiry promoted awarenes and internal and external contact. during the session, the client discovered something new about himself. b. attunement 1 – no sign of attunement between client and therapist. the therapist did not resonate with the client on cognitive, affective, developmental, rhytmicall or relational level. 2 – there were few moments of effective attunement between the client and the therapist.the therapist was able to resonate with the client on one level (e.g. cognitive), but not on other levels. the other possibility is that the therapist had difficulties in differentiating between himself and others (i.e. he colluded with the client). 3 – the therapist and the client were attuned for the most part of the session. the therapist demonstrated a good capacity to resonate with the client on all levels. however, attunement of the therapist was more connected with the conscious materials than with the unaware split off parts of the client. 4 – excellent attunement. the therapist demonstrated a capacity to attune at cognitive, affective and rhytmical levels, as well as in terms of relational needs. with attunement, the split off parts of the client were accessed and brought into awareness and experience. international journal of integrative psychotherapy, vol. 1, no. 2, 2010 9 c. involvement 1 – no sign (or few signs) of involvement from the therapist. the therapist was not emotionally present and not available for contact. 2 – the therapist was involved through the session and used acknowledgment, validation and normalisation. however, the involvement was not congruent with the client (involvement was not connected with attunement). limited capacity for presence. 3 – the therapist showed good capacity for involvement and used acknowledgment, validation and normalisation of the client's experience. involvement promoted new relational experiences which invited the client out of his old repetitive patterns (script). 4 – the therapist showed an excellent capacity for involvement. he effectively acknowledged, validated and normalised the client's experience. he was fully present and invited the client to a state of presence. during the session, it was observed that the client deepened the contact with himself and the therapist. the client made steps out of the script. d. therapeutic interventions 1 – therapeutic interventions were ineffective or even reinforced the client's repetitive patterns of behaviour, feelings and cognition (script). interventions were not attuned to the client. 2 – the therarapist used interventions, but it could not be observed during the session whether the intervention had a positive impact on the client. the therapist did not monitor the impact of the intervention on the client. 3 – therapeutic interventions promoted movement out of script and were based on contact with the client. during the session, the therapist used few different interventions. 4 – the therapist skillfuly used interventions, which promoted integration of affect, cognition, behavior and physiology. the therapist used a variety of interventions, focusing on different levels of experience (cognitive, affective, behavioral, physiological). the therapist checked the impact of interventions on the client on an ongoing basis. international journal of integrative psychotherapy, vol. 1, no. 2, 2010 10 part 3: additional scales for understanding the therapist’s work (this scales are not to be used for assessment purposes. they are aimed at understanding of the therapist’s work from a relational perspective) relational epistemological stance (philosophy) a – the therapist worked primarily from a one-person psychology stance. he did not acknowledge his impact on the client's behavior and experience. the therapist was uninvolved and behaved as if he'd possess the truth. b – the therapists showed awareness of the process of co-creation between the client and the therapist. however, this was at the background during the sessions. the therapist was primarily concerned with the client's experience. c – the therapist was aware of the mutuality in the relationship and of his contribution to the relationship. he acknowledged that the client and the therapist form a system of reciprocal influence and that neither possesses the 'objective' truth. the therapist used his countertransference experience either directly or indirectly and through careful self-diclosure. understanding and the use of transference a – the therapists was not aware of transference. b the therapist directly worked with or within transference. from the session, it was not clear whether this had a positive impact on the client. c – the therapist expertly worked with or within transference. new insight(s) or new relational experience was evident through this process. international journal of integrative psychotherapy, vol. 1, no. 2, 2010 11 international journal of integrative psychotherapy, vol. 1, no. 2, 2010 12 understanding and the use of countertransference a – the therapist was not aware of his countertransference experience. he acted it upon the client without reflection. b – the therapist showed some awareness of his countertransference response. however, he did not use it to understand the client or the dynamics betweeen them. c – the therapist made effective use of his countertransferential response (i.e. in order to understand the client, self-disclosure) part 4: overall rating a. how would you rate the psychotherapist overall in this session, as an integrative psychotherapist? 1 – poor or no sign of competency 2 – some signs of competency 3 – satisfactory (good) competency 4 – excellent competency. b. final score (sum of all the numbers / 8): _____ / 8 = _____ alcoholism is such a common condition that therapists must be exposed to clients who suffer from it, whether the therapist is attachment, relational-needs, and psychotherapeutic presence richard g. erskine abstract: humans require the contactful presence of another person who is attuned and responsive to relational-needs. insecure attachment patterns are the result of repeated disruptions in significant relationships. this article describes eight relational-needs that, when repeatedly unsatisfied, lead to insecure attachment patterns based on the fears of loss of relationship, vulnerability, violation, and invasion.the healing of insecure attachment patterns occurs through a contactful psychotherapeutic presence that occurs when the attitude, behavior and communication of the psychotherapist consistently respects and enhances the client's integrity while responding to relational-needs. the article is the keynote address given at the 5th international integrative psychotherapy association conference in vichy, france, april 21, 2011. key words: attachment theory; relational needs, psychotherapeutic presence, insecure attachment ____________________________ from birth to death we are motivated by our biological need for attachment – the need to be in relationship. relationship is a biological imperative that exists throughout our lives. who we are and what we achieve occurs in an extensive matrix of relationships. it is through these emotional attachments and because of these relationships that we exist, grow, change, and achieve the things we do in life. our matrix of relationships constitutes a life-giving, nurturing and stimulating network of attachments (trautmann & erskine, 1999). “to be human is to be in relationship with others” (erskine, moursund, & trautmann, 1999, p. 4). we cannot avoid being connected with others. none of us exists except in relationship; we are born in relationship and need relationships to know who we international journal of integrative psychotherapy, vol. 2, no. 1, 2011 10 are in this world. the essence of our humanness is inextricably tied up in our attachments and the ways we relate to others. we are conceived and born within a matrix of relationships and we live all our lives in a world that is inevitably and constantly populated by other humans --even when we are in a fantasy, we are often in relationship with someone, either approaching someone or distancing from someone. developing the many relationships that we have is a fundamental aspect of our growth (gazzaniga, 2008). we cannot live as humans without relationships, and our environment must provide us opportunities to develop and use them as we move through life. every person, and especially every child, requires relationships in which the other person is reciprocally involved. we require the contactful presence of another person who is sensitive and attuned to our relational-needs and who can respond to them in such a way that the needs are satisfied (clark, 1991). as therapists, we frequently find ourselves working with clients for whom such relationships have not been consistently or dependably available. such clients experience not only the needs of a here-and-now relationship, but the unmet relational-needs of past insecure attachments as well. our therapeutic presence, our attunement, and our involvement must extend beyond the needs of the present; we must also be responsive to our client’s old unmet needs -not that we must satisfy those archaic needs. attempting to satisfy a relational-need of a previous decade is an impossible task. in an in-depth relational psychotherapy we respond to our client’s un-met archaic needs through our attunement, acknowledgement, explanation, and validation so that the client can understand and appreciate his or her own experience of being. often the intensity of old unmet relational-needs overshadows and distorts the relational-needs of the here-and-now therapeutic relationship. a major task of the psychotherapist is to help the client differentiate between current needs and archaic needs. relational-needs are present throughout the entire life cycle from early infancy to old age. people do not outgrow their need for relationship. these needs are the basis of our humanness. even as adults we attach to others because we perceive them as being able to satisfy our variety of needs. when our relational-needs are met, we have the capacity to be expansive, creative and intimate. when relational-needs are repeatedly not met, we experience a sense of insecurity and emotional disturbance. we adapt to this insecurity by developing attachment styles or patterns that compensate for the disruption in relationship. these insecure attachment styles and patterns are the result of repeated disruptions in significant relationships. often these insecure attachment styles and patterns become fixated and endure over a long period of time. another major task of psychotherapy is to help our clients resolve their fixated insecure attachment patterns. international journal of integrative psychotherapy, vol. 2, no. 1, 2011 11 attachment when a child’s caretakers are inconsistently responsive in satisfying the child’s relational-needs, a pattern of clinging and over-dependency develops -a pattern wherein the child is nervous, constantly focused on the caretaker, and worried about the loss of nurturance. the phenomenological experience of such relational inconsistency is in a sense of “neediness”. the person becomes sensitive to other’s misattunements and highly adaptive to others in order to get some semblances of his or her needs satisfied. later in life they often experience that other people will not take their needs seriously. they have an implicit fear of loss of relationship and will often do anything to cling to a relationship even if it is not good for them. this history of inconsistency in need satisfaction results in a pattern of attachment that is uniquely different from those who had caretakers who were predictably unresponsive to the child’s relational needs. when parents, caretakers, teachers or other significant people are consistently emotionally unavailable and predictably unresponsive to relational-needs, the child’s needs for security, validation, or self-definition get ignored. when a child’s feelings and needs are consistently ignored eventually the child can predict that “i will not get any emotional sensitivity” or “my needs will not be met”. in these situations children often give up trying to be connected to significant others or they may even give up sensing their own needs. a child who lives with significant relationships that are consistently misattuned and emotionally unresponsive may later in life compensate for the lack of need satisfaction by avoiding intimacy and undervaluing the importance of relationship. they may appear to be emotionally detached and even disdainful of their own or other people’s needs and emotions because they have an implicit fear of vulnerability. when significant people in a child’s life are predictably punishing, particularly when the child is in the midst of expressing his or her relational-needs, there is a disorganizing traumatic reaction within the child’s brain and body. this disorganization is profoundly disturbing internally hence subsequently in relationships. if the very person on whom the child depends for need satisfaction is the same one who is predictably punishing, then the child’s experience of body sensations, affects, needs, and relationship will be profoundly confusing. this confusion may endure later in life as a highly disorganized style or pattern of attachment because they have a physically intense implicit fear of violation. when a child’s natural dependency on significant others for their satisfaction of relational-needs is repeatedly met with invasive and controlling caretaking --an accumulation of rhythmic and affect misattunements --the child may then develop patterns of relationship and attachment marked by a social façade, psychological withdrawal, and the absence of emotional expression. people with international journal of integrative psychotherapy, vol. 2, no. 1, 2011 12 an isolated attachment style or pattern have an implicit fear of invasion that is reflected in the both their diminished affect and withdrawal in interpersonal contact. to be authentic is sensed as dangerous. i have been describing four styles or patterns of insecure attachment. each has its antecedents in the quality of relationship that the child has experienced in his or her history of relationships. and each of these four types of attachment is based in a sub-symbolic, implicit fear: fear of the loss of relationship, fear of vulnerability, fear of violation, and/or fear of invasion. these four classifications of attachment are based on the research and clinical writings of a number of authors (ainsworth et al, 1978; doctors, 2007; hesse, 1999; main, 1995; o’reilly-knapp, 2001). however, clinical experience has shown that there are many more insecure attachment styles, patterns and disorders than the four mentioned here. any of these four may be in combination with the other three. there may also be distinctly unique expressions of attachment that our client’s may reveal to us if we are sensitive to the unconscious expression of their relational history and how that attachment history is enacted in the here-andnow. as psychotherapists we must look beyond this limited taxonomy of relationships and discover with the client his or her unique ways of being in connection with others. in fact, we each may have more than one attachment style or pattern. children develop in a matrix of relationships wherein each significant other may respond to the child’s relational-needs in a different way. over time children may develop one type of attachment with mother, another with father, and another with an older or younger sibling. teachers from preschool to university, as well as peers (particularly during adolescence), have a significant impact on a child’s various ways of being in relationship. each of these interpersonal influences forms the person’s unique matrix of relationships --a matrix that may be composed of different styles of attachment, each of which may be used in a different relational situation. relational-needs bowlby (1988) described secure attachment as emerging from the mutuality of both the child’s and caretakers’ reciprocal enjoyment in their physical connection and emotional relationship. children grow up with a secure attachment when caretakers enjoy satisfying the child’s relational-needs -such as the need for validation, the need for companionship, the need to have someone “stronger and wiser” to lean on (bowlby, 1988, p.12), or the need to influence what is occurring in the relationship. i have just mentioned four relational needs. in the qualitative research conducted at the institute for integrative psychotherapy on the needs essential in human international journal of integrative psychotherapy, vol. 2, no. 1, 2011 13 development, eight relational needs were identified in our factor analysis (erskine, 1998). although there may be a large number of relational-needs, the eight to which i am referring represent those needs that clients most frequently describe as they talk about significant relationships. relational-needs are the needs unique to interpersonal contact; they are not the basic physiological needs of life, such as food, air or proper temperature. they are the essential psychological elements that enhance the quality of life and the development of a positive sense of self-in-relationship (erskine & trautmann, 1996/97). relational-needs are the component parts of a universal human desire for intimate relationship and secure attachment. they include 1) the need for security, 2) validation, affirmation, and significance within a relationship, 3) acceptance by a stable, dependable, and protective other person, 4) the confirmation of personal experience, 5) self-definition, 6) having an impact on the other person, 7) having the other initiate, and 8) expressing love (erskine, moursund & trautmann, 1999). mary ainsworth and her research colleagues (1978) found that mothers of secure infants were attuned to the affect and rhythm of their babies, sensitive to misattunements, and quick to correct their errors in attunement. there are five implications in both this research and in bowlby’s writings (1969, 1973, 1980) for the effective practice of psychotherapy. the five essential components are: 1) the necessity for the therapist’s on-going attunement to the client’s rhythm and affect; 2) the importance of the therapist’s sensitivity to his or her therapeutic misattunements; 3) the significance of the therapist taking responsibility for therapeutic errors; 4) the therapist’s awareness of and flexibility in responding to the client’s changing relational-needs; and 5) the importance of the therapist’s vitality and reciprocal enjoyment in the relationship with the client. the healing of insecure attachments occurs through a contactful therapeutic relationship --a relationship replete with respectful inquiry, acknowledgement, validation, and the normalization of both relational-needs and the client’s style of compensating for unmet needs. if we are to be effective in healing our client’s fixated, insecure attachment patterns such inquiry, validation, or normalization must always be based on a foundation of sustained affective attunement. attachment style, pattern and disorder it is time to make a distinction between attachment style, attachment pattern and attachment disorder. i relate these three categories to the extent, pervasiveness, and quality of relational disruptions throughout the client’s history. international journal of integrative psychotherapy, vol. 2, no. 1, 2011 14 i think of these three categories on a continuum from mild to moderate to severe. we all have a repertoire of attachment styles. we cannot escape the multiple influences of our rich history of relationships. an attachment “style” is not particularly problematic to the person or to others. to know and appreciate our style of attachment is often useful in managing current relationships and in understanding our dynamics with others. attachment “pattern” refers to a more problematic level of functioning with other people on a day-by-day basis. often an individual’s repetitive attachment pattern is more uncomfortable to family members and close associates than to the individual. an attachment pattern is more pervasive and problematic than an attachment style. attachment “disorder” refers to a person’s continual reliance on fixated childhood models of relationship and archaic methods of coping with relational disruptions. an individual’s archaic form of coping and attachment is pervasive in nearly every relationship with people and in nearly every aspect of the person’s life (erskine, 2009). psychotherapeutic presence the concept of psychotherapeutic presence is illusive. it is like trying to describe a handful of fog. you can see the fog, feel it on your skin, even taste it, but describing a handful of fog requires the imagination of a poet. in the same way we can feel the presence of someone who is contactful. when someone is fully “with us” and “for us” we can feel the vitality of the communication even when it is non-verbal. but describing presence is illusive because presence is an ever-changing human dynamic. presence is more than just communication; presence provides a sense of interpersonal communion. psychotherapeutic presence begins with the therapist’s attitudes about each client. carl rogers described his attitude toward his clients as “unconditional positive regard” (rogers, 1951). martin buber chose the term “i-thou” to illustrate his attitude that the other person was sacred (buber, 1958). the intersubjective psychoanalysts describe the attitude of “being with” their client in the term “sustained empathy” (kohut, 1977; stolorow, brandschaft & atwood, 1987). i have described that psychotherapeutic presence occurs when the attitude, behavior and communication of the therapist consistently respects and enhances the client’s integrity (erskine, 1998). presence occurs when the therapist de-centers from his or her own needs, feelings, fantasies, or hopes and centers instead on the client’s process. it involves being fully mindful of the client: watching every little movement and gesture; listening to every word, sound and even the silence. it includes being fully with them in their silences, embracing the pregnant pauses so the client can international journal of integrative psychotherapy, vol. 2, no. 1, 2011 15 discover the full extent of his or her feelings and experiences. presence also includes the converse of de-centering; that is, the therapist being fully contactful with his or her own internal processes and reactions. the therapist’s history, relational-needs, sensitivities, theories, professional experience, own psychotherapy and reading interests all shape unique reactions to the client. each of these thoughts and feelings within the therapist are an essential part of therapeutic presence. the therapist’s repertoire of knowledge and experience is a rich resource for attunement and understanding. presence involves both bringing the richness of the therapist’s experience to the therapeutic relationship and de-centering from the self of the therapist and centering on the client’s process. presence is provided through the psychotherapist’s sustained attuned responses to both the verbal and non-verbal expressions of the client. presence includes the therapist’s receptivity to the client’s affect --to be impacted by their emotions and yet to stay responsive to their emotions; to not become anxious, depressed or angry but to stay calm and patient. presence is an expression of the psychotherapist’s full internal and external contact. therapeutic presence occurs when full interpersonal contact is combined with therapeutic intent and therapeutic competence (yontef, 1993). it includes the therapist’s ethical commitment to the client’s welfare. presence involves using all the information gained through inquiry and all the sensitivity of attunement to maintain a genuine, caring and responsible relationship within which the client can find the support he or she needs in order to relinquish old attachment patterns and disorders and find secure attachments in their current lives. presence describes the therapist’s provision of a safe interpersonal connection. the dependable, attuned presence of the therapist counters the client’s insecure attachment and the discounting his or her self-worth. the quality of presence creates a psychotherapy that is unique with each client, attuned to and involved with the client’s emerging relational-needs. through the therapist’s full presence, the transformative potential of an integrative, relationship-oriented psychotherapy is possible. author: richard g. erskine, ph.d has been the training director at the institute for integrative psychotherapy in new york city since 1976. he is a licensed clinical psychologist, licensed psychoanalyst, certified clinical transactional analyst (trainer and supervisor), a certified group psychotherapist, and a ukcp and eapa certified psychotherapist. he is the author of numerous articles on psychotherapy theory and methods and has twice received the eric berne scientific/memorial award for advances in the theory and practice of international journal of integrative psychotherapy, vol. 2, no. 1, 2011 16 transactional analysis. he has co-authored four psychotherapy books that have been published in several languages. references ainsworth, m., behar, m., waters, e., & wall, s. (1978). patterns of attachment: a psychological study of the strange situation. hillsdale, nj: lawrence eribaum associates. bowlby, j. (1969). attachment: volume 1 of attachment and loss. new york: basic books. bowlby, j. (1973). separation: anxiety and anger. volume ii of attachment and loss. new york: basic books. bowlby, j. (1973). loss: sadness and depression. volume iii of attachment and loss. new york: basic books bowlby, j. (1988). a secure base. new york: basic books. buber, m. (1958). i and thou. (r. g. smith, trans.). new york: axribner. (original work published 1923). clark, b.d. (1991). empathic transactions in the deconfusion of child ego states. transactional analysis journal, 5, 163-165. doctors, s.r. (2007). on utilizing attachment theory and research in self psychology/intersubjective clinical work. in p. buirski & a. kottler (eds.), new developments in self psychology practice (pp.23-48). new york: jason aronson. erskine, r. g. (1998). attunement and involvement: therapeutic responses to relational needs. international journal of psychotherapy, 3, 235-244. erskine, r. g. (2009). life scripts and attachment patterns: theoretical integration and therapeutic involvement. transactional analysis journal, 39, 207-218. erskine, r. g., moursund, j. p. & trautmann, r. l. (1999). beyond empathy: a therapy of contact-in-relationship. philadelphia: brunner/mazel. erskine, r. g. & trautmann, r. l. (1996). methods of an integrative psychotherapy. in r. g. erskine, theories and methods of an integrative transactional analysis: a volume of selected articles. (pp.20-36). san francisco: ta press. (original work published 1996, transactional analysis journal, 26, 316-328.) gazzaniga, m. s. (2008). human: the science behind what makes your brain unique. new york: harper perennial. hesse, e. (1999). the adult attachment interview: historical and current perspectives. in j. cassidy & p. shaveer (eds.), handbook of attachment: theory, research, and clinical applications (pp.395-433). new york: guilford press. kohut, h. (1977). the restoration of the self: a systematic approach to the psychoanalytic treatment of narcissistic personality disorder. new york: international universities press. international journal of integrative psychotherapy, vol. 2, no. 1, 2011 17 international journal of integrative psychotherapy, vol. 2, no. 1, 2011 18 main, m. (1995). recent studies in attachment: overview with selected implications for clinical work. in s. goldberg, r. muir, & j, kerr (eds.), attachment theory: social, developmental and clinical perspectives (pp. 407-474). hillsdale, nj: the analytic press. o’reilly-knapp, m. (2001). between two worlds: the encapsulated self. transactional analysis journal, 31, 44-54. rogers, c.r. (1951). client centered therapy. boston: houghton mifflin. stolorow, r.d., brandschaft, b., & atwood, g.e. (1987). psychoanalytic treatment: an intersubjective approach. hillsdale, nj: the analytic press. trautmann, r.l. & erskine, r. g. (1999). a matrix of relationships: acceptance speech for the 1998 eric berne memorial award. transactional analysis journal, 29, 14-17. yontef, g. m. (1993). awareness, dialogue and process. highland, ny: gestalt journal press. date of publication: 12.9.2011 alcoholism is such a common condition that therapists must be exposed to clients who suffer from it, whether the therapist is the script system: an unconscious organization of experience marye o’reilly-knapp & richard g. erskine abstract: this article describes the script system with a case study to illustrate the four primary components: script beliefs; behavioral, fantasy and physiological manifestations; reinforcing experiences; and the intrapsychic process of repressed needs and feelings. the article was originally published in life scripts: a transactional analysis of unconscious relational patterns, edited by richard g. erskine, reprinted with kind permission of karnac books. keywords: script system; unconscious organization; integrative transactional analysis psychotherapy ____________________ in early writings about life scripts, berne (1958, 1961) describes the script as a complex set of transactions that determines the identity and destiny of the individual. he goes on to explain the script as similar to freud’s repetition compulsion and more like his destiny compulsion (berne, 1966, p 302). most of the transactional analysis literature regarding scripts has focused on the historical perspective. the literature has addressed how scripts have been transmitted through parental messages and injunctions, and a child’s reactions, such as unconscious conclusions and explicit decisions. additionally, some contemporary transactional analysts have examined several processes such as early child-parent attachment, shared language acquisition, and the expression of narrative as central in the formation of scripts. each of these historical perspectives has provided the clinician with theories and concepts that have guided a variety of clinical interventions. the script system the script system was designed to provide a way to analyze how the script is active in life today. rather than taking an historical perspective, the script system identifies how the decisions, conclusions, reactions, and/or introjections are unconsciously operationalized in current life as core beliefs, overt behaviors, international journal of integrative psychotherapy, vol. 1, no. 2, 2010 13 fantasies and obsessions, internal physical sensations, and reinforcing memories. the intrapsychic dynamics of the script system serve to keep the original needs and feelings that were present at the time of script formation out of awareness while also maintaining a semblance of attachment with others. the script system categorizes human experience into four primary components: script beliefs; behavioral, fantasy and physiological manifestations; reinforcing experiences; and the intrapsychic process of repressed needs and feelings (erskine, 1982/1997; erskine & moursund, 1988/1998; erskine & zalcman, 1979/1997: moursund & erskine, 2004). script beliefs are the compilation of survival reactions, implicit experiential conclusions, explicit decisions, self-protective processes, self-regulating fantasies, relational coping strategies, and reinforcements that have occurred in the process of relating to others over the course of one’s lifetime. script beliefs are often a condensed expression of an unexpressed life story. they represent, in one phrase, an elaborate, often unexpressed, narrative. script beliefs, which are usually not conscious, are the person’s unique understandings and interpretations of the value of self, significant relationships and life’s events. script beliefs, in and of themselves, are not pathological; rather, they represent a desperate, creative process of meaning-making. they function to provide a sense of self-regulation, compensation, orientation, self-protection, and an insuring prediction of future relational interactions. they also self-define one’s integrity. in essence, script beliefs provide an unconscious organization of experience. these beliefs may be described in three categories: beliefs about self, beliefs about others, and beliefs about the quality of life. once formulated and adopted, script beliefs influence what stimuli (internal and external) are attended to, how they are interpreted and whether or not they are acted on. they become the selffulfilling prophecy through which the person’s expectations are inevitably proven to be true because they create a sequence of “repetitious relational experiences” (fosshage, 1992, p.34). the script system is unconsciously maintained in order (a) to avoid reexperiencing unmet needs and the corresponding feelings suppressed at the time of script formation, (b) to generalize the unconscious experience of self in relationship with others, (c) to create a homeostatic self-regulation, (d) to provide a predictive model of life and interpersonal relationships (erskine & moursund, 1988/1998; moursund & erskine, 2004). suppression, generalization, selfregulation and prediction are important psychological processes particularly relied upon when there is uncertainty, a crisis or trauma. although a previously created life script is often personally and relationally destructive, it does provide psychological balance and homeostasis; it maintains continuity with the past while it also provides the illusion of predictability (perls, 1944; berne, 1964; bary & hufford, 1990). any disruption in self-regulation, interruptions in continuity or international journal of integrative psychotherapy, vol. 1, no. 2, 2010 14 change in the predictive model of the script system produces anxiety. to avoid such discomfort, people organize current perceptions and experiences so as to maintain a life script and to justify their behavior (erskine, 1981; erskine and trautmann, 1993/1997). in the case example that follows, john´s life story illustrates how his script system was a repetition of his past and also how his script determined both his identity and his relationships with people. in addition, his story illuminates how the quality of interpersonal contact in the therapeutic relationship facilitated the client becoming conscious of his script beliefs and in making significant changes in his life. as john´s narrative unfolds, look for the various ways his five core script beliefs are portrayed in his behaviors, fantasies, body tension, transference, and reinforcing memories. each of these expressions of a life script are often evident in the therapeutic relationship, either by observation or through transference, long before the actual words of the script beliefs are put into social language. script beliefs are frequently expressed through the client’s unaware prefixes, parenthetical phases or concluding statements to either a current or an old story. unconscious script beliefs are often observable through various expressions, such as body posture and movement, forgotten appointments, misplaced objects, repeated physical injuries, or errors in reasonable judgment. it is an essential task of the psychotherapist to decode the behavioral, international journal of integrative psychotherapy, vol. 1, no. 2, 2010 15 imaginative, transferential, and physiological expressions of a life script. the decoding is accomplished through phenomenological and historical inquiry, therapeutic inference within a developmental perspective and a relational dialogue (erskine, moursund & trautmann, 1999). as the client´s life narrative is revealed in the therapeutic relationship, the script beliefs are expressed, often without awareness, as a way to tell the condensed version of a significant emotionally-filled story of personal relationships. john’s loneliness when john first came to therapy, he had no knowledge of how pervasive his script system was in determining the course of his life. he was not particularly aware of his core beliefs, cognizant of his behavior and physiological reactions, or conscious of his feelings and needs. he had only a general knowledge of his experiences as a child. he remembered the house he lived in and the woods where he spent a lot of time playing with his dog. his father had been a caretaker on a large estate and his only time with other children was when he went to school. he remembered spending hours walking in the woods. the one feeling he could identify was that he was lonely a lot of the time. he said this as a factual statement with no apparent affect present. john could not remember sensitive family interactions such as gestures of caring, words of encouragement, or conversations about his feelings. john had consulted with his primary care physician who referred him to psychotherapy. john’s eyes focused either on the floor or the wall as he described the two major losses in the previous year – a divorce from his wife and the death of his father. he reported that he kept busy at work ¨ in order not to have my imaginations -bad thoughts and feelings¨. “this is what i have always done my whole life, just to keep going”, he told me. when i asked him about his reason for coming to see me he said it was because his doctor thought it might help him if he talked with someone about his losses. i asked john how he understood psychotherapy to work and john replied, “i have to build some strength to help myself”. he went on to describe his father’s motto as “keep a stiff upper lip and just do it”. over several sessions it became evident that john, in the process of growing up, came to the decision that to do whatever it was he needed to get done, he had to be strong and follow his father’s advice. in the intake interview, i asked a number of questions about john’s history and family relationships. his answers were simple and direct about his teenage years and either vague or non-existent when i asked about his school and pre-school years. although his answers in the initial interview did not seem disorganized or contradictory, there appeared to be a significant lack in his ability to form a consistent narrative about his early life experiences and relationships. international journal of integrative psychotherapy, vol. 1, no. 2, 2010 16 i wondered about the quality of his interpersonal relationships with each of his parents. i ended our initial session thinking about what internal images john may have of significant others, including extended family members and teachers and what internal influence those significant others may still have in his life. in our second session i asked john to describe how he envisioned a therapeutic relationship with me. he talked about his mistrust of therapists in general and he wasn’t sure that any professional person could help him. i inquired about how he experienced talking to me. he said that he thought that he “might be able to trust” me but that i probably could “not be helpful” for some things that had already happened. his body appeared very tense and he would look at me periodically and then quickly look away. i told him that i understood his reluctance to trust me and i assured him that, if he let me, i could most likely help him resolve the emotional losses of his wife and father. i explained to john that, as he told me more about himself, the significance of his losses would become clear to both of us. in my own mind i raised several questions about what prior childhood losses may have occurred and may not yet be available to consciousness, either because they were so early or that they may never have been talked about with an interested and involved other. later, as our psychotherapy progressed, i thoroughly inquired about his early childhood and the quality of his significant relationships. in our first few sessions i realized the depth of john’s loneliness that was portrayed in his descriptions of his childhood, his struggle to be with me and by the fragmentary information he gave me about his family life during his school and pre-school years. his lack of narrative about his family life left me feeling an emptiness and wondering about the emotional neglect that may have existed within his family. my countertransference was already forming and informing. over the next several sessions we established our psychotherapy relationship. i focused on the qualities i could bring to our therapeutic work: my unconditional regard for john, my commitment to sustaining a relationship of quality between him and me, my sense of presence in helping him to regulate his affect, and my interest in the development of john’s narrative of his life. in subsequent sessions he then went on to talk about how difficult it was for him to understand that anyone could be interested in listening to him. he did not have a frame of reference that included someone being there for him and certainly not someone being interested and involved in his well-being. as i encouraged him to put words to his experiences with people he said, “people are only interested in themselves”. often as i sat and listened attentively, he would say that he could not comprehend how i could listen to his ‘rhetoric’. my responses were to tell him that i wanted to listen to him, to everything he said, to his emotions and even to his silences. i wanted to hear about his experiences. i wanted to be there with him and for him. in the following session i encouraged john to tell me more about his term ‘rhetoric’. my phenomenological and historical inquiry guided him into a memory of being at the dinner table with his parents. john remembered that he had started to tell his parents about making a speech in his third grade class that day. his father responded with, “that’s just a bunch of rhetoric” and his international journal of integrative psychotherapy, vol. 1, no. 2, 2010 17 mother remained silent. he was devastated by his father’s remarks as well as his mother’s non-involvement. john, like his mother, went silent; he had never spoken to anyone about this memory. when i responded compassionately, john spontaneously remembered another time; when driving to his grandparents’ house, he had started to tell his parents about a new friend he made that day in school. his father’s immediate response was that “friends don’t stay around, so don’t get too excited”. in both of these instances, john’s experiences of excitement and joy were dismissed. as he finished these two stories, i inquired about what he was feeling. he gave what i later discovered to be his typical answer, an “ok”. he said that his father’s remarks didn’t bother him. i told him that i was feeling sad for a little boy who compensated by saying it was ¨ok¨ when it was not. i reiterated that he had been excited about his third grade speech and about finding a new friend. i expressed that i was excited for him as that little boy. after a few minutes of silence, john responded with the wish that his mother could have said those words to him. he said, “no one is ever there for me”. i again said that i was glad for him as a little boy who was excited about his speech and finding a new friend. i also told him that i was quite sad to hear that no one had been excited for him. in doing so, i identified the sadness about which john could not speak. together we acknowledged his sense that in these two instances no one was emotionally present for him and that he was deeply sad. in the last half of the session i had him imagine giving his third grade speech in front of the classroom. he described showing a picture of a bear to his class. he was again excited as he fantasized telling his fellow students about the way bears hibernate in the winter. this eight year old boy had interesting information about the habits of bears and he wanted to share it with the class. i also imagined being in his classroom listening with interest to his presentation, much as a proud parent or good teacher might do. when he was finished, i voiced my excitement about his enthusiastic presentation. although i could not satisfy his archaic needs to define himself, to make an impact on others, and to be acknowledged for his accomplishments, i did validate these as important relational-needs of the eight year old boy as well as the current needs of a mature man. he looked at me and smiled. his body posture relaxed as he sighed. phenomenological inquiry, developmental attunement, and my emotional involvement were deepening our connection and providing an opportunity for him to talk about his memories, feelings and physical sensations. i was forming an understanding of the meanings john made of these memories and how he unconsciously organized his life experiences. during the next few sessions it became clear that john’s childhood experiences were organized around his beliefs about self : “no one is ever there for me”, “i have to do everything myself” and “my feelings don’t matter”. his motto, which he manifested in his day-to-day activities, was “work hard and don’t complain”. i realized that this motto was a derivation of his father’s “keep a stiff upper lip and just do it.” together we continued to identify how active these three core beliefs were in determining his behaviors, both when he was alone and when he international journal of integrative psychotherapy, vol. 1, no. 2, 2010 18 was with other people. in every situation he was convinced that he had to do things all by himself because no one would be there to help him; “people are only interested in themselves”. his orientation of self-in-relationship-with-others, which originated in his relationships with his parents, was being repeated with everyone in his adult life. i continually inquired about his life. unemotionally, john talked about how his father never showed any interest in playing or talking with him. john had no siblings and the only children he spent time with were those at school. he spent a lot of time on his swings or with his dog. he reported spending hours alone in the woods on the estate. when asked about each of these experiences he could not identify any feelings. his affect was, at best, flat and often non-existent. as he continued in therapy, john began to talk more frequently about his memories. he was able, through my phenomenological inquiry, to discover his feelings of sadness and loneliness. several times he was surprised at the extent of his feelings and that he was telling me about how he managed his loneliness. as a child he had never thought to go to his parents; he was certain that they would be neither emotionally present nor interested in him. he never got angry or complained. he repeatedly experienced that protest or complaints ¨only made matters worse¨. he had no memories of his mother ever complaining about his father’s constant criticism of everyone or his lack of interest in either her or john. ¨she appeared sad a lot of the time¨ but neither she nor his father talked about what she was feeling. on many occasions he saw his father ¨shut down when any feelings started to surface¨, ¨feelings were never talked about¨. he learned early on that any sadness he expressed was identified as tiredness by his mother. anger was not to be voiced. loneliness was his secret! john recalled how even with his former wife he never talked about his loneliness. several times i inquired about his experience in the marriage. he described how his wife was “only interested in herself” and repeated his belief, ¨my feelings don’t matter¨. he later connected both of these script beliefs to his mother having told him that he was ¨a burden¨ when he was a young child. she never explained how he was a burden; that was left to his imagination. he fantasized that he had been too active and too emotional for her. he realized he had always expected that his wife would also say that he was too emotional for her, so he told her nothing of his feelings. as john’s therapy continued, i strove to establish an attuned and involved relationship that provided security for him to remember many never talked about childhood memories, to sense his physical tensions and related experiences, to identify relational-needs, and express a whole range of feelings. i became the “one there” to counter his belief, “no one is ever there for me”. in order to facilitate john’s becoming conscious of his childhood experiences, he and i were engaged in a dialogue that gave validation of his feelings, reactions, and coping skills he used as a child. as a preschool and school-age child he neither had the international journal of integrative psychotherapy, vol. 1, no. 2, 2010 19 concepts, necessary language skills, nor parental encouragement to talk about his feelings. his mother and father did not engage him in dialogues wherein he could express himself. because there was no relational language in the family, his emotional experiences were never acknowledged; they remained unconscious. prior to psychotherapy, john’s explicit memories were few. his feelings, fantasies, bodily sensations, and significant experiences were not part of any conversation. in our psychotherapy, i continually inquired about john’s bodily sensations and the extent of his beliefs about himself, others and the quality of his life. i listened to the nuances of his sadness and comforted him with compassion and validation. i encouraged him to take deep breaths and to let out the sounds and tears of his sadness. he repeatedly cried about how “life is lonely”. when he was angry i maintained a space for him to talk about his anger and to seriously attend to how he both experienced it in his body and also attempted to “shut down” like his father. as john struggled to articulate the narrative of his life he had my constant attention; he was validated and accepted by me. we often focused on how john used his script beliefs as an organizing schema both to create meaning and to reaffirm his childhood identity. we identified his repetitive behaviors, explored his fantasies, and clarified the function of his various script re-enforcing experiences. as a result, john was increasingly able to own his feelings, identify his relational-needs, and express his own uniqueness. . while spending many hours as a child without companionship, john fantasized himself doing things all alone but reaping appreciation from others for what he accomplished. in his play with toy soldiers, he imagined himself returning from war as a hero, greatly admired and cheered by all the people. as an adult, whenever he did something he waited for the ‘cheers’ that never came. a frequently re-occurring dream involved scenes of john walking with his father on one side of him and his mother on the other. they are all holding hands and listening to john as they walk together in the woods. the dream would abruptly end and he would be flooded with sadness. each of these failed fantasies and interrupted dreams reinforced his script beliefs and childhood sense of being all alone. as we discussed his loneliness and his mother’s lack of emotional contact with him, john remembered a man who worked with his father. ted had kind eyes and was interested in what john was doing. ted would stop working and talk with john. sometimes ted would share his lunch with john and entertain him with stories about being in the army during the war. then, one day, john found out that ted had been seriously injured on the job and that he would not be coming back to work. he never saw ted again. in response to john’s missing ted, his father gruffly told him that ted was lazy and deserved to get hurt. john wept as international journal of integrative psychotherapy, vol. 1, no. 2, 2010 20 he described how ted would listen to him. he continued to weep while talking about the wooden gun that ted had carved for him. in the next session we explored how his earlier script conclusion made in reaction to his parents’ behavior and lack of emotions had become reinforced when his friend ted disappeared. that early childhood conclusion, “no one is ever there for me”, was cemented into a formidable life script with this reinforcing experience. i challenged the “no one will ever be there for me” with the question “ever?” i then had him close his eyes, look at the image of ted and to talk to ted about how he had been so significant in his life. after this emotion filled experience, john was able to retain a memory of his connection with ted. he later referred to his relationship with ted, ¨at least someone was once there for me¨. john’s life script was changing. one day he came into session and said that he had a new dream. he was in the woods near my office and this time he was with someone. they were talking and laughing together. he did not know who was in the dream yet he knew he liked the person. i asked him what the dream meant to him and he said that “maybe this is what is in the future for me”. he smiled slightly and then gave a big, relaxing sigh. i asked, “what do you experience with that sigh?” “i went through a lot”, john answered. “now i do not feel so crazy and so alone anymore. my body is not as tense as it used to be”. he then went on to talk about his father and his wish that his father were still alive so that he could “now have a real relationship”. as john’s therapy continued, he developed a new sense of self. after two years, he was able to articulate the narrative of his life script. his script beliefs were no longer active; he changed many of his behaviors and he was expressive of his feelings. he understood and appreciated the coping, self-protective functions that his script beliefs once served him. john took the quality of our interpersonal therapeutic relationship as a model in forming meaningful work and social relationships. he began meeting regularly with his mother and their new relationship became increasingly satisfying. he no longer felt driven to keep busy all the time to avoid his feelings. after a vacation, he reported that he thoroughly enjoyed relaxing and doing nothing. he said, “i no longer feel lonely”. the theory into practice when under stress, or when current relational needs are either not responded to or satisfied in adult life, explicit and/or implicit memory, physiological reactions or explicit decisions may be stimulated. a person is then likely to engage in compensating behaviors and/or fantasies that, in turn, distract from the internal emotionally-laden experience by verifying script beliefs. these compensating behaviors and fantasies are referred to as the script displays. international journal of integrative psychotherapy, vol. 1, no. 2, 2010 21 these script displays include any observable behaviors, such as choice of words, sentence patterns, tone of voice, displays of emotion, and/or gestures and body movements, that are the direct displays of the script beliefs and the repressed needs and feelings (an intrapsychic process). people usually act in a way defined by their script beliefs, such as john never asking friends for help even in situations where it was needed, believing “i have to do everything myself.” as a result, his friends neither knew what he needed nor offered to help. the absence once again of his friends offering or providing help reinforced the script beliefs “i have to do myself” and “people are only interested in themselves”. script beliefs may also be displayed through the absence of situationally appropriate behavior, such as the lack of eye contact or the socially typical expression of emotions in intimate interpersonal communications. john’s lack of eye contact in his earlier sessions and the absence of natural emotional expressions are two examples of how an internal script belief will be externally displayed. both of these types of behaviors emanated from the script beliefs “no one is ever there for me” and “my feelings don’t matter”. each of these behaviors also serve to reinforce the script beliefs because they interrupted important interpersonal contact. figure 2 is a diagram of the intrapsychic and behavioral dynamics of john’s script system. international journal of integrative psychotherapy, vol. 1, no. 2, 2010 22 john’s script system script script reinforcing beliefs/feelings displays experiences beliefs about: observable behaviors current events self no one is ever there for me. absence of emotional expression no emotional conversation with i have to do everything in interpersonal communication. wife. myself. lack of eye contact. wife divorcing. my feelings don’t matter. observable body tension. father dying. works hard. little emotional contact with no complaints. mother. others “just keep on going.” no help from friends. people are only interested therapists “not helpful”. in themselves. struggles to be with therapist. old emotional memories quality of life mother and father “don’t get life is lonely. reported internal excited”, “don’t get angry”. experiences protesting made matters worse. muscle tension. mother: “you were a burden.” erratic breathing. sadness identified by mother as tiredness. mother remembered as silent (intrapsychic process) and non-involved. father critical of everyone. repressed feelings loss of ted. lonely awareness of muscle tension of sad “i have to do everything myself.” angry repressed needs fantasies result of fantasies to be validated and as child: being a “hero”. no actual appreciation for acknowledged. getting appreciation from others. being a hero. to rely on someone. (dream) holding hands and talking no actual holding of hands to have companionship. abruptly ends. and talking. to define one’s self. as an adult: being admired by others. waits for admiration. to make an impact. imagining wife being interested in only many examples of wife’s herself. interest only in herself. exaggerating father’s criticisms. father: “a bunch of rhetoric” “i’m too active and emotional for and “friends don’t stay mother.” around”. figure 2 john’s script system ______________________________________________________________________________________ international journal of integrative psychotherapy, vol. 1, no. 2, 2010 23 as part of the manifestation of the script, individuals may have physiological reactions in addition to, or in place of, the overt behaviors. often, these internal experiences are not readily observable; nevertheless, the person can give a selfreport on bodily sensations such as fluttering in the stomach, muscle tension, headaches, colitis, or any of a myriad of somatic responses to the script beliefs. in john’s situation, his body tension was easily observable and reflected all three of his script beliefs. careful attention to john’s body sensations, such as his erratic breathing and muscle tension, was essential in helping him experience the existence and depth of his affect. the manifestation of the script also includes fantasies in which the individual imagines behaviors, either his/her own or someone else’s. these fantasized interpersonal interactions and the quality of the outcome lends support to script beliefs. fantasized behaviors function as effectively as overt behaviors (in some incidences even more effectively) in reinforcing the script beliefs and keeping the original needs and feelings out of awareness. at the beginning of his psychotherapy, john reported that he kept busy at work in order to avoid his “imaginations, bad thoughts and feelings”. with consistent phenomenological inquiry about the full nature of his imaginations and “bad thoughts”, it later became apparent that the content of his fantasy about his former wife and father actually functioned to confirm his beliefs “no one is ever there for me” and “my feelings don’t matter” and “people are only interested in themselves”. his fantasies were an elaboration of what he already believed. fantasies act within the script system exactly as though they were events that had actually occurred. an understanding of how fantasy reinforces script beliefs is particularly useful to psychotherapists in organizing the psychotherapy for clients who engage in obsession, habitual worry, and fantasies of abandonment, persecution or grandeur (erskine, 2002). as we explored john’s childhood fantasies of being a hero and his current fantasies of being admired, the content of these fantasies did not directly reinforce his script beliefs. but, when he compared his wonderful fantasies with his actual reality in which no one cheered or listened to him, the contrast provided evidence that “no one is ever there for me”. any script manifestation can result in a reinforcing experience a subsequent event that “proves” that the script belief is valid and, thus, justifies the behavior. reinforcing experiences are a collection of affectively-laden memories, either implicit or explicit, either real or imagined, of other people’s or one’s own behavior, a recall of internal bodily experiences, or the retained remnants of fantasies or dreams. john clung to the memory of his mother’s silence and his father’s criticism of his school story as “a bunch of rhetoric”. he often recalled that event both at work and during his therapy when he was about to say something important. retaining that selected memory and repeating it many times served to reinforce his script belief, “my feelings don’t matter”. john’s frequent memories of the loss of ted and his father’s pessimistic comment international journal of integrative psychotherapy, vol. 1, no. 2, 2010 24 “friends don’t stay around” were often in john’s mind. these repeated memories served to continually reinforce his script belief “no one is there for me”. because of the homeostatic self-stabilizing function of life scripts, reinforcing experiences serve as a feedback mechanism to further strengthen script beliefs and to prevent cognitive dissonance (festinger, 1958). only those memories that support the script beliefs are readily accepted and retained. memories that negate the script beliefs tend to be rejected or forgotten because they would challenge the beliefs and the whole self-regulating, homeostatic process. the intrapsychic process of repressed needs and feelings are an unconscious accumulation of intense affects experienced over time when crucial physiological and relational-needs were repeatedly not satisfied. these feelings and needs are usually not conscious because the memory is either implicit, traumatically dissociated or reflects a repressed explicit experience. also, the biological imperative of both physiological and relational-needs is not conscious, particularly in infants and young children. often clients in psychotherapy gain awareness of these needs and feelings in the secure, reliable and respectful therapeutic relationship where there is sufficient affective and rhythmic attunement accompanied by a nonjudgmental phenomenological inquiry (erskine, 1993/1997). john could speak of his loneliness early in therapy but it was a long while before he could express the depth of his sadness or even talk about being angry at his parents’ refusal to talk about emotions as well as the absence of intimacy. he was eventually able to identify and articulate his needs in relationship with people. five unrequited relational-needs were evident in john’s narrative: to be validated and acknowledged; to rely on someone; to have companionship; to define one’s self; to make an impact on others. awareness of these crucial needs and feelings was no longer repressed by his script beliefs nor distracted by his behaviors or fantasies. script beliefs are a creative attempt to make sense of the experiential conclusions (usually non-conscious), explicit decisions and coping reactions. script beliefs serve to cognitively mediate against the awareness of the intense feelings that the person lived during script formation. this cognitive mediation distracts from an awareness of both current relational-needs and the developmentally crucial physiological and relational-needs. the intense affects and needs may remain as fixated, implicit memories until life altering experiences or an effective therapeutic relationship facilitate integration. prior to psychotherapy, john was perpetually immersed in his loneliness. the dream wherein he was walking with a friend near his therapist’s office demonstrates the life altering effectiveness of an involved therapeutic relationship. john’s life script of loneliness was coming to an end. each person’s set of script beliefs provides a subjective self-regulating mental framework for viewing self, others and the quality of life. in order to engage in a international journal of integrative psychotherapy, vol. 1, no. 2, 2010 25 manifestation of the script, individuals must discount other options; they frequently will maintain that their behavior is the “natural” or “only” way they can respond. when used socially, script manifestations are likely to produce interpersonal experiences that, in turn, are governed by and contribute to the reinforcement of script beliefs. this cybernetic closed system provides a homeostasis, thus each person’s script system is self-regulating and selfreinforcing through the operation of its four interrelated and interdependent subsystems: script beliefs; behavioral, fantasy and physiological manifestations; reinforcing experiences; and repressed needs and feelings. the unconscious script system serves as a distraction against awareness of past experiences, relational-needs and related emotions while simultaneously being a repetition of the past. the script system represents the client’s unconscious organization of experience and provides a useful blueprint to help the psychotherapist and client understand how the script is lived out in current life. a cybernetic system such as the script system is made up of “a set of components or parts that interact to form an organized whole” (piers, 2005, p.230). therefore, a change in one of the parts or subsystems will effect a dynamic change in the whole system. by therapeutically attending to physiological sensations and bodily experiences, behaviors and the functions of behaviors, fantasies and dreams, conscious and unconscious (implicit) memories, affects and relational-needs, and the client’s core beliefs about self, others and the quality of life, the psychotherapist facilitates changes in the various subsystems that comprise the life script. hence, the more areas attended to in the process of psychotherapy, the more likely we will facilitate a “script cure” (erskine, 1980/1997). marye o’reilly-knapp, ph.d., rn is an associate professor at widener university school of nursing and a certified transactional analyst. she maintains a private practice as a psychotherapist and certified clinical nurse specialist in adult psychiatric/mental health nursing. for the past two years, marye has served as executive director of the international integrative psychotherapy association. she is a frequent presenter at international conferences and has published on the psychotherapy of trauma, dissociation, and the schizoid condition. marye is an associate of the international integrative psychotherapy association of new york and has contributed to the development of theory in both transactional analysis and integrative psychotherapy. since 1997 she has served as a lecturer at the moscow transactional analysis institute in moscow, russia. richard g. erskine, ph.d has been the training director at the institute for integrative psychotherapy in new york city since 1976. he is a licensed clinical psychologist, licensed psychoanalyst, certified clinical transactional analyst (trainer and supervisor), a certified group psychotherapist, and a ukcp and eapa certified psychotherapist. he is the author of numerous articles on international journal of integrative psychotherapy, vol. 1, no. 2, 2010 26 psychotherapy theory and methods and has twice received the eric berne scientific/memorial award for advances in the theory and practice of transactional analysis. he has co-authored four psychotherapy books that have been published in several languages, the most recent with jane moursund, entitled integrative psychotherapy: the art and science of relationship (2004, thompson: brooks/cole). references bary, b., & hufford, f. (1990). the six advantages to games and their use in treatment planning. transactional analysis journal, 20, 214-220. berne, e. (1958/1976). transactional analysis: a new and effective methods of group therapy. in e. berne (ed.), beyond games and scripts. new york: grove press. (original 1958, american journal of psychotherapy). berne, e. (1961). transactional analysis in psychotherapy: a systematic individual and social psychiatry. new york: grove press. berne, e. (1964). games people play: the psychology of human relationships. new york: grove press. berne, e. (1966). principles of group treatment. new york: grove press. erskine, r. g. (1980/1997). script cure: behavioral, intrapsychic, and physiological. in r.g erskine, theories and methods of an integrative transactional analysis: a volume of selected articles (pp. 151-155). san francisco: ta press. (original work published 1980. transactional analysis journal, 2: 102-106. erskine, r.g. (1981, april). six reasons why people stay in script. lecture. professional training program, institute for integrative psychotherapy, new york. erskine, r. g. 1982/1997). transactional analysis and family therapy. in r. g. erskine, theories and methods of an integrative transactional analysis: a volume of selected articles (pp.174-207). san francisco: ta press. (original work published in a.m. horne & m.m. ohlsen (eds.), family counseling and therapy (pp.245-275), itasca, il: f.e. peacock publishers,1982. erskine, r.g. (1993/1997). inquiry, attunement and involvement in the psychotherapy of dissociation. in r.g. erskine, theories and methods of an integrative transactional analysis: a volume of selected articles (pp. 37-45). san francisco: ta press. (original work published 1993. transactional analysis journal, 23: 185-190. erskine, r.g. (2002). bonding in relationship: a solution to violence. transactional analysis journal,32: 256-260. erskine, r.g. & moursund, j.p. (1988). integrative psychotherapy in action. newbury park, ca. & london: sage publications. (reprinted in paperback 1998, gestalt journal press, highland, ny.) erskine, r.g., moursund, j.p., & trautmann, r.l. (1999). beyond empathy: a international journal of integrative psychotherapy, vol. 1, no. 2, 2010 27 international journal of integrative psychotherapy, vol. 1, no. 2, 2010 28 therapy of contact-in-relationship. philadelphia: brunner/mazel. erskine, r.g., & trautmann, r.l. (1993/1997). the process of integrative psychotherapy. in r.g. erksine, theories and methods of an integrative transactional analysis: a volume of selected articles (pp.79-95). san francisco: ta press. (original work published in b.b. loria (ed.), the boardwalk papers: selections from the 1993 eastern regional transactional analysis conference (pp. 1-26), madison, wi: omnipress, 1993. erskine, r.g. & zalcman, m.j. (1997). the racket system: a model for racket analysis. in r.g. erskine, theories and methods of an integrative transactional analysis: a volume of selected articles (pp. 156-165). san francisco: ta press. (original work published 1979. transactional analysis journal, 9: 51-59). festinger, l. (1958). the motivating effect of cognitive dissonance. in g. lindzey (ed.), assessment of human motives. new york: rinehart. fosshage, j.l. (1992). self-psychology: the self and its vicissitudes within a relational matrix. in n. skolnik & s. warshaw (eds.), relational perspectives in psychoanalysis (pp.21-42). hillsdale, nj: the analytic press. moursund, j.p. & erskine, r. g. (2004).integrative psychotherpay:the art and science of relationship. pacific grove, ca:brooks /cole –thomson learning. perls, f.s. (1944). ego, hunger and aggression: a revision of freud’s theory and method. durban, south africa: knox publishing. piers,c. (2005). the mind’s multiplicity and continuity. psychoanalytic dialogues.15(2): 239-254. footnote: the script system was originally published with the title “the racket system: a model for racket analysis” (erskine & zalcman, 1979/1997). because the term “rackets” did not translate well into other languages and because it described elements of script, in subsequent writings it was renamed the script system (erskine & moursund, 1988/1998). original article was published in: o’reilly-knapp, m. & erskine, r. g. (2010). the script system: an unconscious organization of experience. in r. g. erskine (ed.), life scripts: a transactional analysis of unconscious relational patterns. (pp. 291-309). london: karnac books. reprinted with kind permission of karnac books. http//www.karnacbooks.com/product.asp?pid=27778. date of publication: 13.11.2010 international journal of integrative psychotherapy, vol. 7, 2016 49 integrative psychotherapy ‘revisited’ marye o’reilly-knapp abstract: this article revisits aspects of the theory and methods of integrative psychotherapy as written and discussed by richard g. erskine, phd and others. a case study demonstrates the use of integrative psychotherapy as the basis for therapeutic interventions that allow the client to interpret early experiences of relational failures, via a relationally based psychotherapy. revisiting the theory and methods of integrative psychotherapy served to further validate the core of ip and its value as a cohesive and comprehensive psychotherapy. key words: integrative psychotherapy; case study; relational psychotherapy ______________________ as i end my clinical practice my thoughts take me to the theory i have embraced in my work as a psychotherapist. when i first started my practice i used a combination of psychoanalysis, gestalt and transactional analysis. when i joined a training group in new york led by richard g. erskine, phd and then, six years later, the professional development seminar, i became immersed in the theory and methods of integrative psychotherapy. it was like a door had opened and i was in a place where i could learn to be the best i could be and work with clients within a respectful and powerful therapeutic framework. in the last year i began to re-read and carefully examine various works in integrative psychotherapy, assessing the guiding principles intrinsic to its theory and methods. this in-depth study provided me with a deeper appreciation for its comprehensive theory and methods based on sound ethical principles. this article revisits the theory and methods of integrative psychotherapy with a case example that demonstrates how i use integrative psychotherapy as my base for therapeutic interventions. a perspective is needed for all theory. a theoretical framework gives structure to ideas. through his writings, richard erskine has offered both perspective and framework, and developed a concise, systematic body of principles (erskine, 1997; 2015) needed for psychotherapists to work within the therapeutic relationship. as a theory, integrative psychotherapy is a comprehensive theory, meaning that the ideas are organized, coherent sets of international journal of integrative psychotherapy, vol. 7, 2016 50 concepts, and their relationships to each other offer descriptions, explanations, and predictions about events. the organization of the theory in a relational-focused, motivation-oriented, personality paradigm gives the clinician a strong and useful framework for therapeutic approaches. in both the theory and methods of integrative psychotherapy there are principles and values regarding the worth of human beings, the importance of the quality of life, the significance of relationships, and the support of psychological growth through a relational psychotherapy. with emphasis on integrating the personality, erskine (1997) writes: helping the client to become aware of and assimilate the content of his or her ego states, to develop a sense of self that decreases the need for defense mechanisms and a life script, and to reengage in the world and relationships with full contact. (p. 1). integration also refers to the synthesis of suppositions from affective, cognitive, behavioral, physiological, developmental, and relationship theories. integrative psychotherapy as developed by erskine (1997) is rooted in “many views of human functioning: psychodynamic, client-centered, behavioral, family therapy gestalt therapy, reichian-influenced body psychotherapy, object relations theories, psychoanalytic self-psychology and eric berne’s theoretical concepts and ideas” (p. 1). out of this foundation was formed the key concepts which serve as the basis for integrative psychotherapy. the framework of integrative psychotherapy contains the components of the theories of motivation and personality and the psychotherapeutic methods of inquiry, attunement, and involvement. involved in motivation are the biological imperatives of stimulus hunger, the need for the brain and body to be fueled; structure hunger, the organization of perceptual experiences; and relationship hunger, the hunger for human contact (erskine, 1997). the theory of motivation speaks to the needs of the human being for stimulus, for structure, and for relationship. this becomes a gauge to determine the needs around stimulation, organization of perceptual experiences, and connection with the therapist as well as others. the theory of motivation provides an understanding of human functioning and the metaperspective that encompasses and unifies the theories of personality and methods (o’reilly-knapp & erskine, 2003). the theory of personality attends to the psyche and provides a path to work with ego states, introjections, developmental fixations, and life script. the methods of inquiry, attunement, and involvement define the steps needed in the therapeutic process. the combination of the theories of motivation and personality, along with the methods of inquiry, attunement, and involvement provide an operative framework for psychotherapy. international journal of integrative psychotherapy, vol. 7, 2016 51 referred by a colleague, anne walked into my office stating that she wanted to find out more about herself. she had been in therapy two other times and discovered her depression rooted in her childhood where she lived in a dysfunctional family system. at the initial session she told me her mother had been an alcoholic since anne was a small child and that she did not remember much about her mother’s drinking. for a short time, she had attended acoa, a support group for adult children of alcoholics. she realized she needed something “more” to move her through the numbness she still experienced and the lack of memories for part of her childhood and adolescence. i suspected her previous therapy had been shorter-term with the goals of understanding that one can act differently, versus the longer-term goal of working through by remembering with feeling. i wondered if anne’s “more” was about her desire to deal with the conflicts and painful experiences that needed to be felt, in order to emerge from the defensive positions she had formed to protect herself. at the initial session, i found myself wanting to reach out and take her beyond whatever painful memories she held and would encounter in her therapy. the first step in meeting with anne was to begin to structure our relationship. my attention was directed toward providing a secure environment where she could feel safe and begin to trust our relationship. giving her my undivided attention, listening to her requests, respecting her struggles, and setting up a time to meet was part of the structure of the first session. she had told me that she was well organized and prided herself in doing things herself. i suspected that she used structure as a way to handle her need for stimulus and contact. in working with anne, our relationship became the basis for her exploring the relationships she had in her family of origin as well as her contacts with family and friends today. the therapist-client relationship was at the heart of her working through the conflicts presented, beliefs held about self and others, how she was using ways to cope today that were based on the past, awareness of the conclusions and decisions she made, as well as feelings experienced. since the process was long and often painful, it was critical for anne to be “held” in the therapeutic relationship in order to work through what was remembered with what was felt. holding included my presence an unconditional positive regard and acceptance of anne’s experiences – which facilitated her process of integration. when she was quiet, i was there with her silences. when she was angry at me, i was there to help her reconnect with me. anne’s work in therapy encompassed her “being” in all domains of functioning cognitively, affectively, behaviorally, and physiologically. body work helped her learn about the messages her body was sending her. this work occurred by examining body gestures, tightening of the body, breathing patterns, body movement, inhibitions, international journal of integrative psychotherapy, vol. 7, 2016 52 mannerisms, all of which provided material for assessment and interpretation. the use of body work, abreacting events, the expression of emotions associated with repressed material all helpful as she constructed her narrative. her insights brought meaning to her experiences. the use of inquiry, attunement, involvement some have described therapy as a journey, a self-discovery, an adventure where inquiry is used. in the first few months of sessions, inquiry into anne’s subjective experiences began a process for her to discover more about herself. inquiry was a way to expand awareness (moursund & erskine, 2004). inquiry phenomenological inquiry focused on meeting anne in the therapeutic moment, wherever she was, cognitively, affectively, behaviorally, and physiologically. questions invited her to get in touch with her thoughts, feelings, sensations, archaic defenses, relational disruptions both past and present, coping strategies, and vulnerabilities. inquiry allowed for expansion of self-awareness. time was spent in anne’s therapy remembering her early years, realizing her mother’s neglect, connecting her feelings and body sensations to her experiences, recalling her dreams and fantasies, identifying her relational needs, understanding her coping patterns – all while utilizing her relationship with me to deal with the differences between the past and the here-and-now. she could tolerate the intensity of therapy through my being there with her. she was not alone now and could, in relationship with me, grasp and hold her past. for instance, she realized how she was neglected and did not have the resources as a child to get what she needed. she felt the hunger, both physical and psychological, of not getting the nourishment she needed from her mother. she experienced her cries for help and her mother yelling at her. she became aware of the shame she suffered when her classmates made fun of her messy hair and dirty clothes, and dealt with these past humiliations in her therapy sessions. there were times when my inquiry confused anne and temporarily disrupted the connection we had, so i backed off and addressed what she was experiencing internally. the entire process of inquiry reinforces an evolving self and also the development of a relationship with an “other”, in this case the therapist. while working with anne, inquiry guided the process of contact-in-relationship. important to remember in inquiry is internal interruptions to contact. the keyhole (erskine, moursund, trutmann, 1999), as seen in figure 1, places these interruptions alongside each of the areas of inquiry phenomenological, history/expectation, coping, and vulnerability. international journal of integrative psychotherapy, vol. 7, 2016 53 figure 1. the keyhole the four dimensions of inquiry within the relational context enrich the restorative process. linking phenomenological inquiry with existence gives a window into the client’s perceptions and life. for anne, this meant that she could explore her perceptions without questioning the reality of what was experienced. the significance of interruptions to contact and the client’s attempts to resolve the conflicts by coping as-best-as-could-be-done in any given situation gives direct information as to how much credence was put on the significance of experiences and how problems were explained and attempted to be resolved. anne was able to examine the importance of her needs and the massive discounting of these needs. she began to piece together her attempts to resolve her troubles and the means she used then, and even today, to cope. the last area in this portion of inquiry, vulnerability of self, allowed for the continued focus of contact with anne’s self and her transforming sense of self. until anne could learn about her relational needs and how her parent’s neglect impacted her life, until she could feel the anguish that went with these memories, only then could she begin to understand what the pain and numbness international journal of integrative psychotherapy, vol. 7, 2016 54 meant. relational needs discounted or denied were brought into her awareness. she went through a mourning process – the loss of a needed mother and the undoing of her old identity. as a result of the consistency, reliability and dependability of the relationship with me, the seeds planted from the beginning sessions began to take hold. as she began to trust me she trusted herself more. anne started to value herself as a human being who had purpose and worth. her self-worth empowered her to move through the archaic resistances and become more of the person she really was. the “how to” of inquiry involved a respect for anne’s perceptions, facilitating a sense of contact between us, and expanding her awareness of internal experiences and sensations. the initial inquiry contained questions regarding the problems and symptoms the client presented: what brings you here today? tell me about yourself. what would you like from me? as therapy continued, phenomenological inquiry – the deep examination of anne’s experiences was at the forefront of our work. what is this like for you right now? what is going on inside of you? what is your body telling you? what are you feeling? transferential inquiry helped me to assist anne in realizing internal and external disruptions in contact and the sorting out of her feelings. in describing the “psychotherapy of transference” erskine (1997) viewed transferences as: “…. past, developmental needs that have been thwarted, and the defenses erected to compensate; the resistance to full remembering, and paradoxically, an unaware enactment of childhood experiences; the expression of intrapsychic conflict and the desire to achieve intimacy in relationships; or the expression of the universal psychological striving to organize experience and create meaning” (p. 143). awareness of the transference and my own countertransference gave me a clear direction in working with anne. at one point in the session i had this sense of a frightened little girl. i then asked her if she had ever been slapped in the face. anne had been talking about how impatient her mother could be with her at times. she looked at me and at first said she had never been slapped. then her eyes widened and her whole body tightened. she then told about her mother taking a hair brush and hitting anne across her cheek. it was if her body was holding the memory, the repressed experience was transferred to me, and i sensed an image of her mother striking her. the sad, scared and angry feelings connected with this image became part of anne’s working through by remembering with feeling. countertransference as part of my inquiry allowed me to connect with anne and to facilitate her awareness. for example, my body tightened up while anne described her mother hitting her. attunement the next component of the methods of integrative psychotherapy is attunement, “a kinesthetic and emotional sensing of the other” (erskine, 2015, p. 17). there is a deep respect for the other. attunement involves being open and international journal of integrative psychotherapy, vol. 7, 2016 55 responsive to rhythmic, cognitive, affective, developmental, and relational needs (erskine, moursund, trautmann, 1999). assessment of cognitive and emotional dissonance, rhythmic responses, the developmental stage, and relational needs are all part of what needs to be given attention while working with a client. a few of the questions to address in this area involve: what opposition is experienced cognitively and/or emotionally? is the pace too slow or too fast? at what stage developmentally is the client? what needs does the client have at this time? attunement has provided me a means to further understand the client and to provide a resonating response. in our work, anne’s thinking was often distorted because of confusion. focusing on her feelings allowed her to then put thoughts to her emotional state and reduce a great deal of her bewilderment. this occurred because at the core of affective attunement is the need for a reciprocal response. anne’s sadness was met with my compassion, her fear with the sense of my protection, her joy with my pleasure. additionally, i took her anger seriously. in attunement there is an “entering into the client’s space” cognitively – what the client is thinking…… how the client is thinking it” (erskine, moursund, trautmann, 1999, p. 54). attunement is also about knowing where the client is developmentally – what is needed in the therapeutic regressions to access the archeopsyche or child ego states, address old conclusions, change old decisions, and for the therapist to provide a sensitive, respectful presence and satisfying response during this work. when anne told me about her mother slapping her in the face, i listened intently to her story, reciprocated by voicing my sadness and concern for her, and slowed the pace for working through her child ego state’s early conclusions and decisions. all this allowed the space, time, and presence she needed for her mind to process this information. involvement parallel to inquiry in the ‘keyhole’ is involvement. acknowledgement, validation, normalization, and presence are placed along the contact-inrelationship continuum. acknowledgement recognizes existence of what is occurring, validation gives significance to what has been acknowledged, normalization stabilizes the occurrence, and presence says “i am here with you” and value you. throughout the therapeutic relationship anne’s experiences were acknowledged and validated by me. through our discussions, she was able to identify the struggles in growing up, to grasp their significance, to understand her coping strategies and to appreciate how different it is now where she has support and guidance. my involvement with her included my commitment to her welfare and the ability to be with her as she worked through often intense situations. the enactments in her sessions facilitated anne’s progress and they also called for my full attention to her safety and well-being. regression to compartmentalized international journal of integrative psychotherapy, vol. 7, 2016 56 memories meant dealing with the past as well as anne realizing my presence with her in this process. sometimes holding onto my hand and asking her to squeeze it to feel me with her, at other times saying softly “i am here with you” were needed so she would not go into her memories all alone. her awareness of my being with her was critical in that it brought her to the here-and-now while dealing with the past. acknowledging and validating her, normalizing her defensive/protective reactions, along with my full presence added notably to the efficacy of treatment approaches in her therapy. inquiry, attunement and involvement facilitated the therapeutic relationship. the three methods created an intersubjective space for contact-in-relationship – a space that allowed anne and i to work together. she moved beyond the numbness and her feelings of despair and hopelessness. she no longer denied or diminished her childhood experiences and gradually could even identify some “good times” in growing up. she no longer discounted the needs she had and could stay connected with herself. her connection with me enabled her to bond with others. the models three visual models were developed to illustrate the theories of personality in an integrative, relationship-focused integrative analysis: “the self-inrelationship system” (erskine, 2015), “the script system” (erskine, 2015), and “states of the ego” (erskine, 1988). each one gives a specific, concrete, visual road map for working with clients. in working with anne, the “self-in-relationship” model had been a way for me to check where she may be open or closed to contact and interruptions of contact. anne demonstrates how contact with her body was closed off as well as feelings. she would numb her body when she started to experience scare and anger. helping her to stay with her body and at the same time feel her feelings was a process that helped her move forward in her healing. how this was done was for anne to stay in the present with me, while at the same time dealing with her sensations and feelings which had been constructed in the past. such therapeutic interventions included: periodically reminding her ‘i am here with you’ when she would start to lose contact with herself, and with me, as a result of the force of her feelings and body sensations; repeating back to her the words she was giving to her experience; validating and normalizing her affective and physiological reactions; and dealing with the fundamental defensive fixations – all the while maintaining a calm and relational presence in order to neutralize the intensity of the situation. all this allowed anne to accept and integrate parts of herself. the “states of the ego” model facilitated an understanding of anne’s introjections and the fragments of archaic fixations. her mother’s alcoholism loomed over her terrified child ego state. when anne was a child she was left in international journal of integrative psychotherapy, vol. 7, 2016 57 her room for hours all alone. she became aware of rocking herself in her bed to pass the time. this is a striking example of her attempt for stimulus and her need of contact. she learned in her earlier therapy that she was alone so much because her mother started drinking from early morning. two of her aunts corroborated her mother’s behavior. they had pleaded with their sister to get help and she refused. anne was now back in therapy to deal with the neglect and loneliness she had carried with her for years. her child ego states froze these early memories. an understanding of both the child and parent ego states allowed for not only an acceptance but also an appreciation of the child’s dilemma in dealing with an absent, neglectful mother. a ‘me’ at the center was trying to figure it out all alone and could not. her ‘me’ in the relationship, with me as the therapist, gave anne the needed support for her mind to understand and accept her experiences. sorting out her ego states, giving voice to these parts, and accepting her reality ultimately led to integration. psychotherapy provided anne the opportunity to challenge her script beliefs and understand the components of her script system. “the script system “(erskine, 2010), an integral part of integrative psychotherapy, allows for unconscious relational patterns to be examined. such beliefs as “no one loves me, there is no one there to help me, life is confusing”, left anne overwhelmed and contributed to her thinking that she had to do most things by herself, in addition to feelings of bewilderment a great deal of the time. the therapeutic relationship, although at times creating a juxta-position where she was now experiencing what was needed in the relationship with her mother, permitted her to get in touch with repressed feelings and needs. to be in the presence of another, to be seen, to be heard, to be understood, were all important and much needed for anne to fill in the gaps of her past. beliefs about herself, others, and the quality of her life, as well as a better understanding of her feelings, sensations, behaviors, fantasies, needs and desires were addressed. with the use of the models of the “self-in-relationship” and the “script system” as a guide, she was able to construct her narrative, resulting in a sense of continuity and confidence. a basic philosophy one’s own values are inherently woven into our thoughts and actions. for me, the core values of integrative psychotherapy are comparable to my fundamental beliefs: all people have innate value and are unique; each has a thrust toward a life that has meaning; psychotherapy guides a person to be the best he/she can be through the intersubjective experience of client and therapist. connecting with anne to her unique life events and the meaning she gave to her experiences, understanding her thoughts, feelings and behaviors as a way for her to express herself, and a willingness to provide a holding environment for her to international journal of integrative psychotherapy, vol. 7, 2016 58 explore, helped anne experience her importance and worth as a human being and gave her the needed support to work through her intrapsychic and interpersonal struggles. conclusion a basic and critical premise of integrative psychotherapy is that healing is in the relationship. my relationship with anne, as well as with other clients i have worked with throughout the years confirm the significance of the therapeutic relationship. relationship-focused integrative psychotherapy has been my psychotherapeutic framework for most of my professional career. the organization of the theory in a relational-focused, motivation-oriented, personality paradigm along with the methods of inquiry, attunement, and involvement have given me a strong and useful framework. as a member of the professional development seminar in kent, connecticut i was part of an exciting time where concepts and constructs were further developed. and as a client in both individual and group psychotherapy, along with kent 10-day residential seminars, i feel privileged to have been a part of integrative psychotherapy professionally and personally. “revisiting” has given me the opportunity to explore once again the essence of integrative psychotherapy, and in this journey to recall my convictions and appreciation for the scope, complexity and richness of integrative psychotherapy’s theory and methods. author: marye o’reilly-knapp, rn, phd is a founding member of the international integrative psychotherapy association. retired from her clinical practice she continues to write and present on the theory and methods of integrative psychotherapy. note: a special thanks to carol merle-fishman for enriching this paper with her edits. references erskine, r.g. (1988). ego structure, intrapsychic function, and defense mechanisms. transactional analysis journal, 18, 15-19. erskine, r.g. (1997). theories and methods of an integrative transactional analysis: a volume of selected articles. san francisco, ca: ta press. erskine, r.g. (2010). (ed.). life scripts: a transactional analysis of unconscious relational patterns. london: karnac books. international journal of integrative psychotherapy, vol. 7, 2016 59 erskine, r.g. (2015). relational patterns, therapeutic presence: concepts and practice of integrative psychotherapy. london: karnac books. erskine, r. g. & moursund, j.p. (1988). integrative psychotherapy in action. newbury park, ca: sage publications. erskine, r.g., moursund,j.p., trautmann, r.i. (1999). beyond empathy: a therapy of contact-in-relationship. philadelphia, pa: brunner/mazel. moursund, j.p. & erskine, r.g. (2004). integrative psychotherapy: the art and science of relationship. pacific grove, ca: thomson: brooks/cole. o’reilly-knapp, m. & erskine, r.g. (2003). core concepts of an integrative transactional analysis, the transactional analysis journal, 33, 168-177. date of publication: 11.2.2017 the feminist approach to psychotherapy integration the feminist approach to psychotherapy integration lorena božac deležan abstract: the goal of integrative psychotherapy is to establish full inner and external contact (moursund & erskine, 2004). the most important goal in feminist therapy is the transformation of an individual as well as the transformation of the society as a whole (herlihy & corey, 2004). in my work i attempt to integrate both: to help the client establish inner and external contact, but also help him/her to become aware and recognize inner messages connected with his/her gender and replace them with constructive beliefs of his/her own, as well as for him/her to learn, regardless of his/her gender, to trust his/her intuition and experience. in this article i present my approach to integration in psychotherapy and the way i use feminist principles in integrative psychotherapy. key words: feminist principles, integrative psychotherapy, contact, gender ____________________________ my professional path my approach to integration in psychotherapy is under the influence of feminist theory. i work at the women counseling service as a counselor on the program for psychosocial support and help for women that were experiencing or had experienced violence. my work includes individual work with women that have survived different forms of violence. i also coordinate a group for women that have survived sexual abuse in childhood and a group for women that have survived abuse in their relationships with their partner. during all these years i have been active in the field of educating various profiles of professionals who encounter women and children victims of violence at their workplace. i have been also actively engaged in the creation of policies and change of legislation and professional approaches in this field. the gradual changes in my professional career began in 2004, when i began studying integrative psychotherapy. after many years of engagement in the social environment on changing prejudices and stereotypes connected with international journal of integrative psychotherapy, vol. 2, no. 1, 2011 50 violence against women, especially violence within the family, my studies and personal therapy influenced the fact that my interest started shifting more and more towards the field of psychotherapeutic work with people, whether individual or group work. the studies of integrative psychotherapy and personal therapy have significantly contributed to my new orientation. when thinking about my professional identity, the first thought that comes to my mind is that »i am a feminist«. for me personally being a feminist means being a person that continuously strives towards anti-discriminatory practices concerning gender or other differences between people. as a feminist i respect and accept differences between people without judging. in all the years working for organizations, whose member and employee i am, my title was a counselor, more precisely a feminist counselor. this comes with specific knowledge and skills, but also with a specific view of the clients i have worked with as well as of the society and the way it is organized. during the years of studying integrative psychotherapy my identity has been complementing itself, and the knowledge and skills i have been gaining took me towards the goal of becoming a »feminist integrative psychotherapist«. all the knowledge and skills i have gained represented an important complement and gave me a new framework in which i could place all my previously accumulated knowledge and integrate it with new contents. the very reason integrative psychotherapy fascinated me is in the fact that it is relational, focused on the relationship with the client, and it also allows the integration of different theoretical approaches and methods. the studies of integrative psychotherapy and regular supervision have also significantly contributed to my own personal changes. during my studies and personal therapy i started becoming more aware of myself, as well as my knowledge and skills. i increased my self-esteem and became more relaxed and open. additionally, i learned to take more care of myself and my needs, and to give more meaning to establishing contact with myself and others. for many years, since i have been working in the field of violence against women, i have been regularly attending supervision with different supervisors. after a series of years working jointly with a psychoanalytic therapist supervisor, i continue my work with an integrative therapist supervisor. their different approaches greatly contribute to broadening my professional horizons and deepening my knowledge. in conclusion, i can hardly imagine high quality psychotherapy work without regular and high quality supervision. also i myself am a part of my approach, with all my characteristics, knowledge and experience, which i continue to embed in myself with great joy and pleasure. in this way i upgrade myself not just in the professional, but also in the personal sense. international journal of integrative psychotherapy, vol. 2, no. 1, 2011 51 feminist theory and integrative psychotherapy one of the basic principles of feminist theory and the therapeutic approaches that arise from it is the interlacement of the personal and professional. the goals are to change and accept oneself and society. regardless of the modality we use in our work, all feminist therapists have some basic guidance, as follows: constant personal and professional growth, continuous observation of own reactions, the emerging of prejudices and stereotypes inside ourselves as well as in society and working on dissolving them. an important dimension of integrative psychotherapy is the personality of the therapist. in order to create and sustain a high quality therapeutic relationship, the therapist has to develop her ability to listen together with the client, her ability to observe in the relationship and to be emotionally available to the client. in order to do so, she has to nurture her self-awareness (moursund & erskine, 2004). my own personality, self-awareness and involvement in the therapeutic relationship are of the utmost importance in my work. despite the feminist orientation i do not »preach« feminism when working with my clients (chaplin, 1999). however, from my complete attitude it is evident that i am aware of gender differences, different processes of socialization among men and women, my attitude towards gender discrimination as well as other forms of discrimination. it is important that the professional and personal life of feminist therapists is in harmony. herlihy and corey (2004) believe that the therapeutic role is inseparable from certain personal characteristics and that is why feminist therapists are constantly focused on monitoring their own prejudices and distortions. both integrative psychotherapists as well as feminist psychotherapists believe that a therapist has to be fully present in the therapeutic relationship, prepared to share herself and act in the client's best interest. one of the basic purposes of integrative psychotherapy is reciprocal connection of all aspects of human functioning – emotional, behavioral, cognitive, physiological and interpersonal (moursund & erskine, 2004). this principal greatly helps me with my work because it allows me to enter the relationship with the client through the most unsecured door, through the dimension which is most available for the client. by doing this i am aware that dealing with certain parts of the client’s experience means establishing gradual contact also with other parts that are momentarily less available to the client. by building a contact i can help the client to capture more and more dimensions. so, i work where the client is open for contact and through this contact i work with him on constant opening of new contact dimensions. interpersonal contact is a basis of work in integrative psychotherapy as well as in feminist therapy. i consistently take this interpersonal contact into consideration because i believe that the client can reach changes and integration only through a good contact. international journal of integrative psychotherapy, vol. 2, no. 1, 2011 52 principles and methods both feminist principles of therapeutic work and principles of integrative psychotherapy support the position of a client as an expert. as a therapist i respect and consider this position in my work. in my opinion, the position of equality and creating space, where i am constantly aware of different power positions in the relationship, does not mean equality in knowledge. namely, the client expects from me some knowledge he does not have on his own, but this position of equality means creating and increasing the client’s self-esteem, his trust in his own abilities of exploring himself and respect towards his own strengths. in the therapeutic relationship i achieve good contact, authentic relationship and authentic interest in the client and his story by using the methods of integrative psychotherapy of inquiry, attunement and involvement. these methods are very important for me, as my work originates from the feminist context of work. even though some authors already argue that feminist therapy has its own methodology and is not just an orientation and philosophy characterized by certain working principles (herlihy & corey, 2004), i myself missed just that – a method that would give my work a framework, but at the same time allow for all feminist principles of work. integrative psychotherapy as a method offers me a theoretical and practical framework in which i can place in the feminist principles. at the same time the methods of inquiry, involvement and attunement provide to me the connection in my concrete work with clients. inquiry is focused in such a way that it stimulates the external and inner contact in the client. its purpose is to help the client recognize the ways in which he learned to interrupt contact with himself and others (erskine, moursund & trautmann, 1999). i always consider the client’s perspective and i do not force him into going »where he does not want to go«. additionally, i attempt to achieve the goals of inquiry, i.e. that the client becomes aware of himself, recognizes certain aspects within himself and in contact with others. by doing that he is able to improve his intrapersonal and interpersonal contact. in integrative psychotherapy, inquiry involves all aspects of the client’s awareness: physical sensations, reactions, emotions, memories, thoughts, conclusions, decisions, meanings, fantasies, expectations and hopes (erskine, moursund & trautmann, 1999). also in the context of feminist principles inquiry has similar goals. as i see it, it also revolves around gender issues and the influence of external reality on the inner world of an individual and the connection between them (walker, 1990). this means that in my work with clients i consider the perspective that aspects of the client’s awareness are among others connected also with his gender and in this context also with gender socialization and gender roles in the client’s everyday life. when talking about attunement, i perceive as most important the attunement to all the aspects of the client’s experience, especially those that were not accepted. i consider that being in contact with myself and being in contact with the client means to accept and respect the client and to be attuned international journal of integrative psychotherapy, vol. 2, no. 1, 2011 53 to all dimensions of his functioning; the cognitive dimension – in which way the client speaks about himself and his way of perceiving the world, which words he uses when describing that and in what way he thinks. my feminist perspective is most at the forefront precisely in the field of cognitive attunement. how does the client speak about himself in the context of gender? does she use the masculine gender form when describing herself, although she is a woman? the use of language in therapy gives an important insight of experiencing oneself and also the possibilities to change the perspective of experiencing oneself as a representative of a specific gender. when speaking, i consistently use a certain gender form, i.e. the feminine form when i am talking about a woman and the male form when i am talking about a man. by doing this i also give the client a chance to shift in this area and to think about what is his way of speaking about himself, without directly influencing and/or correcting his way of speaking. in fact, it is the first and basic literature that i got during the time i was attending the training in integrative psychotherapy, that convinced me that i could combine feminism and integrative psychotherapy. in their books richard erskine and his coauthors convey a very important message about the dimension of gender and power in therapy. they consistently use the feminine form for the therapist and both gender forms for the client. i think of the rhythmic attunement to the client’s emotional states, developmental and relational needs as that component of attunement where, in my opinion, the part of integrative psychotherapy that is more »art« than »science« is the most visible. in fact, a crucial part of rhythmic attunement is the therapist’s sensitivity and reciprocal responsiveness to the client’s experience. in my opinion, an important part of rhythmic attunement certainly is perception and my own response to the client’s nonverbal communication, as well as attentiveness to the »here and now needs«, for instance the client’s needs for physical activity. i find it also important for the client to be able to use the therapeutic space in accordance with his physical needs, for instance that he can sit in such a position that suits him best, and for him to be able to choose where he will sit. in fact, in the very possibility of being able to choose his seat, i can also observe my consideration of feminist as well as integrative principles in the sense of decreasing the power position of the therapist. the client’s choice of seating can also be a message for me because it can give me a nonverbal message of how the client perceives me, what his needs are and what kind of position in the sense of power and distance he wants to occupy in our work. attunement and involvement are closely connected. the therapist is involved in the therapeutic process with her attuned and oriented responses to the well-being of the client and his experience, needs and thoughts. by being involved through validation and normalization the therapist conveys the following message to the client: that she considers and acknowledges his needs, physical sensations and defenses. the therapist’s presence in the therapeutic relationship is the most important aspect of her involvement; namely consideration, validation and the international journal of integrative psychotherapy, vol. 2, no. 1, 2011 54 normalization of the client’s emotions, needs and defenses are derived from involvement. being present as a therapist means to be in full contact and at the same time to have the therapeutic intention of »being present for the client’s best interest« and to have therapeutic competences (erskine, moursund & trautmann, 1999). in my line of work i often encounter traumatized women. many of them have survived different forms of child abuse and are currently living in relationships with abusive partners. that is why i consider that an important part of the therapeutic relationship is the validation of their emotions, defenses and behavior, as well as the normalization of their survival strategies. as a matter of fact, many of these women are still being judged and misunderstood because of their persistence in an abusive relationship. in that sense validation and normalization are helpful, so that each individual woman can, as zaviršek (1994) says, »define violence or abuse on her own«. these women can then, through the awareness of the use of survival strategies in an abusive relationship, become aware of their own strength that can help them find the way out of a particular situation. taking into consideration the aforementioned psychotherapeutic working methods i also use various techniques in my work. a part of my psychotherapeutic training is also training in psychodrama which was focused on working with traumatized people. my teacher and supervisor adjusted some of these psychodrama techniques for the needs of working with individual clients. for instance, in my work i use the technique of the »social atom«, where the client can present his current important relationships in his life by using various stones of different shapes and colors. i also use these stones in working with detached parts of the client. the client uses these stones to present different parts of himself and the interactions between them. the symbolic meaning of these stones and the way the client arranges them, gives him an insight into the inner and/or external interactions, while at the same time enabling him to have a greater emotional distance. this is in particular important for those clients who are emotionally overwhelmed. in my work i also use the visualization technique and the »two chair« technique, especially when working with ego states. in their work feminist therapists also use techniques from other modalities, which they adjust in accordance to the feminist principles. they also developed some techniques of their own such as assertiveness training (herlihy, corey, 2004). i use this technique in my work and i see it as a technique i could place into the cognitive-behavioral field. transference and countertransference i consider working with transference and countertransference as an important part of supporting the client’s integration. namely, exploring the ways how the therapist and client create, distort and interrupt contact with each other, usually increases the interpersonal contact, which supports the increase of intrapersonal contact and awareness (moursund & erskine, 2004). while working, i often ask my clients to describe the way in which they see me. i international journal of integrative psychotherapy, vol. 2, no. 1, 2011 55 explore this also by searching for the connection in the client’s past and present relationships. this can be of great help for the client to become aware and explore certain issues in his relationships that are constantly reappearing, and to find ways of how to start resolving them. the awareness of my countertransferential reactions is most certainly of great assistance to me. in fact, i share them with the client if i conclude that it is in his best interest. i notice that countertransference helps me the most in attuning with the client. in the part that i myself perceive as the “art in psychotherapy”, transfer and countertransference help me gain an insight into the unspoken, i.e. what the client tries to conceal, but expresses with gestures, looks or other forms of nonverbal communication. it also helps me in dealing with emotions where i inside myself sense the emotional response or the echo of the client’s non-verbalized feelings or an appropriate response to them. i also find it very important in my work to share my emotional responses with the client, if appropriate, and in this way to verify whether they are in accordance to the client’s emotions or needs. mistakes are most certainly an inevitable part of therapeutic work. i experience them as an opportunity for change. by seeing the therapist’s mistakes the client has a possibility to perceive the therapist as a person with all her limitations, which can strongly influence the decrease of idealization. at the same time i believe that it is important to admit my mistakes, which is just another way of showing the client that i am not an expert that has all the answers, but rather his partner in the process, with all my limitations. furthermore, it is important for the client to know that i am just a person that cannot always be perfectly attuned, absolutely understanding and have ideal contact with him. all of this can also, after all, help the client to learn that there is no such thing as an ideal relationship, but that there is always a possibility to repair the interruptions in contact. psychotherapeutic relationship and the goals in psychotherapy integrative psychotherapy focuses on relationships. the foundation of a relationship is contact. the therapist’s most important task is to help the client establish and maintain inner contact and to be aware of his inner experience, his thoughts, emotions, wishes and sensations. also, the therapist must help the client to establish and maintain external contact which includes relationships with other people (erskine, moursund & trautmann, 1999). feminist counselors and therapists focus on empowerment of their clients and help them develop an increased level of self-esteem and control over their own lives (chaplin,1999). the focus of the therapeutic relationship is on the client and on his exploration of his own life. the therapist’s role is to support him and to fully accept him. at my work i can use and see a connection between both the integrative as well as the feministic focus. in my opinion, contact is the most important part of both focuses because without good contact it is impossible to reach the goals international journal of integrative psychotherapy, vol. 2, no. 1, 2011 56 that the two approaches consider as a crucial part of the process. the relationship between the therapist and the client is almost identical in the integrative and feminist approach. both of them consider as crucial the role of the therapist as a partner in therapy who acts in the client’s best interest. in integrative psychotherapy, with the awareness about fixated gestalts, the client gradually reestablishes contact with himself and others, as well as replaces old automated patterns of beliefs and behaviors with new ones (erskine, moursund & trautmann, 1999). in feminist psychotherapy the client gradually accepts himself, regardless of the social expectations that are connected with his gender role. by doing this he is more and more able to live in accordance with his own wishes, needs and beliefs (chaplin,1999). the goal of integrative psychotherapy is to establish full inner and external contact (moursund & erskine, 2004). the most important goal in feminist therapy is the transformation of an individual as well as the transformation of the society as a whole (herlihy & corey, 2004). in my work i attempt to integrate both: to help the client establish inner and external contact, but also help him to become aware and recognize inner messages connected with his gender and replace them with constructive beliefs of his own, as well as for him to learn, regardless of his gender, to trust his intuition and experience. when i repeatedly ask myself about my way and approach to integrative psychotherapy, i believe they are best captured in the thoughts of richard erskine (2001): “we love them through our phenomenological inquiry, through understanding their defensive process, through valuing their vulnerability. we connect with them through affective attunement: when they are sad, we meet them with compassion; when they are angry, we take their anger seriously; when they are scared, we create that psychological holding environment that surrounds them with protection; and when they are joyful, we meet them with vitality. those are the realities of our therapeutic process that make our dreams come true because we share our personal presence in an inter-subjective arena between client and therapist.” references: chaplin, j. (1999). feminist counselling in action. london: sage publication ltd. erskine, r.g. (2001). the psychotherapist's myths, dreams, and realities. international journal of psychotherapy, 6, 2, 133 140. erskine, r. g., moursund, j. p. & trautmann, r. l. (1999). beyond empathy. a therapy of contact-in-relationship. new york: brunner-routledge. herlihy, b. & corey,g. (2004). feministična terapija. [feministic therapy] in g. corey, teorija i praksa psihološkog savjetovanja i psihoterapije. [theory and practice of counseling and psychotherapy]. jastrebarsko:naklada slap. international journal of integrative psychotherapy, vol. 2, no. 1, 2011 57 international journal of integrative psychotherapy, vol. 2, no. 1, 2011 58 moursund, j. p. & erskine, r. g. (2004). integrative psychotherapy. the art and science of relationship. pacific grove, ca: brooks/cole-thomson learning. muller,g. (2002). psihodrama v radu s traumatiziranim ženama. [psychodrama with traumatized women]. notes from workshops. walker, m. (1990). women in therapy and counselling. philadelphia: open university press zaviršek, d. (1994). ženske in duševno zdravje. [women and mental health] ljubljana: visoka šola za socialno delo. author: lorena božac deležan is social worker and certified integrative psychotherapist (iipa). since 1995 she is working with women, victims of violence in relationships and women sexually abused in childhood. she is co-founder of the first slovenian crisis centre for women and children – victims of violence in family. currently she is working at women’s counselling service as counsellor and psychotherapist and in the private psychotherapy practice. date of publication: 30.1.2012 alcoholism is such a common condition that therapists must be exposed to clients who suffer from it, whether the therapist is weaving the fabric of attachment lindsay stewart abstract: this article is the keynote address given at the 5th international integrative psychotherapy association conference in vichy, france, april 21, 2011. in the article author describes development of secure attachment with the help of the case study. key words: attachment theory; integrative psychotherapy; case study ____________________________ the intent of my presentation today is to get us in the moodto get us in the mood to be thinking and talking and sharing about all the ways we can help our clients discover what it means to have a secure attachment. there is no ‘how to’ manual for creating the felt sense of secure attachment but it is useful to look back at our own work and see what really made the most difference for our clients. to illustrate this, i will present a case study a little later covering a decade of therapy where the end result was a secure attachment. like time lapse photography, ten years will get compressed into ten minutes, and, like watching in compressed time the metamorphosis of caterpillar to butterfly, i hope you will feel some of the magic of the transformation. to set the stage i first want to say a bit about what this type of long term and in depth psychotherapy demands from both client and therapist, and i want to talk about some of the theory around contact. i recently saw the term “earned secure” used to describe the achievement of secure attachment after working through the pain, confusion and isolation of insecure attachment. this is no small feat and not for the faint of heart. here are just a few examples why: • from the client it demands the courage to fully embrace the inner chaos and despair of feelings he has tried so hard to push away. • it takes faith that the therapist will not replicate earlier abandonment and leave him before the job is done. • it takes hope to accept on trust the possibility of fulfilling international journal of integrative psychotherapy, vol. 2, no. 1, 2011 1 relationships and emotional intimacy. • from the therapist, it is a long term commitment and a decade of work is not unusual for that transition to happen. • there is the burden of responsibility to contain feelings that seem overwhelming for our client, and at times for ourselves too. i recall the rage and despair one woman felt each time i took a holiday, and her need for me to call her immediately on my return to end the agony of separation. i did suffer alongside her through this. • we must accept that our need to make an impact may go unmet for years. • we need to create in our own lives a quality of stability that in turn gives our clients the consistency and predictability of our presence that is required. on to discussing contact: in his book “beyond empathy”, richard asserts that maintaining contact between therapist and client must be the therapist’s most central and overriding concern (erskine, moursund, trautmann, 1999). i agree. contact is a cornerstone in building the foundations of relationship. it is the means by which we reach through defenses and forge attachments by connecting at our most human level. to explain more about contact means going into gestalt theory, which is a subject close to my heart since my personal therapeutic roots actually lie in gestalt therapy. i did my training as a gestalt therapist between 1985 and ’88. during that same period i began my integrative psychotherapy training and in so doing, discovered how much gestalt theory has contributed to our practice and theory of integrative psychotherapy. the poster boy for gestalt therapy is, of course, fritz perls who carved a radical new direction from the 19thc psychoanalytic traditions. the therapist came out from behind the inscrutable mask of the psychoanalyst and became more fully engaged in the therapy process what we now call ‘involvement’. in addition, the focus was not on the past – it was present centered, dealing with the here and now. the concepts of contact and interruption to contact stood out solidly in the foreground of gestalt theory (perls, hefferline, & goodman, 1951). both fritz and laura perls were involved in developing the theory of contact. laura in particular had been influenced by martin buber, an existential philosopher born in 1875 . a major theme in buber’s writing is that true meaning in our lives is found through relationship with others. considering this heritage, it is no coincidence that in integrative psychotherapy we view the biological imperative for relationship as a primary motivator in human behavior. international journal of integrative psychotherapy, vol. 2, no. 1, 2011 2 martin buber made the distinction between the i-it and the i–thou. the i–it views the other person as an object that is separate from self, that we either use or experience in an impersonal way. by contrast, the i-thou does not objectify the other. in the i-thou encounter, the other is no longer a he or she and barriers are dropped, creating a sacred space involving the full being of each person. buber believed that god is ever-present in human consciousness and that all human relationships ultimately bring us into contact with god. in the more pragmatic terms of our clinical practice, the i – thou is about ‘person to person’ relating, where 2 people mutually coexist, being fully open to and conscious of the other. this living relationship comes into existence through our attunement, presence and our empathic inquiry, where we explore the moment to moment lived experience of our client’s reality. to illustrate the development of secure attachment, i will present a case study. i want to talk about jason: firstly, because jason did reach that place of allowing himself to be fully engaged and vulnerable with a partner in a long term committed relationship, which i believe is an important hallmark of secure attachment. secondly, his trauma history is not complicated so the underlying architecture of needs, feelings and defense stand out in high definition. thirdly, therapy took place over a decade with periods of rapid growth and then plateaus. there were long periods, sometimes years, when we did not meet, but jason would come back when troubling symptoms re-appeared at developmental milestones such as a committed relationship, career challenges, and marriage. the intense distress connected to those transitions brought jason back to therapy to rework the many facets of memory, pain and defense, each time with a different level of awareness, intent and outcome. jason is animated and expressive, with an emotional intensity that is very appealing and engaging. he conveys a sense of warmth and openness and his training as a performing artist has helped him articulate his feelings and express himself through metaphor. this made my job easier, but did not make his work any less excruciating. back in november 2000, the main issue jason presented was conflicted feelings about a relationship, wondering “is this the right woman for me?” can i ever get close to any woman? he had noticed a pattern of distancing and de-valuing in previous relationships once the initial connecting phase was over. in terms of family history, jason’s parents divorced when he was 7 after which he only saw his father for occasional weekend visits. jason did not think he carried any emotional baggage about this, but in hindsight it is clear this was a devastating event for him. if we think in terms of denial, disavowal and desensitization there was denial of the significance of the trauma, disavowal of the existence of painful feelings and desensitization of feelings through numbing and dissociation. he was on auto-pilot and did not know who was at the controls. international journal of integrative psychotherapy, vol. 2, no. 1, 2011 3 in my gestalt training there was much emphasis on being in the moment. it took years to fully appreciate the power of being in the moment and to realize what a potent surgical tool this is to cut through psychological defense, and how respectfully and efficiently we can do this through our style of attuned empathic inquiry. about 3 months after our initial meeting, through phenomenological inquiry, jason began to bring into focus his fear of commitment, fear of being vulnerable with me, and fear of being trapped. he could now feel a quality of hardness in his sternum which was like a protective shield. when this physiological defense was explored, the full emotional force of separation from father after those week-end visits broke through. he had adored and craved connection with his father, and was inconsolable in his grief when separating after visits. on leaving, his father offered no comfort, just the directive “don’t cry”. in this way, jason’s emotional vulnerabilities were not acknowledged, and his needs for security and validation were not met. the pain of separation was almost unbearable, and school on monday morning would be a spacey fog. dissociation was the only option in the face of overwhelming pain. as he began to trust me more, jason disclosed sexual fantasies that were far from the kind of intimacy he really wanted. he also disclosed using telephone sex lines, and with these disclosures came intense shame and self-loathing. jason’s relational needs for contact were not being met and these telephone conversations with faceless women were substitute satisfactions, but they felt hollow and dirty, and he never felt good about himself after them. gestalt theory talks about the needs cycle when we experience awareness of a need we mobilize ourselves to get that need met from our environment. when that need is met we feel a sense of completion or closure, which is called a primary gestalt. when the original need is not met, we begin to look for substitute satisfactions to take its place. when this happens it is called a secondary gestalt, which does give closure of a sort, but is always second choice, like telephone sex, and fundamentally unfulfilling. the shame of revealing his inner turmoil inhibited jason from really letting me know what was going on, but at nine months into the work, he was moving from ‘talking about’ to the more risky ‘experiencing’ his deepest feelings in session. i now had a clearer picture of the hidden pain jason suffered as an adult such as the weekends paralyzed by depression and a constant undercurrent of self-loathing just below the surface. there were intrusive sexual fantasies and compulsions to call the sex lines. unconditional acceptance and normalization helped reduce jason’s shame and self-loathing, and allowed objective international journal of integrative psychotherapy, vol. 2, no. 1, 2011 4 exploration into the motivations and needs that lay behind the compulsive urges. empathic inquiry into the hopes and dreams which fueled the fantasies helped jason realize that calling the sex line provided both a jolt of excitement that distracted from his depression, and the illusion of connection that kept his crushing loneliness at bay. at 15 months into therapy, jason had periods of dissociation which were terrifying – the lonely disconnected floating feeling was heightened by inner voices telling him he was going insane. in these times, the relational need of having a stable and dependable other was met by me; someone who provided protection from the escalation of fear and helped quiet the inner voices through reassurance, normalization of what he was going through, and my therapeutic presence. more memories came back of his father’s leaving, and jason reexperienced the feelings of failure and powerlessness of being unable to get his parents back together. one poignant memory that surfaced was of jason’s spending hours by himself shooting hockey pucks into the net behind the house, always imagining his father in the background calling out “great shot son – way to go”. as therapists, we need to continually respect the creative power of fantasy in filling unmet relational needs, but also be attuned to an over-reliance on fantasy as a defense against genuine human connection. these explicit memories had never before been verbalized or openly acknowledged. putting these types of experiences into words in the context of a supportive empathic relationship hastened the thawing of archaic defenses, setting the stage for the next level of work. as jason’s relational needs for security were met in therapy, he felt safe enough to take a monumental step, as he totally relinquished control of his feelings allowing me to contain them and keep him safe. he slipped into the vulnerable felt experience of the boy who, again and again, had been overwhelmed by inconsolable pain. jason was no longer ‘talking about’ his inner world, but fully immersed in the despair and anguish of his child ego state. this experience in integrative psychotherapy is the supported regression. a strong therapeutic presence was essential to keep jason from pulling back into his shell, and was conveyed through the physical anchor of holding my hand as long as needed while he wept, through my words and tone of my voice, and the expression on my face. i talked about contact in a theoretical way earlier, but it is in moments like this that the “i-thou” becomes a living relationship which engages every aspect of body and mind. where, for a little while, nothing else in the universe matters except the acute awareness of some fundamental human essence we share. these are the moments of contact that gradually and cumulatively erode the international journal of integrative psychotherapy, vol. 2, no. 1, 2011 5 hardened defenses that keep people so isolated within themselves. it is not a quick fix but it is a healing moment that, once experienced holds the hope it can happen again. through our contactful presence, we offer a way out of the lonely prison of the hidden self initially with ourselves and eventually to be experienced with others out there in the world. jason’s core shame of exposing vulnerability came out in the fear “if you see me like this you will lose respect for me and leave ”. this is another example of a secondary gestalt. the child is haunted by the question “why did you leave me?” drawing the conclusion “because there is something wrong about me” does help the child make sense of why a parent has left. this is a called a cognitive closure and in the absence of empathic support this decision becomes established as a script belief, out of conscious awareness but still exerting its negative influence. these fears can also be viewed through the lens of transference – where fears of abandonment by father are projected onto me and we work through, in the now, the fundamental dilemma of defensive self-protection versus allowing full contact. through the transference, the possibility of a corrective experience exists through learning “in my most vulnerable moments i will be understood and comforted.” during the intensity of full regression, it was meaningful to jason that i felt honored and moved by the work he was doing, which met his need to make an impact on me. through 2002 the theme of shame around intrusive sexual fantasies and use of telephone sex lines was still strong. each time jason processed shame about phone sex he would come face to face with the desperately lonely part that yearned for the sense of merger, to “share each other’s most secret places”. maintaining consistent therapeutic presence kept jason from getting lost in despair and self-recrimination. receiving nourishing emotional support became juxtaposed with the early memories of non-support and loss, triggering the release of more pent up grief. in 2003, there was a certain amount of approach avoidance with jason in his therapy. the fear emerged “if i let you be too important, then you can hurt me”. separation anxiety had emerged in the transference. there are different strategies we can use to regulate separation stress; hyper-activating, deactivating, dissociation or collapse. deactivating by slowing therapy was jason’s way of titrating the intensity of the work. as a boy the separation stress was so acute it did feel like going crazy, and dissociation was a protective mechanism. in the present, jason felt terror of falling back into that ‘crazy’ disconnected floating state and thus his need to pull back in therapy. international journal of integrative psychotherapy, vol. 2, no. 1, 2011 6 it is a difficult judgment call as a therapist – how, when and if to confront avoidance. my gut sense was that jason was doing as much as he could and would flee if pushed or confronted. i decided to just let jason call the shots. not long after, we moved through this impasse and a potent memory surfaced that proved a catalyst for an important shift: jason told me “i remember the steep hill i walked up every day on my way to school. it was such hard work and i was so alone. i’d see those other kids walking up the hill with their dads and wished so much i had a dad who would help me up the hill, and how much easier that would have made it.” in the evening after this session jason wept for 2 hours – grieving with abandon and without self-criticism, experiencing a level of self-acceptance he had never felt before. jason experienced the full depth of his grief without having to deflect or distract from it and after the tears stopped, he tore up the sex line code number. to him, this was symbolic of not wanting to hurt himself anymore and opening himself to full and genuine connections with women. this was an epiphany in the true sense of the word since he also felt a powerful spiritual awareness and sense of being closer to god – opening himself to the supportive presence of something/someone greater than himself. now when he thought of that image of the boy without a dad ‘walking up the hill to school’, he could imagine god giving him the hand he needed. in integrative psychotherapy, the spiritual aspect of human experience has not been emphasized. there is, however, a stance of permission and acceptance, which acknowledges how individual our ways are of connecting with the divine. i do encourage you to read rebecca trautmann’s article on spirituality and psychotherapy which beautifully illustrates this and can be found on the website: www.integrativetherapy.com (trautmann, 2003). three months after his epiphany, jason began seeing julie who he married 5 years later in 2008. we had reached a plateau and took an extended break, but more difficult work still lay ahead. fast forward to february 2007. in his relationship with julie, jason had “talked about” much of his history and inner world but he felt there was still a wall up that prevented him from being more genuine and emotionally real with her. we talked about the importance of being fully vulnerable with julie and holding nothing back, which in itself brought about intense dread. we reached an impasse, and it took eight more months for jason to be ready to have this conversation with julie. this inner struggle created overwhelming anxiety and feelings of panic about the marriage to julie scheduled for april 2008. each successive step in international journal of integrative psychotherapy, vol. 2, no. 1, 2011 7 wedding planning felt like a deepening trap. stress symptoms such as insomnia, palpitations, sweating and vomiting before performances made it almost impossible to continue with his work. he experienced dread and emotional pain he would not wish on his worst enemy. we came to a decision to use short-term medication to manage the excruciating anxiety he was experiencing, which allowed him to function at work but did not resolve the inner conflict. what took us through the impasse was a series of couple’s sessions with julie and jason where the focus was on allowing full transparency in their relationship. jason was able to reveal and communicate his most vulnerable feelings to julie, demonstrating his capacity to tolerate his shame and his fear of rejection “if she really sees who i am”. julie consistently gave jason the loving message “i’m not going to let you push me away,” which is the message jason had so desperately wanted to hear from his father. for the first time jason felt truly excited about the shift in his life: he had a sense of ‘growing up’ into adulthood and gaining the upper hand over the voice that said ‘run’. the wedding went ahead and the marriage continues to thrive. is the therapy finished? no there have been many moments where overwhelming dread has broken through. for example, seeing julie acting in a play as a highly sexualized and passionate woman brought up intense jealousy, abandonment and panic. it was profoundly disturbing for jason to realize he now felt dependent on julie – the flip side of his earlier distancing pattern. where we are in therapy now is a ‘holding and maintaining’ phase. by that i mean that the influence of the original trauma is still felt; for example, the urge to run away to avoid being hurt again. however, a conscious decision has been made to not move into defense, but to remain fully open to self and other. jason recently told me about seeing a ragged and hollow-eyed man smoking in the shadows totally absorbed in the numbing ritual of his addiction. jason said, “that could have been me – a mirror of who i could have become. i still struggle every day with that choice of feeling or being emotionally dead. i reach the edge of the pit and feel terror and want to run to numbness, but now i can hear julie’s voice calling from the pit saying ‘i’m down here, come and join me’ and i do.” jason thought for a minute then looked me in the eye and said “i’m proud of myself, you know, i really am proud of myself’. when i shared this paper with jason he wept with compassion for the anguished child he once was, with relief that it was over, and with gratitude for his relationship with me which had helped foster his capacity for secure international journal of integrative psychotherapy, vol. 2, no. 1, 2011 8 international journal of integrative psychotherapy, vol. 2, no. 1, 2011 9 attachment. i am blessed to experience the trust and intimacy of this work and those moments in which i gave so much of myself and felt so enriched in return. author: lindsay stewart is a registered clinical social worker in vancouver, canada. lindsay has been using the integrative psychotherapy model since 1986 and is a founding member of the iipa and a trainer/supervisor with the organization. lindsay sees individuals and couples in his practice in addition to doing process group work and clinical consultation. references erskine, r.g., moursund, j.p., & trautmann, r.l. (1999). beyond empathy: a therapy of contact-in-relationship. philadelphia: brunner/mazel. trautmann, r. (2003). psychotherapy and spirituality, transactional analysis journal, 33, 32-36. perls, f. s., hefferline, r.f., & goodman, p. (1951). gestalt therapy: excitement and growth in the human personality. new york: julian press. date of publication: 9.9.2011 lindsay stewart is a registered clinical social worker in vancouver, canada. lindsay has been using the integrative psychotherapy model since 1986 and is a founding member of the iipa and a trainer/supervisor with the organization. lindsay sees individuals and couples in his practice in addition to doing process group work and clinical consultation. references international journal of integrative psychotherapy, vol. 11, 2021 28 depression or isolated attachment? part 1 of a 5-part case study of the psychotherapy of the schizoid process richard g. erskine1 abstract this case study explores depression as a presenting symptom that reflects an isolated attachment pattern, a core feature in the personality of psychotherapy clients who rely on a schizoid process as a form of emotional stabilization. the psychotherapist’s various forms of countertransference—responsive, reactive, and identifying—were an essential part of uncovering the client’s use of a relational withdrawal and in offering a reparative relationship keywords: attachment, isolated, isolated attachment, schizoid, depression, integrative psychotherapy, relational psychotherapy, reactive countertransference, responsive countertransference, identifying countertransference, developmental image in wildness is the preservation of the world, when we walk, we naturally go to the fields and woods: from the forest and wilderness come the tonics and barks which brace mankind. — henry david thoreau, 1862/2002, walking 1 institute for integrative psychotherapy; deusto university international journal of integrative psychotherapy, vol. 12, 2021 29 allan’s physician recommended that he call me for a series of psychotherapy sessions. in the initial phone contact, allan said that he had been taking antidepressant medication for 3 years but without any noticeable results. he said that he always felt “low down” and did not have much energy, particularly when he was home. the doctor wanted allan to try psychotherapy “to see if it will work.” allan and i agreed on three sessions to evaluate if psychotherapy was appropriate for him and whether we could work well together. when allan entered my office 2 days later, i saw a tall, thin man who was dressed like he was going hiking in the mountains. his attire and high boots were unusual for someone living in new york city. he spoke slowly and softly. when i inquired why he was seeking psychotherapy, all he could say was that he wanted his depression to stop. as i tried to establish a contract that would define the outcome of our work, allan had difficulty stating any definable objective. i presumed that it was too soon to establish any goals; perhaps we needed to get to know each other first. in the next two sessions, i learned that allan was 50 years old, never married, and had lived in the same apartment since he was a young child. a bookkeeper in a large accounting firm, he was content with his job and liked the people at work, although he did not socialize with them because “i never go to bars.” he said that he attended church almost every sunday because he was in charge of the church’s finances. allan spent saturdays and holidays hiking various portions of the appalachian trail and his 4 weeks of summer vacation camping in the wilderness where he could be “all alone with nature.” allan’s mother had died 4½ years earlier. as i inquired about allan’s possible grief, he was slow to respond. after shrugging his shoulders, he hesitantly told me about his mother’s painful struggle with cancer. he claimed that he was not sad about her death but that he did miss her cooking. there was an absence of sensitivity in his response to my questions about his mother’s death (erskine, 2014a, 2014b, 2014c). i wondered if his flat affect indicated that he was not ready to talk about losing her or if it reflected a personality pattern. allan had no memory of his father, who died when allan was in kindergarten. allan had a sister who was 5 years older whom he had not spoken with since his mother’s funeral. he sarcastically said, “i can’t be in the same room with her. she’s a know-it-all.” then he added, “life is better all alone.” in our third session, allan was contemptuous of his medical doctor’s abrupt manner of speaking. at two different moments i inquired about his feelings of international journal of integrative psychotherapy, vol. 11, 2021 30 anger at his doctor’s behavior, but allan avoided my questions. the doctor had decided that allan would slowly reduce and eventually stop the antidepressants. allan said that he wanted to continue psychotherapy sessions with me “because it could help.” he was not interested in forming an outcome-defining contract (berne, 1966), but he volunteered that he would come for individual psychotherapy once a week for a year. it was time for me to do some introflection, a sensorial search of my internal process: i found allan pleasant, shy, and either withholding his responses or slow to respond to my questions. he was interesting when he talked eagerly about hiking and camping. at the end of this third session, i doubted whether i could help allan resolve his depression. i still did not feel an affective connection with him. he was evasive whenever i asked him about his body sensations or other subjective experiences. other clients had taught me that i need to maintain my own vitality and curiosity when i am working with someone who is depressed. with many such clients, i rely on phenomenological inquiry and carefully observe their style of answering my questions. that style is often more revealing of who they are than is the content of their answers. in the first three sessions with allan, my phenomenological inquiry seemed to be more of a hindrance than a help. unlike many other clients, allan did not respond to phenomenological inquiry (erskine et al., 1999). although his medical doctor described him as depressed, allan did not manifest some of the symptoms of a depressive disorder. he had previously said that he lacked energy, yet he described himself as engaging in intense physical activities and being a “diligent worker” both on the job and in volunteering for his church. he said that he ate and slept well but was uninterested in social activities with people, even with the “nice people at church.” in evenings after work, he was “plagued with miserable feelings.” allan defined himself at those times as “depressed” and added that in those moments he was compelled to “get out and walk … even if it is near midnight.” was he depressed? yes. but it did not appear appropriate to diagnose him as having a depressive disorder. it was clear to me that the various things he said about himself required careful attention. i did not understand his internal processes, but i listened for the covert meaning in his stories. i needed to be patient, attentive, and attune myself (the best i could) to his indistinct and subtle affects. i was reminded of guntrip’s writings in which he described several of his “schizoid” clients who entered psychotherapy because of depression (as described in hazell, 1994). international journal of integrative psychotherapy, vol. 12, 2021 31 i asked allan if he had any thoughts of suicide. he described how he had always imagined escaping to “another world.” as i inquired further, he said that he first thought about killing himself when he was 13 years old and that throughout his life he had continued to think about dying and going to “a place of peace and quiet.” i asked if he had ever attempted suicide, to which he answered “no.” he lamented that he could not kill himself while his mother was alive because “i had to take care of her. i was all she had.” while telling me this story, he used the word “despair,” and the way he said it evoked concern in me. when i inquired further about what he was feeling, he dismissed my question with, “i’m fine.” each time i inquired about his affect he changed the subject. i asked allan how he imagined killing himself. with hesitation he described shooting himself in the head but quickly added that he did not now, nor had he ever, owned a gun. he described dying as going into a “peaceful, everlasting quiet.” he was worried that suicide was a sin and that if he killed himself he would “not attain peace and quiet.” by the end of that session, i was not worried that he was in imminent danger of suicide, but i was concerned that a long-term risk remained. his ideas about the quietness of death, the absence of close friends, the lack of energy when at home, and the death of his mother were some markers that could indicate a major depression, but he did not have many of the other characteristics (american psychiatric association, 2013). he ate well, walked extensively, and was able to concentrate on his work. he said that his apartment was neat and clean and that he was making plans for next summer’s camping trip in northern canada. as i reflected on all that he had told me, i was certain that encoded in his selfdescriptions and behaviors were unconscious relational patterns that were being lived out in his daily life (erskine, 2010). if we were to continue with psychotherapy, i would have to explore several clues that he had given me: his sense of despair, his longing for peace and quiet, his excessive walking late at night, the family dynamics of his childhood, and various body sensations and tensions that indicated disavowed affect. i only had a few minutes left in the third session. we had not formed a sufficiently close relationship such that a no-suicide contract would be effective. as we concluded the session, i felt that it was necessary for me to rely on his religious convictions and his statement that he did not possess a gun. and i had his word that he would come for psychotherapy each week for a year. i sensed that something vital was missing in allan’s life. i was not sure what it was, but i kept thinking about how his life was devoid of any intimacy. internally i international journal of integrative psychotherapy, vol. 11, 2021 32 made an emotional commitment. i wanted our psychotherapy to enhance the quality of his life and provide him with a desire to live. i walked home from the office that night questioning myself: “was i wanting more for allan than he wanted or was willing to do?” i knew what was possible in an in-depth psychotherapy, but i had no evidence that allan knew the commitment, perseverance, and time that would be required to make some fundamental changes in his life. the first year the evening before our fourth meeting, as i contemplated allan’s agreeing to come to weekly psychotherapy, i was touched by how alone he seemed, how he preferred to be in nature and not with people, and how he had difficulty talking about feelings. i thought about his “depression” and wondered if he was describing the results of a prolonged schizoid withdrawal. one of the clues was that he did not respond well to my phenomenological inquiry. i was not sure if i could be effective in helping him achieve a satisfactory comfort in his life, but i was willing to invest myself in our therapeutic relationship. i was relying on my perception that allan was serious about resolving his depression. he must have had some form of connection with me because he was willing to make a commitment for ongoing work. in the first few weeks of sessions, i tried to inquire about the “low down feeling” and lack of energy that allan had mentioned in our initial interview. he deflected my questions by talking about his work situation. he felt gratified by the “challenges of solving difficult tax problems” and “the freedom to do it on my own,” but he disapproved of his coworkers’ behavior because they were not as diligent as he was: “they waste a lot of time talking to each other.” he chose not to include himself in their lunch or after-work activities. i asked about other friends; allan was vague and eventually admitted that he had none. as i raised my concern about how much time he spent by himself, allan said, “some nights after dinner i prefer to walk the neighborhood for a couple of hours. i watch people a lot, i often see faces i recognize.” as i imagined myself in that situation, i felt an intense sadness. yet allan spoke of his situation matter of factly, with no emotion. he lapsed into long pauses, looking at the ceiling. in the next few sessions, allan continued to describe his late night walks through new york city and how he distracted himself from feeling “low down” by watching international journal of integrative psychotherapy, vol. 12, 2021 33 people. when i asked if he ever talked with anyone on his walks, he said, “i would never do that.” these stories caused me to wonder what he was not telling me. did he have some secret that he was keeping private? i was curious about allan, but my inquiries were only partially effective. he answered my questions but often with reticence. i wanted to know him, to know the depth and extent of what he felt, what he had lived as a boy, and how he managed his life. it was necessary to continually remind myself to be patient, to just let his story unfold. two months later, allan again told me that he was “irritated” by his coworkers and wanted some changes in the office. there was a condemning tone to his voice. i wondered if his unhappy work situation was contributing to his low energy when he came home at night. but when i implied that he could talk to his coworkers about his displeasure, allan made it clear that he would never reveal his discomfort to anyone. his solution was to stay distant. incidentally, from the moment i suggested that he could engage with his coworkers, he was distant with me. he averted his eyes and proceeded to talk about camping equipment that was currently on sale. it became evident that whenever i made a suggestion about changing his behavior, allan would put an end to the discussion. apparently he was closed to any therapeutic focus on his behavior just as he was closed to my inquiring about his affect. in the next few sessions, rather than focusing on his behavior, i increased my use of phenomenological inquiry, particularly about his affect and body sensations. although he was slow to answer, he usually identified tension in his neck and chest. somehow that led us to talking about his difficulty in expressing emotion to people. he said, “i want to remain private. i don’t want anyone poking their nose into my business.” i asked if that included me. allan answered, “yeah, sometimes your questions are too damn invasive.” i responded, “what happens inside you when i ask such questions?” allan shrugged his shoulders and remained silent for the remainder of the session. during the next couple of sessions, he struggled to describe how he became physically tense, expecting me to criticize whatever he said, and how he quickly searched “for the right answer.” i recognized that psychotherapy was not happening when he was giving me “the right answer.” i asked him to look me in the eye and tell me about his irritation, first with me and then with his coworkers. i wanted him to see my face and how i was impacted by what he did not like. it was difficult for him to voice his discontent, but after several sessions he was able to articulate some anger. i was not sure if international journal of integrative psychotherapy, vol. 11, 2021 34 these sessions were therapeutic or not. allan’s expression of anger may have been authentic or he may have been complying with my request or a bit of both. i was surprised when a few months later he said that he felt better after the sessions in which he expressed his anger. i was curious about allan’s childhood, and over the next months i asked several questions about his early family life. allan was physically tense whenever i did this and did not want to talk about his past. he often said, “i don’t remember my childhood.” i was curious about whether what i was observing with allan pointed to his having an avoidant attachment style. that stimulated me to think about the formation of unconscious relational patterns in childhood—unconscious patterns that determine the quality of interpersonal relationships in later life (erskine, 2008, 2010). it is evident from the child development literature that children who develop avoidant attachment patterns most likely had parents who were rejecting and punitive (cozolino, 2006; wallin, 2007) or at least predictably unresponsive to the child’s needs and self-expressions (erskine, 2009). main’s (1995) research indicated that mothers of infants with an avoidant attachment style were emotionally unavailable; they tended to be neglectful when the child was sad and were uncomfortable with physical touch. it is now well recognized that, as an accommodating survival reaction to the caretaker’s predictable unresponsiveness to their affects and relational needs, children learn to inhibit communicating emotions, needs, and internal experiences. as a result, they create an unconscious relational schema by which they inhibit emotional expression and undervalue the importance of relationship. they create an imago of interpersonal relationship where intimacy does not exist. such children may form interpersonal relatedness strategies in which they do not express, or may not even be conscious of, their attachment-related feelings and needs. they may be disdainful of vulnerability and tender expressions of affection and/or prone to anger (hesse, 1999; kobak & sceery, 1988; main, 1990). these ideas about unconscious relational patterns served to heighten my curiosity about allan’s childhood. i wanted to inquire about both his current life and his childhood, but he was not ready. allan wanted to talk about the people at work and his activities at church. each week he insisted on telling me about his experience hiking the previous saturday. i began to form a developmental image of allan as a 6to 8-year-old boy, a child without a father to take an interest in his adventures (erskine, 2019). international journal of integrative psychotherapy, vol. 12, 2021 35 this developmental image evoked feelings of compassion in me and increased my interest in his stories. i wanted to go hiking with him and see the woodland trail that he saw, to smell the same forest smells, to be a companion. i listened intently and asked factual questions about his hiking and work. periodically, he allowed me to inquire about what he was feeling, imagining, or remembering. then i was able to have a glimpse of his internal world, a private world he was reluctant to reveal. i felt an emptiness, like a vacuum, in my belly when i imagined that allan’s world was deprived of intimate contact with people. when i listened quietly to his stories, i used my face and body gestures to indicate that i was present and attentive. i wanted to convey empathy even though he expressed little emotion. when i asked about his affect, he generally gave me vague answers and rapidly went into details about his current life. i stayed present and interested. we were developing an emotional connection but it was still fragile. i was perplexed and questioned myself: was my wanting allan to have contact and possible intimacy with people a countertransference reaction or was my desire responsive to his needs? (loewald, 1986). pondering this question allowed me to modulate making any comments, interpretations, or observations about his life. i knew that there was so much more to learn about allan. patience, observation, sensitivity, and curiosity were my therapeutic tools. our therapy proceeded in this way throughout the first year. i, in a countertransferential way, slipped into responding like a good father, curious and listening to his stories, which alternated between the events at work and what he did on his days off. periodically, he talked about the people he saw on his evening walks. i still did not know much about what he was experiencing emotionally, such as when he was at home or when he walked the streets late at night “hoping for distraction from feeling empty.” but i felt myself fully attentive and involved. i was perplexed. i read some of the classic psychoanalytic literature about the transference-countertransference matrix (brenner, 1979; freud, 1923/1961; greenson, 1967; heinmann, 1950). was i experiencing what theodor jacobs (1986) termed a “countertransference enactment”? were my behaviors concordant or complementary (racker, 1968)? over several months, my psychoanalytic peer group helped me to delve into my feelings and motivations. i took these conversations into account, formed impressions from what i was reading, and thought about several clients and the different forms of countertransference they stimulated in me (novellino, 1984). i categorized my various internal experiences in three ways: reactive, responsive, and identifying (erskine, 2012, 2013a, 2013b). international journal of integrative psychotherapy, vol. 11, 2021 36 sometimes my emotions and behaviors were reactive, a reliving of some unfinished emotionally charged experience in my own life. in these moments. i was self-centered and the client’s therapy was disrupted. in many situations, i was responsive and attuned to the qualities of interpersonal contact that the client needed in order to heal from the wounds of neglect and trauma. in these instances, my affect, attitude, and behavior provided a “healing relationship” (erskine, 2021). often my affect, demeanor, and words reflected my identifying with the client’s unspoken affect or visceral sensations. these various identifications guide me as to when to speak and when to be patiently quiet, in forming the phenomenological inquiry i might make, and in assessing the client’s developmental level of functioning. i challenged myself with several questions: • were my various affects, urges, and caring behaviors a useful pathway to understanding allan’s inner experience? i was sensing the desire of a 6to 8year-old boy to have an adult as his companion (identifying). • was i attuned to possible relational neglect that he might have experienced as a child? and would my compassionate responses actually be therapeutic (responsive)? • was the work with allan reactivating unrequited relational needs from my own past (reactive)? • was my caring for him an unconscious identification with how allan had prematurely cared for his mother (identifying)? • was i reacting to allan’s possible desire to be rescued by a good father (reactive)? • were we cocreating what he needed (responsive)? i never found definitive answers to most of these questions. i was continually left to think about my motivations and to decipher the unconscious story enacted in his behavior, entrenched in his unrevealed affect, and envisioned in his fantasies about camping in the wilderness (erskine, 2009). isolated attachment patterns i kept thinking about unconscious relational patterns: those that can be described as “avoidant attachment” and those that take the form of “isolated attachment” international journal of integrative psychotherapy, vol. 12, 2021 37 (erskine, 2009). allan lived his day-to-day life in a more solitary way than individuals who manifest an avoidant attachment pattern. although people with such a pattern often avoid expressing tenderness and empathy, they usually have a social life that includes group activities and superficial relationships. perhaps allan’s unconscious relational pattern was more isolated; he was a loner. in this first year of psychotherapy, allan did not talk about any interpersonal connection, and he avoided talking about his relationship with his mother. there was no indication of any emotionally close relationship in his current life and, i suspected, not in his childhood. in drawing on my therapeutic work with other clients and discussions with members of an ongoing professional development seminar, it became apparent that a person may form an isolated attachment pattern as the result of a series of experiences in which caretakers were experienced as repeatedly unresponsive to the child’s relational needs, untrustworthy, and/or criticizing and controlling of the child’s emotional expressions (o’reilly-knapp, 2001). because vulnerability was sensed by the child as dangerous, they succumbed to an implicit fear of control, criticism, and invasion. as a reaction to such noncontactful parenting, the child may develop patterns of withdrawal from interpersonal relationships, a social façade, intense internal criticism, and the absence of emotional expression (erskine, 2001). on cursory observation, such people often appear to be emotionally reserved, quiet in the presence of others, and self-sufficient. in looking back over the years of my psychotherapy practice, i often overlooked the significance of these subtle signs of the schizoid process. it has taken me a number of years to become sensitive to the unspoken story of such clients, a story replete with fear, shame, disavowed loneliness, self-criticism, and a compulsion to isolate. allan was one of the clients who taught me to listen for the therapeutically significant story encoded in what such individuals do not say. as allan’s first year of psychotherapy came to an end, i hypothesized that his pattern of attachment was isolated. he was a loner, had no meaningful relationships, and was reluctant to talk about feelings or his childhood experiences. in some sessions, he implied that he frequently criticized himself. although i always inquired about his internal criticism, he would not reveal any content. during the second part of the year he had acknowledged and expressed some discontent with his coworkers, and on one occasion, with me. he still did not initiate conversations with anyone. when i encouraged him to reach out to people, he was annoyed with me, turned away, and quietly said, “you’re bossing me.” yet he also said that he liked coming to our sessions, and he never missed one. i hoped he was forming some embryonic attachment to our relationship. international journal of integrative psychotherapy, vol. 11, 2021 38 when we parted for summer vacation, i realized that allan was teaching me how to relate to someone who was always suspicious of interpersonal contact, particularly if it was intimate in any way. i suspected that he was deeply afraid of what he called “invasion,” but why? i was also curious about both his selfcriticism, which seemed to lurk below the surface of our conversations, and the little criticisms he directed toward others. i looked forward to september when we could work together again. he was teaching me about relational isolation while i hoped that i was helping him with interpersonal contact. references american psychiatric association. (2013). diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176 appi.books.9780890425596 berne, e. (1966). principles of group treatment. oxford university press. brenner, c. (1979). working alliance, therapeutic alliance and transference. journal of the american psychoanalytic association, 27, 137–158. cozolino, l. (2006). the neuroscience of human relationships: attachment and the developing social brain. norton. erskine, r. g. (2001). the schizoid process. transactional analysis journal, 31(1), 4–6. https://doi.org/10.1177/036215370103100102 erskine, r. g. (2008). psychotherapy of unconscious experience. transactional analysis journal, 38(2), 128–138. https://doi:org/10.1177/036215370803800206 erskine, r. g. (2009). life scripts and attachment patterns: theoretical integration and therapeutic involvement. transactional analysis journal, 39(3), 207–218. https://doi.org/10.1177/036215370903900304 erskine, r. g. (2010). life scripts: unconscious relational patterns and psychotherapeutic involvement. in r. g. erskine (ed.), life scripts: a transactional analysis of unconscious relational patterns (pp. 1–28). karnac books. erskine, r. g. (2012). early affect-confusion: the “borderline” between despair and rage. part 1 of a case study trilogy. international journal of integrative psychotherapy, 3(2), 3–14. international journal of integrative psychotherapy, vol. 12, 2021 39 erskine, r. g. (2013a). balancing on the “borderline” of early affect-confusion. part 2 of a case study trilogy. international journal of integrative psychotherapy, 4(1), 3–9. erskine, r. g. (2013b). relational healing of early affect-confusion: part 3 of a case study trilogy. international journal of integrative psychotherapy, 4(1), 31– 40. erskine, r. g. (2014a). what do you say before you say good-bye? the psychotherapy of grief. transactional analysis journal, 44(4), 279–290. https://doi.org/10.1177/0362153714556622 erskine, r. g. (2014b). the truth shall set you free: saying an honest “goodbye” before a loved-one’s death. international journal of psychotherapy, 18(2), 72– 79. erskine, r. g. (2014c). saying an honest “goodbye”: part 2: three case examples. international journal of psychotherapy, 18(3), 52–62. erskine, r g. (2019). child development in integrative psychotherapy: erik erikson’s first three stages. international journal of integrative psychotherapy, 10, 11–34. erskine, r. g. (2021). a healing relationships: commentary of therapeutic dialogues. phoenix publishing. erskine, r. g., moursund, j. p., & trautmann, r. l. (1999). beyond empathy: a therapy of contact-in-relationship. brunner/mazel. freud, s. (1961). beyond the pleasure principle. in j. strachey (ed. & trans.), the standard edition of the complete psychological works of sigmund freud (vol. 18, pp. 3–64). hogarth press. (original work published 1923) greenson, r. (1967). the technique and practice of psychoanalysis: vol. 1. international universities press. hazell, j. (ed). (1994). personal relations therapy: the collected papers of h. 1. s. guntrip. jason aronson. heinmann, p. (1950). on counter-transference. international journal of psychoanalysis, 31, 81–84. international journal of integrative psychotherapy, vol. 11, 2021 40 hesse, e. (1999). the adult attachment interview: historical and current perspectives. in j. cassidy & p. shaveer (eds.), handbook of attachment: theory, research, and clinical applications (pp. 395–433). guilford press. jacobs, t. j. (1986) on countertransference enactments. journal of the american psychoanalytic association, 34(2), 289–307. https://doi.org/10.1177/000306518603400203. pmid: 3722698 kobak, r. r., & sceery, a. (1988). attachment in late adolescence: working models, affect regulation, and representation of self and others. child development, 59(1), 135–146. https://doi.org/10.2307/1130395 loewald, h. w. (1986). transference-countertransference. journal of the american psychoanalysis association, 34(2), 275–287. https://doi.org/10.1177/000306518603400202. pmid: 3722697 main, m. (1990). cross-cultural studies of attachment organization: recent studies, changing methodologies, and the concept of conditional strategies. human development, 33(1), 48–61. https://doi.org/10.1159/000276502 main, m. (1995). recent studies in attachment: overview with selected implications for clinical work. in s. goldberg, r. muir, & j. kerr (eds.), attachment theory: social, development and clinical perspectives (pp. 407– 474). the analytic press. novellino, m. (1984). self-analysis of countertransference in integrative transactional analysis. transactional analysis journal, 14(1), 63–67. https://doi.org/10.1177/036215378401400110 o’reilly-knapp, m. (2001). between two worlds: the encapsulated self. transactional analysis journal, 31(1), 44–54. https://doi.org/10.1177/036215370103100106 racker, h. (1968). transference and countertransference. international universities press. thoreau, h. d. (2002). walking. in r. finch & j. elder (eds), the norton book of nature writing (p. 192). norton. https://www.theatlantic.com/magazine/archive/1862/06/walking/304674/ (original work published 1862) wallin, d. j. (2007). attachment in psychotherapy. guilford press. international journal of integrative psychotherapy, vol. 12, 2021 192 reflections, thoughts, and considerations on regression work in group using online video platforms claudine adjagba abstract one of the regrets frequently expressed by colleagues in these times of pandemic and restrictions on in-person, face-to-face meetings is that regression work is not possible due to the limitations inherent in videoconference sessions, and that we are forced to stick to cognitive work, or at best to emotional work, but only in the here and now. however, this should not be considered a hard and fast limit. in this article i give an example of group regression therapy via zoom. i describe the conditions and possible limits to regression work when provided online. keywords: developmental model of the sense of self, attachment theories, integrative psychotherapy, relational trauma, implicit memories daniel stern’s developmental model for daniel stern (2015), the sense of self is the way in which we experience ourselves in relation to others. it arises from preverbal and therefore nonconceptual elements, resulting from direct relational experiences which are the precursors of the later objectifiable, verbalizable, and reflective self. as the infant develops new skills, it forms new subjective organizing perspectives regarding its own self and those of others: the sense of self domains. the development of the “sense of self” can be thought of as occurring in a series of age-related domains. w ith continuing internal coherence and relation building, each domain of the sense of self thus formed persists for life, with each new relational experience inducing a process of re-evocation and reinforcement or reorganization of all areas of the sense of self. the usually recognized domains and age ranges are: emergent (0–2 months), core (2–8 months), intersubjective (8–15months), verbal (15 months and up), and narrative (3 years and up) (stern, 2015, pp. 43, 52–53). it is a bit like a traveler who goes around the world, reorganizing his suitcase during his journey according to the climates encountered. w hen he gets home, it international journal of integrative psychotherapy, vol. 12, 2021 193 is the same suitcase, containing the same fundamentals—e.g., jeans and sneakers—and yet, it is not quite the same since it has been embellished with a pretty loincloth, a fur shapka, a sari, and a gaucho hat. case history i will explore the conditions for doing online regressive therapy using a case history. sophie, a hospital supervisor, was put on sick leave by her doctor for two months for “burnout.” she has felt badly treated during the pandemic by the paradoxical demands of her institution: availability of beds, reassignment of personnel, incessant reworking of schedules, and so on. she has been in group therapy for many years, attending two sessions per month. once she stopped working, she came to individual therapy sessions with me between the group sessions. since the first pandemic lockdown (march 2020), all the sessions have been done via zoom. her life process, because of an avoidant-anxious attachment pattern, urges her to be constantly alert and anticipating impending disaster in all aspects of her life. from the age of six she kept herself awake, making it her mission to watch over her father to be sure he would not die during the night, a behavior which did not seem to disturb her mother. she grew up in a dysfunctional family system impacted by her bipolar father’s long depressive episodes and by an ambivalent mother who was both abandoning and rigid. when sophie was eight years old, she was given “a great present:” a little sister. her father and, to a lesser extent, her mother were ecstatic. sophie felt cheated and began struggling to outdo her sister in the eyes of her father and competing with her sister to please her mother. the failure of the “be strong” message reactivated, in an individual session, an implicit archaic memory of her underlying experience of abandonment: as a baby she was placed in an incubator a few days after birth because she did not eat and was not gaining weight properly. because her mother found it “too difficult” to see her bound up with all the incubator tubes and appendages, sophie was effectively deprived of her mother’s support. in the following group session, sophie shared her integration of the previous individual session with her peers, and to my great surprise, this triggered a panic attack. she once again described the frozen rigidity of her infant physiology, her international journal of integrative psychotherapy, vol. 12, 2021 194 inability to breathe, her painful body. i invited her to welcome these sensations as “they have something important to say to you” (erskine, 2019, p. 7). she made contact with the memory of the incubator experience again and realized that this tension was protecting her from her own temptation to let go of everything and die (small, 2004, p. 10). i sensed that a protocol experience of disorganized attachment was emergi ng. the avoidant-anxious attachment, with the decision to “be strong,” had been put in place later in her growth to protect her from the risk of making contact with disorganization. the tension in her physiology protected her from a psychotic outburst and remained as a bodily inscription in the emergent sense of self. for stern (2015), throughout our lives, the bodily and sensory imprints of the relationships created in our first days continue to be elaborated and reshaped by necessity, because babies are born with the need and capacity to build attachment and create coherence. in the first two months of life, the infant internalizes the relational process and the result of this process; this is the beginning of one’s internal organization (stern, 2015, pp. 66–67). suddenly, sophie began hyperventilating. i started to breathe in rhythm with her and invited her to look into my eyes. (technically, via zoom, she could only look at an image of me looking at her image.) i guided her to gradually slow down her breathing in time with mine. i also instructed her to look at the other group members who had begun to breathe with us. finally, the crisis calmed. my attunement to the exaggerated rhythm of sophie’s breathing and to her developmental age and affect allowed me to guide her towards the integration of a rhythm that she could make her own. this would help her to gain security in relationship and therefore re-structure the developmental domain of the core sense of self (erskine, 2019, p. 8). in the domain of the core interpersonal connection, the baby resonates with the other and lives itself as part of a great whole, while at the same time the notion (without concept) emerges that “this is what it is to be me.” in this domain the developmental baby’s challenge is to integrate rhythms; to develop affectivity, the sense of continuity, and agency; and to begin managing oneself (stern, 2015, pp. 98–99). at this point, i thought i could stop the work, but i checked by asking her how she was and how the baby felt. she answered, “it’s okay, but i am afraid that tonight the baby will start again.” (note: her companion was working that night.) the incongruence of the tone of her answer, without energy, and the generalization international journal of integrative psychotherapy, vol. 12, 2021 195 “okay” plus her clinging tense appearance were significant. i became immediately alert and aware of the tension that i was feeling in my back. this was a warning signal for me not to be caught in what i identified as a parallel process of hypervigilance related to the little girl of six to eight years old who was made to carry responsibility too early. i took the initiative to tell sophie, and i expect also the little girl inside her, that she could call me at any time during the night if she needed, and i promised i would answer. i felt deeply connected with her trauma: the experience of abandonment as an infant in an incubator, reinforced by the experience of a little girl of eight who had to prevent her baby sister from crying and getting on daddy’s nerves while mum went out to play cards with friends. obviously, this girl was too young to manage such a level of responsibility. by attuning myself to her trauma, my therapeutic intention was then to offer reliability and consistency to the ages that had lacked it. the other members of the group expressed their concern for her, saying how they were touched by her work. they described the intense experience it had been for each of them to live, in a parallel process, the temptation of interrupting contact with the feeling of the risk of death (hers and possibly theirs), and to rely on my voice to allow themselves to risk living this oppression with her—without identifying with her. in the group process they expressed words of relief and hope for her after she accepted my offer. this was a reassuring indication of the effectiveness of emotional regressive work even at a distance. actually, sophie did not call me despite waking up several times. she remembered our common breathing and my offer, and that was enough. the next morning, the other group members messaged her to check on her. in an individual session, she came back to the paradox of feeling ambivalence. her doctor, a man, had responded to her fear of having to return to work by extending her sick leave for two months. he also guaranteed her that he would extend the leave as long as she felt the need. she said she felt reassured. he verified that she was continuing her therapy and prescribed an antidepressant. sophie again expressed her anxiety and her hesitation to accept this offer because it meant that “she was depressed and would never be as strong as she used to be.” i understood the situation as a juxtaposition (erskine, morsund, & trautmann, 2019, pp. 196–197); the symbolic parental couple, the female therapist and the male doctor, were really looking after her. her fear was taken seriously by them. international journal of integrative psychotherapy, vol. 12, 2021 196 she regressed to holding on to the paternal depression (like father, i am depressed, but i don’t want to be, so i fight my need to rest). in my understanding it was less painful to reconnect with father’s depression than with the mother’s abandonment. i normalized and summarized the current situation: we talked again about the need to relive the pain, just for a limited time. w e discussed the depressed but resilient infant she was carrying inside. w e clarified that feeling depressed was not the same thing as being depressive and that when she felt ready, we would organize with her doctor to discontinue the medication. she then accepted that. in the second group session, still on video, sophie talked again about her astonishment at having made contact with this infant part of herself who is tempted to let go of her body and die and her fear of this temptation. she indicated that, following the session, she felt the need to scream into a cushion. as she spoke, i again observed the tension in her neck and shoulders, the inward gaze, and the quickening of her breathing. i thought back about the experience of the newborn baby in the incubator, whose whole being was mobilized to survive to the point of not having the strength to emit a sound. i hypothesized that the expression of the infant’s distress, since it was now externalized, was to be welcomed as the manifestation of an integration. i regretted, at the same time, the reiteration of the trauma, as this external ization happened in solitude, even though there was a reliable, stable and consistent other (me) available for her, but at a distance. the issue is still the integration of the self in the domain of the core sense of self, where the intuitive notion of an “other,” who is potentially there in a predictable and reliable way and who meets needs as they emerge, is integrated (small, 2012– 2015). nevertheless, i chose not to invite sophie to feel neither the baby’s distress, nor, as i suspected, the little girl’s anger. my concern was that by inviting my client to relive this distress, there was a risk of regression to a protocol (first interaction) level that would be difficult to physically contain using our remote online platform. i chose to stabilize and anchor a minimum of basic stability in the emerging and core senses of self, knowing we would have to deal with the archaic need for security in relationship, through bodywork, when sanitary conditions would allow this again. international journal of integrative psychotherapy, vol. 12, 2021 197 i hypothesized that restoring this basic stability would then allow the expression, in relationship, of the little girl’s anger. my preoccupation at that moment was to prepare the medium-term moment of the end of the medication: we had a contract about this with sophie’s adult ego state, but more importantly, my immediate aim through this “medication topic” was to create a structure for her experience: with a beginning, an unfolding, and an end. by doing so, i hoped to address all of the domains of the development of the sense of self and all the ages where the difficulty of one moment was experienced as being there forever (small, 2012–2015). i therefore normalized her astonishment at breaking through the “be strong” system and making contact with the baby’s temptation to let go and die. i affirmed that it was smart for both the baby to resist through body tension and the little girl to decide to always be strong. i validated that for the baby, the little girl, and the grown-up, holding herself frozen and uptight was the baby’s way to stay alive and keep her emerging sense of self aggregated and functioning. i explained that for her to be alive meant being in her frozen body. sophie nodded and relaxed. i considered stopping the work here, but she tensed up again and held her stomach. i asked her to tell what was going on. she said, “the baby is a pain in the ass, we will have to take care of her again. she is all tight inside and prevents me from breathing.” w hat had clearly emerged in the relational setting offered by the group was a little girl of six to eight years old—a little girl that had to act as a parent much too young, and to whom it was necessary to offer an interposition. i addressed the little girl to tell her that “little girls like to learn how to take care of babies, sophie, and i am going to teach you.” w e were going to do it together, and then she could go to sleep peacefully because “little girls also need to learn that it is the grown-ups who take care of troubled babies.” she agreed. i invited sophie to put her hand on that place that was all tight, to feel the frozen baby, and to notice her sensations. the baby felt held, tightly, under her buttocks and lower back. i invited her to visualize her insides and very slowly widen that space a little bit, and to nod when she had done so. i then suggested that maybe the baby is relaxing a little bit, first a leg, then a shoulder or an arm and so on, with each nod from her we widened a bit more. meanwhile the little girl watched and told us that “the baby still has pain in her leg or her neck” while the whole group began to breathe in rhythm with us. i checked on the level of pain from time to time as it lessened progressively. international journal of integrative psychotherapy, vol. 12, 2021 198 i invited sophie to tell the baby inside that she will always be there for her. i also invited her to tell the little girl that “they can do this together for the baby, but she doesn’t have to, she has her own eight-year-old things to take care of with sophie.” i told the eight-year-old girl that she would sleep well tonight. she now knew how to cope with babies, but it was sophie who would take care of the baby if needed. i finished by giving sophie the instruction to repeat the experience of welcoming the baby with the little girl, to feel full internal contact at least once a day, and she agreed. during this work, everyone in the group openly offered their empathy to sophie. empathy is one of the achievements of the structuring of the intersubjective domain, made possible by the activation of the mirror neurons which are operational from the first days of life in the brain’s physiology (guarella, 2017). this potential aptitude of the infant to meet the other’s emotions is enabled through his early relationships during the process of structuring the emergent and core domains. according to stern (2015), this ability develops in the emotional system of the baby and allows the structuring of the baby’s sense of self in the intersubjective domain. the baby has the sense that his perceptions, sensations, and emotions belong to him. he begins to have the intuition that the other also has an internal world and discovers and verifies whether, with whom, and to what extent the subjective experience can be shared. the baby hopes for an other “who feels as i do and to whom i can respond emotionally, in an experience of full contact. but in this development phase the baby will also experience dissonance” (stern, 2015, pp. 164–166). at the same time, as an integrative psychotherapy therapist, i committed myself, with my client, to the realistic and life-giving hope that she would emerge from her suffering regardless of her developmental age (cadot, 2011; erskine, 2020). in this work of repairing the traumatic relational experience with the client, i remained attentive to stimulating sophie to mobilize her own resources. in or der not to offer hope as a panacea, i was careful to propose attuned options that were in harmony with the rhythm, emotions, and type of trauma and to verify her commitment to herself. in this work, simultaneously and implicitly, both the group members and the therapist formed an internal image of a family, with the therapist as the head who guarantees the safety of all, and with everyone cooperating to take care of the baby’s and the little girl’s welfare. each family member expressed their own experience and their experience of the baby. each member put their energy into international journal of integrative psychotherapy, vol. 12, 2021 199 serving the baby and co-creating a safe relational space, where the baby has nothing to do for the family, where the baby has only to deal with being herself, with her internal experiences, and with the manifestations of these. the group was a determining factor in the impact of the therapy on sophie’s progress. the group offered a stable and consistent process through lockdowns, deconfinements, fear of contamination for oneself or one’s relatives, and experiences of loneliness and sometimes isolation during the covid-19 crisis. all of this reactivated everyone’s archaic systems of protection. every group member had the opportunity to (re)experience the lack of the “other,” was encouraged to express it, and was welcomed in this expression. they assumed the responsibility of being present for their peers as themselves, with their own authenticity, awkwardness, and relevance. both the little girl and the grownup sophie benefited from this peer group where their emotions could be expressed, where they were welcomed and understood, where experiences and practical options were shared, and where solidarity was expressed and acted upon—even outside the group’s scheduled working times. the group became a relational cradle that offered a reliable and stable holding, providing a shield for the baby’s and the child’s over-excitement. particularly for this type of work and under these conditions, the group was both process and matter, the relationship that heals. therefore, everyone, including sophie, revisited and rearranged by and for the group all the domains of the sense of self in a strong process of coalescence. each of the group members, and the group as a whole, were offered permission, protection, and power and experienced the process of integration of the self. regression work via videoconference from the above case history, we can see how group regression work in videoconferencing, despite the distance, can provide a process of developing one’s own and the group’s sense of self. when we talk about regression work, the question we are often asked is to define whether we are dealing with spontaneous regression or induced regression. in my opinion this is almost a false debate. the only truly spontaneous regressions that i have encountered in twenty years of practice were the results of a massive traumatic shock: a sudden death, violent crime, the suicide of a loved one, incest or sexual abuse, etc. the type of support offered in such cases fundament ally international journal of integrative psychotherapy, vol. 12, 2021 200 depends on the therapist’s attunement to the degree of alliance established with the client and with the therapy group. in the case i’ve described, it should be obvious that the group and therapist already had a long-shared history. most of the time what we call spontaneous regression is a regression induced by the reaction to a rubber band situation. a stressing situation in the here and now invites the client to remobilize memories of an original trauma, to contact her belief system and relaunch, in relationship, the emotional and behavioral survival decisions based on a long-established script dynamic. in more favorable situations, regression is not induced by the therapist who merely guides and accompanies it, but by the therapeutic work that continues within the client, on their own (like sophie screaming into her cushion), in between sessions. bodywork and work with the body at a distance another question often raised about regressive work concerns the difference between bodywork and work with the body. bodywork is a specific therapeutic intervention to facilitate the client’s contact with the impact of a massive traumatic shock or with distress that was physiologically inscribed at a preverbal age. the objective is to allow the client to come out of the process having lived a restorative experience in a healthy physical proximity that is emotionally protective and relational. this will then generate in the brain new neuronal and synaptic connections and a new gestalt of a soothing and safe encounter with the other. in my practice, i use the mediation of bodywork only for the treatment of the first unattuned protocol interactions, when their impact was damaging for the structuring of the sense of self of my clients. i also use bodywork for treatment when there is in my clients’ history the awareness of serious traumatic events that hinder their ability to hold onto their sense of self in stable personal psychic boundaries. from my point of view, the offer of regression bodywork, probably and to a certain extent, leads the client’s child ego state to confluence with the therapist, who is fantasized as a good parent. therefore, such work requires the express and adult consent of the clients who do understand the possible impacts of these traumatic memories on their lives and who choose to go through them again in order to emerge lighter, joyful, and free to make their own life choices. international journal of integrative psychotherapy, vol. 12, 2021 201 indeed, in this project with the true self of the grown-up client (cadot, 2011), i need to observe their whole physiology in order to verify they don’t over-adapt with the bodywork proposal from a terrified and confused child ego state, especially in the presence of trauma resulting from physical or sexual abuse. confluence is an intrinsic component of this type of trauma, in which the person is confronted with such a psychic implosion that the only reference point that emerges afterwards and remains is a kind of loyalty to the aggressor. this reaction is an attempt to give meaning and predictability to such an experience, even at the cost of dissociation, and to remain in agreement and attachment with the total or partial denial practiced by the family system. from another perspective, my own personal experience of bodywork as a client in a therapy group brought undeniable resolution for me, but left me with few conscious or constructed memories. this seems logical since this type of work touches on a preverbal trauma and repairs at an age when the child cannot think about or express their experience. as a therapist, i theref ore know that the clients may emerge from this work with few organized memories of their experience. there may be a feeling of physical and emotional fatigue, followed, later on, by an adult awareness of the liberating impact of this specific therapy work on the rest of their life. to do this work in group is of primary importance; the group members’ trusting and attuned presence offers holding, providing implicit and explicit psychic regulation that the clients lack from birth or from the onset of a traum atic experience, whether acute or cumulative. w hat’s more, the group’s holding implicitly validates and normalizes the therapist’s intervention. insofar, as affect confusion or even affect disorder (understanding: emotion, sensation, and behavior) is an intrinsic part of a traumatic experience, the physical holding and containing presence of the group brings back, in the work setting, a dimension of shared reality that contributes to a sense of protection for the clients against possible fantasies of traumatic reiteration. i only consider bodywork with clients who demonstrate a good enough plasticity of their ego state boundaries and can return easily to their adult ego state (which excludes people with an underlying psychotic core), and only when they have already built up enough security in their daily lives and relationships and enough re-appropriation and understanding of their history. this means that these clients already have a usual experience of working with the body. this is my choice: according to me, the treatment of protocol inscriptions or spontaneous regression through bodywork requires physical presence and the international journal of integrative psychotherapy, vol. 12, 2021 202 presence of the group. however, as soon as my clients have gained confidence in our therapeutic relationship, i feel free to routinely work with the body, in both individual and group settings. in this respect, working via videoconference didn’t require any change in my way of supporting my clients. i practice in the french alps, and quite often, in winter, clients have trouble reaching my office to attend their session because the roads are too snowy. in this pandemic, i found myself greatly trained by my first ten years of work as a therapist, when neither w hatsapp, skype, nor zoom were available. w e had to manage by phone. i learned, in such situations, to close my eyes, imagine a bubble around me, and concentrate on the voice and breath of my clients. i keep in mind that there is a difference between presence, meaning the geographical context of the session, and presence, meaning the availability to unconditionally and empathetically welcome, on a psychic level, the vulnerability of the other. fortunately, the second type of presence does not always require the first. there are however exceptions: during the recent lockdown, i found it necessary to have two face-to-face sessions with another client to address an archaic issue of abandonment while responding to the here and now need for mutuality. despite the lockdown, i decided it was therapeutically justified for my patient to attend. t his client, with a borderline structure and a strong propensity for denial and insensitivity, was plunged into an intense panic on seeing the frozen faces of her group on the screen. this was caused by a technical failure of internet and she regressed to a too-young age to be soothed by the sms support we had established. i knew this client would benefit from a bodywork session, and i was aware that her reaction was related to the therapy contract she had elaborated (telling her mother about her anger). my choice was, at this point in her ongoing therapy, to make an exception for her. i offered physical proximity to make my being present for her affect and need more tangible for her. my objective was to validate her need for self-definition in the relationship, her need to be acknowledged, even distinguished, which her mother had never satisfied. w e were then able to work with her body so that she could recommit to her ability to remain physically and mentally consistent by learning to moderate her comfort distance with me. international journal of integrative psychotherapy, vol. 12, 2021 203 protection for the therapist w orking at a distance (via zoom) when accompanying and treating regression with the body nevertheless requires setting up additional and particular protections. it is imperative for the therapist who is willing to accompany her clients through regressions to revisit, if necessary in therapy, her own experiences of previous unchosen separations (because this is what lockdown is). this is needed to be able to conduct a therapy process that is not contaminated by a transferential dimension, and thus to avoid unconsciously imposing one’s own project of personal reparation on the client (cadot, 2011). it is also important to remember that even chosen separations are not free of grief or nostalgia and to acknowledge this and normalize it for ourselves and our clients. w orking with regression therapy from a distance requires the therapist, who now cannot work with physical proximity or touch, to be more open to her own vulnerability in order to keep a close focus on the client’s vulnerability, to be attuned to voice inflections, choices of vocabulary, the rhythm of “phrases,” silences, breath, feedbacks, and so on. the loss of the face-to-face meeting deprives the therapist of the possibility “to live her bodily involvement as an encounter with the other. it makes it difficult to be fully attentive to her bodily counter-transferential experience and feelings in her function as therapeutic mirror, and to her capacity to modulate her bodily tone in relation to the other” (gourbin, 2017, p. 16). the therapist must therefore accept in advance the possibility of being surprised, and she must be prepared to make contact with her own personal feeling of fear or powerlessness. a therapist’s insecurity while accompanying her client in regressive therapy may be amplified in the context of distance work and could be linked to the (momentary) loss of a resource inscribed in each of us from the first spark of physis: the memory, even if only cellular, of the desire for contact and for the physical presence of the other. our clients may also experience this loss, effectively without any filter, since one of the first effects of isolation is to question their relational systems of protection and adaptation. the therapeutic work thus demands more energy, as the need for holding and bounding is stronger. it is then of vital interest for the therapist to systematize personal physiological, emotional, and relational resourcing modes for herself, in real life—for example, by recalling memories of strong satisfying physical and emotional contacts (the anchor model of neuro linguistic programming). international journal of integrative psychotherapy, vol. 12, 2021 204 protections for the group the possibility of a loss of the internet connection during a session is certainly the first risk. w hat can be done in the event of a sudden loss of contact should be discussed in advance, and explored with each member of the group. the discussion should include how such a situation might be experienced both internally and in relationship with the others. like the virus, the loss of the network can happen without warning, and this may undermine our all-mighty phantasmatic childhood illusions of guarantee that “as far as my environment and my relationships are concerned, everything is under control, nothing changes everything remains as it is forever.” it is therefore necessary to set up a ritualized process of pre-contact and recontact within the group, with the aim of providing each person with a sense of security and continuity, of leaving no one in isolation, in order to cope with a possible feeling of loss of the relation. w e therefore set up a “watch” by text message, defining in advance who maintains contact with whom, during the time it takes to recover the network. moreover, each member of the group identified and specified what they would need to hear from their partner while maintaining contact by text message, which turned out to be their antidote to self-generated criticism or personal survival decisions. in addition, the group expressed its need to be updated on the ongoing therapy of those members who would ask for individual sessions between two group sessions. the decision was, in such a situation, after two days for private integration, to send written keynotes to all by mail. it is also necessary to take into account the fact that each member of the group participates in the session from his or her private geographical space, which is not insignificant. this is a big change from the usual functioning of a therapy group where the common space is provided by the therapist. according to me, an essential protection during the first remote group session consists of offering a psychic space for the exploration of each person’s experience due to the change of the usual session setting. there could be the loss of the group’s geographical “between us self,” the fear of being interrupted or listened to by a family member, the reinforcement of a feeling of separateness or isolation. careful and caring discussion in this area and respectful historical enquiry may allow members to renew emotional connections despite the physical separation. international journal of integrative psychotherapy, vol. 12, 2021 205 painful memories may then emerge in the clients’ consciousness. these might include never having been able, as a child or adolescent, to invite friends home. these memories might be associated with the feeling of shame of having to hide something intimate about the family (extreme poverty, family violence, parental addictions, or educational neglect), or of not having been able, despite the enjoyment of a room of one’s own, to be protected from repeated incestuous abuses. on the other hand, some may recall memories of a sense of relief in a depressive family environment due to the arrival of benevolent bearers of joy and openness. additional dynamics taking into consideration the above, working via videoconference could be considered as a helpful factor in the integration of the self rather than as an obstacle to the therapy. once the experience of intrusion/invitation into the private and intimate space has been elaborated, this way of working favors both mutuality and self-definition in the relationship. and this internal positioning of each member of the group within their own boundaries helps to protect each of them from possible identifying or projective reactions from their peers. in this particular framework and with the limits it imposes, it is especially necessary that the therapist thinks of the group as a therapeutic “entity” or even “person,” of which she is a part, with a specific responsibility: offering everyone a foundation of reliability and consistency for their different developmental needs. the therapist is the guarantor of everyone’s intimate boundaries, facilitating, when necessary, the verbalization of “what is theirs, what is yours” and of the boundaries of the group as a whole (“what is ours”). she also monitors and manages, as necessary, the energy put into participation and on which the therapist and the group rely. from this perspective, the therapist, as “shepherd of the client’s hope,” engages her own hopeful function. she carries within her the hope for the client that, through re-experiencing trauma in an involved and attuned relationship with the group, the client will come to reach the best of their potential (cadot, 2011). and the therapist commits herself with the same hope for the group because the latter, through its accompaniment, holding, and bounding, also grows and is transformed in its specific “relational color.” international journal of integrative psychotherapy, vol. 12, 2021 206 in addition, even if the members of the group do not cognitively analyze the therapist’s intervention options, they actively participate in them, with equal involvement for themselves and for the others and with equal attunement. each member of the group participates from both their own experience of the trauma, thus mainly from the intuition of what they lacked at that moment, or from the internalization of a previous and personal repairing experience. conclusions the debate between bodywork, work with the body, and regression support, whether in a face-to-face or remote setting, is first and foremost a matter of therapeutic indication: of the personality’s diagnosis, i.e. the degree of solidity in the structuring in the domains of development of sense of self; of the understanding and taking into account the person’s script dynamics; of the progression in the treatment plan; of the nature of the trauma; and of the client’s membership in a sufficiently mature group. from this point of view, the pandemic or similarly isolating circumstances does impose a different or additional set of working conditions on us. but these conditions have not fundamentally changed my practice or my orientations in terms of choice of therapeutic intervention options, insofar as i reserve bodywork for regression to the face-to-face and ingroup setting. however, whatever the context of the session, but even more so when conducted at distance, the therapist will have to be extremely careful to verify the security of the framework that she proposes. she should not be reluctant to question it, for herself internally but also for the group, and to share this questioning in the group. in doing so, she will reinforce her functions as the moderating influence of over-excitement and as the guarantor of a stable and coherent reliable structure. the members of the group, and the group as a whole, by experiencing this process, will be able to internalize it. moreover, it is interesting to note that therapy groups where regression support through work with the body is the least demanding and the most powerful, are those whose members have developed, over time, their own processes of mutual questioning, sharing (difficulties as well as successes), and support outside of the actual session times—when the therapist is not directly involved. international journal of integrative psychotherapy, vol. 12, 2021 207 the therapist will need to internalize the group as a therapeutic ally, to whom each person contributes in their own personal and responsible way, but all with equal involvement and attunement. the result is like a dance, where one of the partners assumes the lead role in the tempo of the music and the other partner offers their grace and lightness; the couple then lives the happiness of a shared movement. the demand for online therapy is becoming more common and will probably increase due to the continuing risks of new pandemics or other catastrophic events, or simply because of the need to limit our carbon footprint. w e need to remember that the framework of the therapy that we have integrated was d esigned years ago, in and for rather secure and predictable living contexts where face-toface work was not a problem. in light of this new situation, we now need to reelaborate the contractual framework of therapy’s work setting, most of all regarding the protections and boundaries of the therapeutic transferential space for our clients. on an additional note, we can hypothesize that the digitalization of our intrafamily and societal relational space may promote, more and more, the emergence of highly disorganized personality structures. the freedom and anonymity of the internet allows people to externalize and enact the affects of an extremely disturbed child ego state without having to directly confront relationships. w ith such clients, in-person face-to-face encounters, combined with attuned involvement, allowed us to offer acceptance of pain while invoking principles of reality. w e were then able to define both limits and boundaries for these clients’ injured sense of self. but as we now integrate into our practice this new challenge of conducting therapy without in-person presence, it is necessary, beyond the few options offered here, to carry on elaborating the structure, boundaries, and containment we need to build and make available to our clients. from this perspective the therapy group, in its process and “countenance,” will constitute one essential key to the success of this development. international journal of integrative psychotherapy, vol. 12, 2021 208 acknowledgements my gratitude to guillaume adjagba who dedicated time, interest, and exactness as the editor for the initial french draft. a very special thanks to each of my four translators, sally oppenshaw, maury lanman, lise small, and steffi tarade, for their involvement and enthusiasm in supporting this text. references cadot, h. (2011). hope for the client, hope for the therapist [w orkshop]. paris. erskine, r. g. (2020). compassion, hope, and forgiveness in the therapeutic dialogue. international journal of integrative psychotherapy, 11, 1–13. erskine, r. g. (2019). developmentally based, relationally focused integrative psychotherapy: eight essential points. international journal of integrative psychotherapy, 10, 7–8. erskine, r. g., morsund, j., & trautmann, r. (2019). au-delà de l’empathie : manuel de psychothérapie relationnelle intégrative (g. slottje, trans.). intereditions. (original work published 1999) gourbin, o. (2017). de la contention à la contenance : pour une approche transpersonnelle de la thérapie psychomotrice [post-graduate thesis, irett]. https://ceshum.net/de-la-contention-a-la-contenance/ guarella, e. (2017). mind, body, and spirit [conference session]. 8th international integrative psychotherapy association conference, milan, italy. small, l. (2012–2015). construction du sens de soi et pratique clinique [w orkshop]. neuchâtel, switzerland. small, l. (2004). être compétent… même si l'on ne sait pas tout. les editions d'analyse transactionnelle, 109, 1–30. stern, d. n. (2015). le monde interpersonnel du nourrisson : une perspective psychanalytique et développementale (a. lazartigues & d. pérard, trans.). presses universitaires de france. (original work published 1985) https://ceshum.net/de-la-contention-a-la-contenance/ case history alcoholism is such a common condition that therapists must be exposed to clients who suffer from it, whether the therapist is international journal of integrative psychotherapy, vol. 1, no. 2, 2010 29 an integrative psychotherapy of postpartum adjustment carol merle-fishman abstract: becoming a mother is a time of transition, transformation and sometimes trauma. the immediacy of meeting the needs of an infant, combined with the immediacy of becoming a mother, often collide to produce depression, anxiety and stress. shame, confusion, isolation and cultural expectations often prevent women from seeking the postpartum support they need, which may result in long lasting depression, anxiety and unresolved trauma. integrative psychotherapy, transactional analysis and attachment theory offer ways to understand postpartum adjustment as well as methodologies for addressing this unique developmental event in the life of women. key words: postpartum adjustment; integrative psychotherapy; pregnancy; birth ____________________________ becoming a mother presents a unique opportunity in the life of a woman for transformation, integration and redefinition. prior to childbirth, many women are unaware and unprepared for the deep impact motherhood will have on their lives. while opportunities for childbirth preparation abound, there is a contrasting and alarming lack of preparation for the many tasks and responsibilities of motherhood. as a result, many women are often surprised, shocked and confused by the life changes that occur with the arrival of a baby, sometimes feeling betrayed that they were not forewarned (maushart, 1999). as women rapidly transition from pregnancy to parenthood, they express wonder and anger, often thinking that they were protected from well kept secrets about the truth of early motherhood, which some describe as “mother shock.” (buchanan, 2003). comments like, “this is not what i expected,” “it wasn’t supposed to be like this,” or “why didn’t anyone tell me it would be this way?” are common from postpartum women. international journal of integrative psychotherapy, vol. 1, no. 2, 2010 30 the postpartum experience is uniquely different for every woman, and can even differ dramatically with each child she bears. defined medically, “postpartum” refers to the time during which a woman still has the physical symptoms of birth; an enlarged uterus, stretched and swollen cervix, and lochia. these symptoms typically resolve at the end of six weeks (bing and coleman, 1997), and when they do, women are generally released from medical care to navigate new motherhood on their own. in contrast, “psychological postpartum recovery,” the time during which women experience the emotional symptoms of birth, may last for months or even years, with some women reporting that they are “postpartum for the rest of their lives because they feel permanently changed by the birth of their child.” (bing and coleman, 1997, p.98). most women are left to resolve their psychological postpartum recovery alone; a recovery that impacts the rest of their lives, their children’s lives and the culture at large; a recovery with long lasting and far reaching social and relational implications. family members, friends, medical professionals and psychotherapists alike frequently overlook, misinterpret or misunderstand the lingering effects of postpartum recovery. as erskine notes, “the recent literature on neuroscience, child development, and early child/parent attachment research has been a siren call reemphasizing the importance of psychotherapists focusing the therapeutic relationship on the client’s early childhood preverbal relational experiences.” (2009, p.2), a focus which by default must also include an examination of their own mother’s postpartum recovery. at best, the postpartum period is a time of sleepless nights cushioned by the loving presence of relatives and friends who come to admire the new baby and help welcome this new little person into the world. at its worst, the postpartum period is a nightmare; a seemingly endless, unanticipated excursion into sleep deprivation, uncertainty, confusion, physical recovery from an unexpected cesarean section and/or traumatic birth, failed attempts at breast feeding, lack of connection to the infant and an overall sense of loss of self and any ability to anchor to familiar markers of a life previously known and lived. as the daily needs of the infant increase and intensify, self care is often necessarily neglected. sleeping, eating, and bathing become longed-for luxuries. recreation, relaxation, contact with one’s partner, friends and even the outside world, become distant memories. the acute needs of the new family can lead to cumulative self and relational neglect, chronic stress, and an unanticipated experience of trauma, during what was supposed to be one of the happiest times of life. the immediacy of meeting the needs of an infant, intertwined with the immediacy of learning how to parent, often collide to produce depression, anxiety and stress. literature about the postpartum period, both popular and clinical, often contributes to misconceptions about postpartum women by failing to normalize psychological postpartum adjustment. early clinical literature about postpartum women often emanated from a psychoanalytic perspective, with countless case studies pointing international journal of integrative psychotherapy, vol. 1, no. 2, 2010 31 to conflict, ambivalence and repressed fantasies which interfere with “healthy” mothering (mendell & turrini, 2003) and seemed to inherently blame women for postpartum or parenting difficulties. currently, postpartum women who report any difficulties or “symptoms” are grouped according to three categories of increasing pathology: baby blues, defined as “transient feelings of unexplained crying, fleeting despair, or brief moments of not feeling quite yourself lasting the first few weeks after birth” (bing & coleman, p. 24); postpartum depression, defined as a more intense and longer lasting version of baby blues, which may include feeling sad, anxious, guilty, and/or worthless, in addition to changes in eating patterns, sleeping patterns, activity levels, panic attacks, difficulty concentrating, preoccupation with death and/or suicide, mood swings, obsessions about the baby and/or intense fears of hurting the baby (bing & coleman, p. 226); or postpartum psychosis defined as intensified blues or depression, which may include confusion, incoherence, irrational thinking, and/or delusions and hallucinations which seriously impair self-care and/or care of the baby (bing & coleman, p. 241). although presented as distinct categories, these experiences may actually flow together or cycle back and forth, with “psychosis“ occurring during periods of acute stress. missing from this standard taxonomy is the simple, yet necessary, concept that all women and their partners experience postpartum adjustment; a psychological reorganization after the birth of a child which is a required and necessary adaptation to a change in the structure and homeostasis of the individual and the family. this, like any change to a dynamic system, requires time and support as new internal and external adaptations and accommodations emerge. it is understandable that women may feel disoriented, depressed, anxious, preoccupied or even irrational, while exhibiting changes in appetite, sleep and activity levels. their entire physical, psychological and social homeostasis has been altered. however, rather than normalize their unique adaptive responses, women are defined, categorized and “pathologized,” if they demonstrate anything other than a seamless, happy adjustment to motherhood. popular literature and media also subtly reinforce unreasonable expectations regarding the adjustment to becoming a parent. attractive, cheerful, smiling women and babies fill the pages of parenting magazines and television commercials. women look at these advertisements and wonder, “what is wrong with me?”. they fantasize that every other young mother they encounter in public “has it all together,” while they desperately try to respond and adapt to the culture at large, as well as the unique cultural, relational and historical demands of their own families of origin. sometimes the only information women receive about postpartum adjustment comes from highly publicized stories of celebrities who have experienced postpartum difficulties, but rarely do these celebrity women mirror the life of a typical new mother (shields, 2005). in the privacy of their homes, women often feel isolated, lonely and overwhelmed by the demands of the new baby. they often feel shame about their adjustment to international journal of integrative psychotherapy, vol. 1, no. 2, 2010 32 motherhood. in a culture prone to scrutinizing and criticizing mothers for their failings, women feel vulnerable and frightened by internal and external demands to perform. under these circumstances, many women go into hiding, literally and/or figuratively. as the dsm-iv (1994) notes “women feel especially guilty about having depressive feelings at a time when they believe they should be happy. they may be reluctant to discuss their symptoms or their negative feelings toward their child.” (p. 386). according to a study published in the journal of the american medical association in 2006, one in seven new mothers is estimated to suffer from postpartum depression. even more alarming, is the study’s estimate that postpartum depression goes undiagnosed in roughly 40 50% of new mothers, leading researchers to believe that postpartum issues are even more common than previously believed (munk-olsen, laursen, pedersen, mors, & mortensen, 2006). women who have experienced an unexpected premature delivery, cesarean section, prolonged, difficult or traumatic birth with or without physical injury to either themselves or their babies, or are themselves previous survivors of emotional, physical or sexual abuse, are even further at risk for difficulties during postpartum adjustment (simkin & klaus, 2004). add to this list a history of depression, anxiety, infertility, miscarriage, still birth, inability to establish successful breast feeding, adoption, or emotional or physical loss of one’s own mother at an early age, and the nuances and possibilities for challenge and trauma during postpartum adjustment expand even further. in the absence of explicit memory, difficulties during pregnancy, childbirth and postpartum recovery may be the first indicators of a previous history of cumulative neglect, trauma and/or emotional and physical abuse, leading the way to recovery of previously unconscious memories (erskine, 2008). health care providers who understand this are invaluable in guiding pregnant or postpartum woman towards the help they need to resolve these issues so they may successfully approach childbirth, postpartum adjustment and parenting with appropriate here and now expectations, as free as possible from the burdens of past trauma, unresolved neglect or relational failures. given the many varied possibilities of postpartum adjustment, it is imperative that women be offered opportunities for normalization of their experience. as erskine & trautmann write, “...normalization [helps] clients or others categorize or define their internal experience or their behavioral attempts at coping from a pathological or “something’swrongwithme” perspective to one that respects archaic attempts at resolution of conflicts. it may be essential for the therapist to counter societal or parental messages.... and communicate that the client’s experience is a normal defensive reaction a reaction that many people would have if they encountered similar life experience.” (1997, p.32). in this regard, each woman’s entry into motherhood requires normalization, an understanding based on her own unique history, relationships and international journal of integrative psychotherapy, vol. 1, no. 2, 2010 33 attachments, rather than definition of “problematic” postpartum responses based on clinical descriptions and pathology. a clinical model for understanding postpartum adjustment: integrative psychotherapy integrative psychotherapy offers a comprehensive theory and methodology which encompasses a view of “human development in which each phase of life presents heightened developmental tasks, unique sensitivities in relationship with other people, and opportunities for new learning,” (erskine & trautmann,1996, p.316). in this way, integrative psychotherapy provides an excellent framework for understanding and working with postpartum recovery; a specific phase in the life of a woman which presents the heightened developmental task of learning to parent, unique relational sensitivities to both one’s partner and children, and increased opportunities for many areas of new learning inherent in raising a family. the self in relationship the self in relationship model as delineated by erskine (1980) provides a way to understand the cognitive, behavioral, affective and physiological functioning of the new mother. all four of these domains of the self are deeply affected by the birth of a child, and require consideration and integration during recovery in order to meet the required, yet often unanticipated, internal and external demands of motherhood. the developmental task of becoming a mother must occur in “real time” in response to the accelerated physical and psychological development of a baby in the first year of life. in a culture increasingly reliant on technology to inform behavior and response time, it can be challenging to realize that babies do not come with a pause button, or “operating instructions” (lamottt 1993). as the daily needs of the baby emerge, the mother is simultaneously confronting her own cognitive, affective, behavioral and physiological reorganization. while on a roller coaster of emotional highs and lows, often stimulated or influenced by hormonal fluctuations, memories of her own infancy and childhood are being subtly stimulated, often out of awareness. women often report experiences of love and attachment never before known or anticipated. in contrast, other women report feelings of extreme loneliness and neglect. in either case, the world of affect and emotion becomes deeply activated. concurrently, the new mother must engage in immediate problem solving regarding infant care, think through new and unexpected situations, develop a new social and/or medical support system, and learn a vast array of care taking skills and behaviors ranging from breast feeding, to bathing a baby, to managing work and motherhood, while restructuring all aspects of personal and family international journal of integrative psychotherapy, vol. 1, no. 2, 2010 34 time management. many often feel that they are in a continual game of catch up, attempting to keep up with rapid developmental in their baby. they often report that just as they come to understand the current needs of the baby, new needs emerge. for example, a baby who was sleeping through the night last week, is now this week an uncomfortable, wakeful teething baby. the mother’s cognitive and behavioral domains became challenged, stimulated and often stressed. cozolino (2006) discusses the physiological changes to the brain which occur in response to the cognitive and affective stimulation from parenting. he describes the “experience dependent plasticity” of the maternal brain, noting that “having children enriches, stimulates and challenges the brain to grow.” (p. 82). his review of research on brain development leads to an inference that “mothers and children stimulate each other’s brains to grow” (p. 83), noting “parents and non parents have been shown to demonstrate different patterns of brain activation in response to the crying and laughing of infants, reflecting experience dependent brain changes resulting from parenting experiences.” (p. 83). he suggests the possibility that “the emotional lability we see in many new mothers is an expression of a heightened sensitivity to interpersonal cues required for optimum attunement and learning.” (p. 83). in this regard, emotional lability may be viewed as normal and necessary, not pathological. while physically recovering from childbirth, the cognitive, affective and behavioral domains of the self are also challenged. women put their own needs aside in order to meet the survival needs of the infant. all forms of self-care and self-regulation including sleeping, eating, bathing, exercising, entertainment, social interaction and even necessary medical appointments may fall to the wayside, significantly contributing to the potential for cumulative stress, anxiety and depression as the mother attempts to keep up with this highly intensified period of growth and development for both her child and herself. if the mother must return to work, and/or there are other children or family members who require her care and attention, her ability to attend to her own physical and emotional care is even further undermined. the way in which a woman approaches all these cognitive, affective, behavioral and physical challenges is necessarily informed by her own history and attachment style; a history revealed through both implicit and explicit memory and/or disruptions of attachment (cozolino, 2006). in a remarkable parallel of development, a woman integrates, reinvents and grows into motherhood, as her baby simultaneously develops and grows into a human being. life script, memory and attachment according to berne (1972) “the first script programming takes place during the nursing period, in the form of short protocols which can later be worked into complicated international journal of integrative psychotherapy, vol. 1, no. 2, 2010 35 dramas.” (p. 83). for example, the baby who is typically rushed, ignored or lovingly attended to during feeding, will each carry this early protocol into future interactions. erskine (2009) expanded on berne’s idea by delineating the association between life script and attachment patterns formed in early infancy, emphasizing “the significance of infancy and early childhood sub-symbolic, pre-verbal, physiological survival reactions and implicit experiential conclusions that form unconscious procedural maps or internal working models of self in relationship.” this comprehensive definition of life script takes into account the “profound influences of infancy and early childhood (erksine, 2009, p. 4), thus underscoring that the mother’s postpartum adjustment has the potential to deeply influence the psychological development of her infant. the mother’s physical recovery, adjustment to parenting, family and social supports and own attachment patterns must, by definition, affect the creation of the infant’s working models of selfin relationship and script formation. the child is being “profoundly influenced” in relationship with a woman who is undergoing one of the most life altering experiences of adulthood, involving the activation of her own implicit, pre-verbal and sub-symbolic memories of her own infancy and postpartum mother. the mother’s own style, patterns or disorders of attachment, formed in response to her own infancy and childhood, quickly manifest as she begins to care for her own child. layers of past, present and potential relationships begin to emerge in the context of the postpartum dyad; a dynamic and intricate orchestration of two intertwined lives representing the archaic past, present and future relational possibilities. case example: natalie natalie had spent many years in psychotherapy with a variety of therapists. a divorced mother of three, now remarried, she had a history of choosing partners who were unwilling to meet her relational needs beyond the sexual arena, and had discovered as a young teenager that sexual contact was a way to meet needs for affection, validation and security. natalie maintained a staunch adherence to the core belief, “something is wrong with me,” continually searching for the “right” therapist who would agree with her and finally heal her so that other people would love her and be emotionally available to her. as we explored natalie’s family history, stories about her infancy validated her deep internal sense of fragmentation and that something was “very wrong.” there was the time her mother left her in a drawer in a hotel room when she was 6 months old while she went to the movies; the time her mother left 3 month old natalie with a neighbor to go grocery shopping, but did not return in time to feed her. natalie was exclusively breast fed, and by the time her mother returned, natalie was reportedly hysterical with hunger and distress. there was the “blue arm in the bath-tub” story. international journal of integrative psychotherapy, vol. 1, no. 2, 2010 36 mother was giving natalie a bath, usually a pleasant experience, so she could not understand why natalie was crying so hard. “then she looked down and realized she was holding my arm so tightly, that my arm had turned blue.” natalie knew these stories because they had become part of the fabric of family history, often light heartedly told by her mother at family gatherings. in addition, natalie still experienced in the present that “my mother’s hugs are all wrong. she couldn’t even hold my children when they were babies. she seemed so uncomfortable.” through her on-going therapy, natalie came to realize that her mother had been terrified and isolated as a new mother, unable to be fully present for natalie, to see her, know her and meet her needs. natalie’s deep internal experience that “something is wrong with me,” was an on-going creative attempt to change herself in order to get the care taking she so desperately needed. her story was inextricably intertwined with her mother’s postpartum experience. women who thought they had adequately prepared for motherhood are often surprised, or even overwhelmed, by the flood of postpartum emotions and memories stimulated by the birth of a baby and necessary requirements of caring for an infant. psychotherapy with postpartum women provides an exceptional opportunity to understand the mother’s own infancy, early-child dramas and/or script protocols, as lived through the current relationship with her new baby, partner, extended family and friends. as she begins to care for her baby and attempt to self regulate, the woman’s own early story is enacted and embodied as implicit and explicit memories are revealed in her thoughts, feelings, behavior and body. we are able to observe the growing attachment patterns between mother and baby, which offer a window into possible formation of the infant’s own life script. as women grapple with issues related to feeding, sleeping patterns, expressions of love and affection, returning to work versus staying home, the embedded stories of secure, anxious, ambivalent, disorganized or isolated attachment emerge (erskine, 2009). as the story of these two lives unfold and intersect, we are at the confluence of memories and relationship, old and new, with all of the attending opportunities for repetition or reparation. attachments, memories and postpartum adjustments occur even when a woman loses a child. women who have miscarried, had abortions, or a still birth are often maintain deep attachments to their child (davis 1996). marion, 43, provides a heartfelt example of this. she and her husband spent six years and thousands of dollars attempting to conceive a child. they were ecstatic when their second in-vitro fertilization procedure resulted in a viable pregnancy. however, genetic testing at 16 weeks revealed severe chromosomal international journal of integrative psychotherapy, vol. 1, no. 2, 2010 37 damage, and the news that their daughter had not survived the pregnancy. given the choice of being induced versus naturally going into labor, marion chose to wait for labor, and within two days gave birth. although both the doctor and her husband assured her in the midst of her painful contractions that it would all be over soon, she dreaded the end when her baby would finally leave her body. fortunately, she and her husband were allowed to hold, name and photograph the baby, bringing some sense of closure to the experience. marion continued to grieve her lost baby in her therapy sessions, eventually sharing with me the pictures they taken of her, and the baby book she had carefully and lovingly put together filled with early memories, sonogram pictures, happy pictures of marion holding her pregnant tummy, and pictures of family members her daughter would never meet. miraculously, and against many odds, marion conceived another ivf baby 10 months later. as the birth of this healthy baby drew near, marion suddenly slipped into an unexpected depression and anxiety one afternoon after her childbirth class. memories of her first labor and delivery came pouring out. she grieved and berated herself for not asking the nurse to unwrap her daughter so she could have seen all parts of her tiny body. she realized that she had not been able to choose a name for the new baby, also a girl. she could only think about her first daughter, and the perfect name that she had been given. she agonized over what to say when people, seeing her swollen belly, would ask if this was her first baby. on all levels, she began to feel that the coming baby was a betrayal of her love for her first baby. i suggested to marion that she was telling me an important story about attachment and love. she was attached and in love with her first daughter, but at a loss as to how to express this. she needed permission that it was okay to love and welcome another baby. i encouraged marion to write a letter to her lost baby and bring it to her session. she resisted this suggestion for a number of weeks, even though she continually told me about the on-going internal conversation she was having with the lost baby. finally, she arrived at her session with a letter; a poignant expression of her love for this child, regrets over the lost opportunity to ever know her, and commitment to maintain her memory. she asked the baby to watch over her new little sister, and thanked her for being the first to make her a mother. it was a wrenching and painful session for marion. the following week, marion arrived in my office cheerful and energetic. over the weekend she’d had her first pregnancy dream about the coming baby. “i was overwhelmed by the new baby, but i saw her. she was here. i didn’t know what to do with her but it’s all okay because i had a dream about her! i had a normal pregnancy anxiety dream! that’s so exciting! i didn’t understand how writing that letter was going to help me, but it did. thank you.” marion’s final and full acknowledgment of attachment to her lost daughter had now opened the way for her to birth and welcome her next baby. international journal of integrative psychotherapy, vol. 1, no. 2, 2010 38 inquiry, attunement, involvement and relational needs inquiry, attunement and involvement help us reach beyond typical therapeutic empathy towards a deeper relationship in which the client experiences being fully known, responded to and understood by the therapist. on the most fundamental level, this process mirrors the process of early parenting which relies on exquisite and intuitive forms of inquiry, attunement and involvement. in the absence of a shared verbal language or concrete knowledge of the infant’s subjective experience, the mother must rely solely on nonverbal forms of communication, which require an on-going refinement of intuition and sensitivity to her infant (stern 1985,1990). as erskine et. al (1999) writes, “(i)n integrative psychotherapy, our inquiry begins with the assumption that the therapist knows nothing about the client’s subjective experience.” (p.19). as with therapist and client, so it is with the mother and her new baby; a brand new meeting of two individuals, a relationship where neither one yet fully knows the other. engaging in non-verbal modes of inquiry, attunement and involvement become the means by which the mother begins to meet early relational needs for security, value, acceptance, mutuality, self definition, impact, initiation, and love in order to establish secure attachment and promote healthy development (erskine, moursund & trautmann,1999). historical as well as current deficiencies or disruptions in the fulfillment of the mother’s relational needs all necessarily inform how that mother will care for her infant and create a healthy reciprocal relationship. as the mother begins to care for her baby the landscape of her relational past and present begins to emerge. un-met needs from the past may converge and collide with the present in the form of unconscious attempts to repair failures via the relationship with her baby. just as the baby looks to the mother for security, value, acceptance, mutuality, self definition, impact, initiation, and love, the mother is also looking to the infant and others around her for assurance that she is valued, accepted and secure in her new role as a mother. new relational challenges often appear between the woman and her parenting partner, as she turns to him/her as the central figure to meet present needs, as well as repair historical failures. new parents are often completely unprepared for the extent of these challenges to even the most stable marriage or partnership. if a woman felt undervalued by her own mother, or other important people in her development, these memories are likely to emerge as she approaches this most important task of her adult life. she will invariably look to her partner for continual reassurance, acknowledgment and appreciation. if her partner is unable to support her in these ways, a relational crisis is almost certain to ensue. women who felt insecure, unloved, or impotent in their ability to initiate or make an impact early in life, often look to their babies and their partners for validation, acceptance and love. women who have used careers to repair and replace relational deficits, finding value and self definition for their performance in the work place, often find themselves struggling to get through a day where the biggest victories lie in getting a fussy baby to sleep or finding an opportunity to bathe, eat and get dressed (maushart, 1999). they find themselves suddenly and unexpectedly looking to their baby and/or partner to meet the full array of relational needs, as their partners, also coping with their own version of postpartum adjustment, feel befuddled, overwhelmed and also bombarded by their own early memories, as competition for simple physical and emotional needs such as sleep and affection escalate. as one client poignantly expressed in the midst of unexpected postpartum marital conflict, “i finally realize that i need my husband to give to me what i give to the baby every day. if i don’t get that from him, i feel depleted and overwhelmed taking care of the baby, and completely resentful and unavailable to meet any of his needs.” on the other hand, mothers who have a history of secure attachments and relational successes may also struggle with postpartum adjustment due to a variety of unexpected circumstances. for example, a baby suffering from months of colic will challenge and eventually wear down even the most emotionally secure and stable parents. even the partner who has not given birth is prone to postpartum adjustment. as cozolino (2006) writes of one of his patients, “ the birth of his child... contained many cues that triggered painful and violent memories from his childhood... triggered by crying, the smell of baby powder, and the intense feelings of love for, and even the dependency of, his child.” (p.137). men are often unprepared for such surges of memories and feelings in the midst of attending to the dependency needs their new babies and, once highly independent, partners now exhibit. in addition, men commonly experience some degree of loss, as their partners become intensely involved with their babies or preoccupied with their own adjustment. they often report feeling neglected, and typically resort to working hard, justifying long hours at work; a socially acceptable solution as they are often now the primary wage earner. as a result, fathers avoid an array of feelings about their partners, themselves, their babies, and their own early memories. sadly, a vicious and long lasting cycle often begins here, with both parents feeling neglected, angry and resentful, with little support as to how to break this cycle and move forward in a positive direction. further, for a myriad of reasons, men often have even less emotional support available to address this brewing crisis than women do. case example: gina gina came to therapy in the wake of an intense and unexpected postpartum recovery. within one year she had experienced a first trimester international journal of integrative psychotherapy, vol. 1, no. 2, 2010 39 miscarriage and full term pregnancy, and was now suffering from anxiety, inability to sleep or eat and an increasing loss of interest in her baby. within a week of her daughter’s birth by cesarean section, gina had hit the ground running, organizing tasks, interviewing day care providers and seeking support groups. now exhausted, she had missed out on the important rest, bonding and emotional and physical recovery necessary during the early postpartum weeks. she felt especially depressed and anxious while nursing, finding it intolerable not knowing how much milk her daughter was getting. after three weeks she switched exclusively to bottle feeding. the immediate drop in hormones further exacerbated her anxiety, panic and loss of interest in mothering, leading to a referral from her doctor for psychotherapy and prescription for anti-anxiety medication. a personal assistant to the ceo of a multi-million dollar corporation, gina now had the ultimate personal assistant job: mother. yet, she was at a complete loss as to how to get through the day with a new baby, finding the time endless, lonely and empty. she missed her friends, a sense of purpose and accomplishment and independence. although having a family had been an important part of her life plan, she felt intense guilt about her feelings of emptiness and longing for her old life, and could not understand how this had happened when she had planned so well for everything. in addition, gina’s husband, a highly motivated, self employed consultant worked long hours and often traveled for days at a time. although thrilled with the arrival of his child, he was intensely invested in gina “getting better,” in order to lessen the demands on his time and energy. as we began to focus on gina’s experience of emptiness, and i inquired more about her childhood and parents, important clues began to emerge. her immigrant parents had come to america and “worked hard” to make a living and raise their children. gina burst into tears as soon as she uttered the words “worked hard.” she realized that an important part of her anxiety was about being home and giving up her job. despite attending to the constant needs of her baby, she believed that she was not doing enough. she could not rest, she could not just “be” with her baby. she had not even allowed time to grieve her miscarriage before embarking on becoming pregnant again “like a mission,” according to her husband. she could not remember her own mother ever just sitting still. in fact, when her mother came to take care of gina after the baby was born, she had managed to cook, clean, do the laundry, take care of gina and the baby, and run a few errands in between. gina realized, “if i am not frazzled crazy busy, then i am not doing enough. this is the way it is at work. this is the way i have always set up my life. now that i am just home with the baby, i continually feel like i need to be doing something else; like this is not enough, like there has to be something more.” transgenerational script messages (noriega, 2010), deeply embedded in gina’s postpartum story and now brought to awareness, contributed to a life plan focused on performance, success and accomplishment, significantly impacting gina’s postpartum adjustment. international journal of integrative psychotherapy, vol. 1, no. 2, 2010 40 the unique nature of postpartum adjustment can also present paradoxes. at times, women who may be expected to experience postpartum difficulties actually flourish and thrive as new mothers. sarah, 28, presented a perfect example of this. with a history of difficulty completing tasks or establishing a direction in life, she was forgetful, and scattered; constantly apologetic, resolving to become more organized and focused. although extremely intelligent, she had flunked out of college. in the midst of pursuing therapy, exploring her formidable artistic talents and looking for a career path, sarah married and soon became pregnant. i was concerned that new motherhood would be immensely challenging for her. how would she be able to care for a baby, when it was so difficult for her to structure her own life? on the contrary. sarah took to motherhood with a passion, commitment and love she had never before experienced. paradoxically, the lack of daily structure or predictability suited sarah perfectly. she thrived and blossomed in the midst of open-ended days devoted to breast feeding and watching her baby grow. as she noted, “i realize now how well suited i am for this. i’m a roll with the punches girl. i feel very comfortable sitting around all day nursing, changing diapers and making silly faces.” motherhood provided an unexpected reparative life experience for sarah, as she found purpose in her daily life, and comfort in being exactly who she is. since postpartum adjustment represents a significant developmental milestone in a woman’s life, it is essential that it be explored even with clients with older or grown children; an exploration that is often overlooked by therapists and other professionals unaware of how misunderstanding, embarrassment and shame often inhibit women from discussing their postpartum experiences, thus depriving them of important opportunities for insight and healing. in addition, women who have experienced miscarriages or stillbirths, have adopted children or have served as surrogates, have postpartum adjustments that are often completely overlooked by friends, family and medical professionals. case example: rachel rachel and her husband came to marital counseling to address the crippling effects of her anxiety on their marriage and three teenage children. she was constantly anxious, hyper-vigilant and at times terrified, regarding their whereabouts, friends, and activities outside the home. through many varied and creative manipulations, she found ways to keep the children at home when not at school. when her children were permitted to pursue social interests, they were required to constantly check in with her, and would often have to withstand her anger and resentment in the aftermath of not being included in their plans. her inability to allow for their emerging and appropriate independence was impacting all levels of family life. international journal of integrative psychotherapy, vol. 1, no. 2, 2010 41 rachel knew she was ambivalent about her children growing up. all she had ever wanted was to be a mother and make up for the family she had never had as a child. as we talked about what it had been like to pursue that dream, i learned about the birth of her oldest child. she had a normal full term pregnancy until she went into labor. when her water broke, she knew right away that there was meconium in the amniotic fluid. by the time she got to the hospital, the baby was in distress, and delivered by emergency c-section and then immediately transferred to a tertiary care hospital. rachel did not have an opportunity to hold her baby after he was born or see him for the first week of his life. while recovering in the hospital, she was visited by hospital social workers who seemed to be preparing her for the possibility that the baby would not survive. throughout the ordeal, no one offered any possibilities for her to see the baby or options for her to recover in close proximity to him. to manage her mounting anxiety, she began checking in with the neonatal intensive care unit almost hourly, telling me “i learned what to ask for.... for example, how are his blood gasses today?” when told that the baby was rapidly failing, she checked out of the hospital against doctor’s orders, and went to meet her son for the first time, refusing to leave his side. remarkably, the baby began to recover, and within days was released. however, once home, rachel became anxious and overprotective of the baby, afraid to leave the house with him, or allow others to have contact with him as he grew into a colicky, fragile baby, difficult to manage and prone to illness. gently introducing the idea of birth trauma and postpartum stress, i began to validate and normalize the intense anxiety and fear rachel had experienced when the baby was first taken from her, worrying that he might die, and unable to protect, hold or help him. she had been required to shut down and override every biological instinct and imperative in her postpartum body. my suggestion that she was actually still recovering from a misunderstood and undiagnosed postpartum trauma brought tears of relief. eighteen long years of anxiety and parental over protection had been an attempt to tell this long buried postpartum story. an anxious mother who obsessively worries about her baby’s health, childcare, sleeping patterns or feeding schedules is invariably telling a story from her own past. it is rarely helpful to diminish or dismiss her worries. sensitive inquiry which supports, rather than judges or criticizes, is necessary to help bring the underlying story of her worry into awareness. a sensitive, caring, relationally based psychotherapy can offer immense support and relief to a new mother, as the relationship with the therapist models, parallels and enacts the very process she must engage in with her infant; inquiry, attunement and involvement, in a relationship designed to provide security, consistency, validation, acceptance and growth. with the reciprocal here and now involvement of the therapist, the new mother can explore and understand her postpartum responses and relational history, while being supported, encouraged and normalized in meeting the relational needs of her infant. as erskine et. al (1999) writes, “(e)very person, especially every child, requires relationships in which the other person is international journal of integrative psychotherapy, vol. 1, no. 2, 2010 42 reciprocally involved..... clients experience not only the needs of the here and now relationship, but the unmet relational needs of the past as well... the echo of a cry for relationship that has been ringing in the client’s psyche for years.” (p. 123). never is this process more apparent than in working with postpartum women. mothers talking together the potent effects of a relationally based approach to working with new mothers is even more powerful when working in groups with postpartum women. group work offers yet another view of the display of relational needs between the mother and her child, as well as the mother and her peers. when offered opportunities for honest dialogue free from shame and judgment, with the guidance of a therapist able to model normalization, inquiry, attunement and involvement, women experience immense relief, perhaps even the best relief, in discovering they are not alone in confronting the challenges of new parenthood. reassurance or advice from health care providers, family members or partners rarely carries the same strength as that delivered in a postpartum peer group. to witness another mother struggle through the door with a baby stroller, cry with frustration while trying to soothe a colicky baby, or attempt to manage the intensity of internal criticism and self judgment while juggling baby, home, career and marriage, are all powerful antidotes for the isolation and shame many women experience as new mothers. cozolino (2006) helps us understand the value of groups through his explanation of the development of the social brain, which is reliant on interaction with others to stimulate mirror neurons and resonance behaviors. just as the baby needs mirroring and empathy from the mother, so does the mother need social interaction with other mothers to stimulate her mothering behaviors, empathy and resonance with her infant. in addition to providing a venue for the delivery of acceptance, mutuality and impact, these groups provide valuable experiences of social learning, now frequently missing in a culture increasingly reliant on technology to provide information and relationships. women, their children, and their partners suffer when there is an absence of face to face contact to provide relational needs with other human beings engaged in the process of raising human beings. ego states eric berne’s original concept of ego states provides a powerful conceptual and operational model for understanding how a woman may approach the adult developmental task of becoming a mother. berne (1961) postulated three ego states: parent, adult, child, defining the parent ego state as comprised of the thoughts, feelings and behaviors of parents or significant caretakers; the child ego state as comprised of the thoughts, feelings and behaviors of the person’s international journal of integrative psychotherapy, vol. 1, no. 2, 2010 43 past, and the adult ego state as the thoughts, feelings and behaviors of the person’s present; a here and now developmentally appropriate approach to the world. berne (1961) expanded on ego state theory in his hypothesis of ego state contamination, the process by which ego states overlap and influence present day functioning. integrative psychotherapy has further elaborated berne’s ideas by describing a clinical approach based on “the process of integrating the personality... helping clients to become aware of and assimilate the contents of their fragmented and fixated ego states into an integrated neopsyche ego....” (erskine & trautmann, 1997). understanding ego state contamination within an integrative psychotherapy model helps illustrate how many women approach new motherhood. according to berne (1961) contamination is most likely to occur when the individual is under stress, either internally or externally, thus increasing the likelihood that archaic or introjected patterns of thoughts, feelings and behavior will be called upon to manage stress and problem solving, and encroach upon the awareness of other options for thinking, feeling and/or behaving in the here and now. since the postpartum period inevitably presents stress and challenge to all domains of the self in relationship, postpartum adjustment is fraught with opportunities for ego state contamination. even if a new mother has had the opportunity to care for infants in some other personal or professional capacity, she is now presented with a completely new and unique life experience. her adult ego state ( neopsyche) is devoid of here and now information and experience about being a mother to this particular infant. although she may feel immediate “mother love” and attachment to her infant, it is the rare woman who instinctively knows exactly how to care for her new baby in every new circumstances that is presented. under the stress of physical recovery and psychological adjustment, even under the most optimum of circumstances, meeting the physical demands of an infant is stressful. in the absence of medical, familial and/or social support and information, a woman may understandably access her child or parent ego state to inform, problem solve, and manage stress. raising a child creates the potential for continuous stimulation of the parent and child ego state. parenting provides a daily opportunity to experience the memories of one’s own infancy and childhood as well as be reminded of parental influences (siegel & hartzell 2003). in particular, caring for an infant may offer the very first potent reminders of pre-symbolic, pre-verbal memories, often hidden or inaccessible from conscious memory, but held within the child and parent ego states and demonstrated through embedded, embodied and/or enacted stories and behavior (erskine, 2009). how a woman holds her baby, responds to her baby’s cries and demands, and approaches the daily challenges of motherhood, can yield a potent clues into not only what her own infancy may have been like, but how she herself was parented. an understanding of ego states and the potential for postpartum contamination helps women integrate international journal of integrative psychotherapy, vol. 1, no. 2, 2010 44 past fragments and introjected fixations, so they may fully encounter and care for their baby in the here and now. case example: leah leah came to therapy reporting intense anxiety and insomnia as a result of caring for her 4 month old son. although her early adjustment to motherhood had seemed uneventful, a recent change in his sleep schedule had thrown her into an unexplained tailspin. she found herself increasingly unable to leave her house, feeling guilty about doing anything other than caring for her baby and structuring her days around his needs. she described herself as a highly organized person who likes to keep a schedule, always on time for appointments and events, often just sitting in her house and watching the clock until it is time to leave. caring for a baby was challenging. as he was changing, so was the daily schedule. she could not anticipate when to go out and do errands, lest she miss his nap time or a feeding. if she stayed home and waited for him to wake up, she became restless, resentful and angry. she was in an increasingly uncomfortable bind of competing needs. an exploration of leah’s childhood revealed an agoraphobic mother who never learned to drive, and kept a strict schedule of household chores and events. grocery shopping always occurred on saturdays, dinner was always at 5 p.m., and no-one was allowed in the kitchen because things might get “messed up.” in addition, her mother’s anxiety led to extreme over-parenting. “if we were thirsty, she would jump up and get us a glass of water before we could do it ourselves. if we needed to cut something out for a craft project, she would take the scissors out of our hands and do it for us. she would do everything for us before we had an opportunity to do it for ourselves.” now a mother herself, leah knew that she needed to get out of the house and do things for herself and the baby, but could not figure out how to do so. she felt tired and resentful taking care of her son, lonely in her self-imposed isolation and guilty for having these feelings. she felt ridiculous for not being able to figure all this out, compelled to stick to the routine, yet angry at what was expected of her. leah’s postpartum story was a prime example of new motherhood stimulating memories of a little girl raised by an obsessive and frightened mother, as well as the introjected experience of that mother, while desperately trying to function in the here and now. her inability to modulate this archaic internal battle provided fertile ground for postpartum anxiety and stress. international journal of integrative psychotherapy, vol. 1, no. 2, 2010 45 conclusion a woman’s postpartum recovery enters the arena of psychotherapy because she has been in on-going therapy when she gives birth, has sought therapy soon after childbirth due to postpartum stress, or as part of on-going psychotherapeutic inquiry about her history, marriage and/or relationship with older children. every new mother desperately seeks to be more than just a “good enough mother.” whether in or out of their awareness, women enter parenting with the intention of being the best mother there ever could be. difficult or unexpected postpartum adjustment issues are often the first insult to this very understandable fantasy. healthy psychological postpartum adjustment depends on the ability of family, friends, professionals and the supporting environment to inquire, attune and become involved with the new mother as she reinvents herself into a parent. with the presence of a loving family and community, she can embrace the opportunity to remember, understand and heal old wounds, and avoid the transmission of relational failures to her new baby. every new mother needs and deserves sensitivity to her unique personal history and current relationships in order to fully understand her adjustment to motherhood. only in this way can we properly accompany women through one of the most important journeys of their lives, motherhood. carol merle-fishman, m.a., cmt, lcat, lmhc is a licensed mental health counselor and licensed creative arts therapist certified in clinical transactional analysis, integrative psychotherapy and music therapy. carol is in private practice in cortlandt manor, ny, where she works with individuals, groups and families. she is on the faculty of the institute for integrative psychotherapy in new york city, has served as a graduate adjunct clinical supervisor for the institute for music and consciousness at anna maria college in worcester, mass, and is a trainer/supervisor for the international integrative psychotherapy association. as the mother of two daughters ages 24 and 17, carol maintains a special interest in women’s issues throughout the life span. references berne, e. (1961).transactional analysis in psychotherapy: a systematic individual and social psychiatry. new york: grove press. berne, e. (1972).what do you say after you say hello? the psychology of human destiny. new york: grove press. bing, e. and coleman, l. (1997). laughter and tears: the emotional life of new mothers. new york: henry holt and co. black, k. (2004). mothering without a map. new york: penguin books. buchanan, a. j. (2003). mother shock: loving every (other) minute of it. california: seal press. international journal of integrative psychotherapy, vol. 1, no. 2, 2010 46 international journal of integrative psychotherapy, vol. 1, no. 2, 2010 47 cozolino, l. (2006). the neuroscience of human relationships. new york: norton press. davis, d. (1996). empty cradle, broken heart. colorado: fulcrum publishing. diagnostic and statistical manual of mental disorders. (1994). washington d.c. : american psychiatric association. erskine, r. (1980). script cure: behavioral, intrapsychic and physiological. transactional journal, 10, 102-106. republished in r.g. erskine, theories and methods of an integrative transactional analysis: a volume of selected articles (pp. 151-155). san francisco: t.a. press. erskine, r. & trautmann, r. (1996). methods of an integrative psychotherapy. transactional analysis journal, 26(4), 316 328. erskine, r, moursund, j., & trautmann, r. (1999). beyond empathy: a therapy of contact-in-relationship. philadelphia: brunner/mazel. erskine, r. (2007). life scripts: unconscious relational patterns and psychotherapeutic involvement. new york: institute for integrative psychotherapy. retrieved from www.integrativetherapy.com. erskine, r. (2009) life scripts and attachment patterns: theoretical integration and therapeutic involvement. new york: institute for integrative psychotherapy. retrieved from www.integrativetherapy.com. lamott, a. (1993). operating instructions. new york: ballantine books. maushart, s. (1999). the mask of motherhood. new york: penguin books. mendell, d., and turrini, p. (2003). t-he inner world of the mother. connecticut: psychosocial press. munk-olsen, t., laursen, t.m., pedersen, c.b., mors, o., & mortensen, p.b. (2006). new parents and mental disorders: a populationbased register study. journal of the american medical association, 296, 2582 2589. noriega, g. (2010). transgenerational scripts: the unknown knowledge. in r.g. erskine (ed.), life scripts: a transactional analysis of unconscious relational patterns. (pp. 269-290). london: karnac books,ltd. shields, b. (2005). down came the rain: my journey through postpartum depression. new york: christa incorporated. siegel, d. j. & hartzell, m. (2003). parenting from the inside out. new york: tarcher/penguin. simkin p. & klaus, p. (2004). when survivors give birth. seattle washington: classic day publishing. stern, d. (1985). the interpersonal world of the infant. new york: basic books. stern, d. (1990). diary of a baby. new york: basic books. date of publication: 30.12.2010 http://www.integrativetherapy.com/ post-script to part 3 of a case study trilogy marye o’reilly-knapp abstract: author comments on the case study ‘relational healing of early affectconfusion’, written by richard erskine and responses to his article written by maša žvelc, james allen, ray little and grover criswell. key words: integrative psychotherapy, supervision, case study. ________________________ in the last part of the case study trilogy, relational healing of early affectconfusion, richard erskine continues his description of an in-depth psychotherapy. using both historical and phenomenological inquiry, memories of early childhood relational experiences were formed. with both explicit and then implicit memories through the involvement in a supportive age regression, theresa was able to “make many associations and connections to her adult life behaviors and emotional reactions”. in the regression she was given an opportunity, this time in the presence of the therapist as witness, to remember and understand what she experienced in the past and how the past impacts on her present. inquiry heightened awareness of her feelings and cognitive understandings as well as her behaviors and body sensations. within the therapeutic relationship her relational needs were acknowledged, validated, and normalized. richard’s persistence with theresa’s rhythm, developmental level, and relational needs provided her with a secure relationship – far different from the disorganized attachment internalized by theresa in childhood. once again, the responders’ comprehensive comments and questions provided a richness to the dialogue. masa zvelc noted areas of relevance for her and gave concrete examples from the case study. challenges from james allen included: the importance of theresa taking on responsibility; questions as to how long therapy should last; deeming therapy “as a prelude to living, not a substitute for it”; and the thought of comparing the integrative psychotherapy approach with other theorists such as linehan, kernberg, and fonagy. ray little wondered international journal of integrative psychotherapy, vol. 4, no. 1, 2013   62 about the “multiplicity of motivations in theresa’s urgency to have a session before fall sessions were to begin. his descriptions of the transferencecountertransference matrix and his statement about “the power of the therapeutic relationship” reminded me of the privilege that is given to us as psychotherapist. in his comments, grover criswell summarized key concepts in psychodynamic psychotherapy. as i finished reading the trilogy i was reminded of my beginning years as a therapist. i had finished a two year master’s in psychiatric nursing program at the university where the focus was on psychoanalytic theory. i was fortunate back then in my last year in the program to have a preceptor who focused on psychodynamic interventions as he worked with psychotic people. it was a rich program in psychotherapeutic theory and technique and i wanted “more”. during my first year in practice, over thirty-five years ago, i was introduced to integrative psychotherapy. the “more” or missing piece for me was the emphasis richard erskine put on the therapeutic relationship. it was an easy transition for me since freud, rogers, and the behaviorists were considered “the foundation stones of integrative psychotherapy” with the organization based on “the ideas of berne, perls, and the developmental theorist”. (erskine & moursund, 1988, p. 41). erskine (1997) developed his ideas grounded in a humanistic based philosophy with a focus on a theory of motivation and attention to contact, a theory of personality which includes ego states, life script, and the intrapsychic process, and the methods of inquiry, attunement, and involvement. long before publication, in our professional development seminars at kent, connecticut, i was introduced to the theory and methods which provided me with a framework in working with my clients. i used integrative psychotherapy as the basis for assessment and interventions. i remember working with a woman who i would consider as “borderline”. she had been in and out of hospitals for bipolar disorder since she was a teen. she had been on lithium for several years before she saw me. in her second year she announced that she went off lithium, and although i was concerned, she did well. she continued her therapy with me for ten years and in that time celebrated 10 years of sobriety, got married, and had a baby. she left therapy to live her life and contacted me with a yearly christmas card. she called me again a decade after she had terminated therapy. she wanted to come back because she was diagnosed with terminal cancer of the breast. i worked with her about 8 months. i clearly remember the day she died. i had sessions with her in her home as she got weaker. i was to go to my seminar group that weekend and had arranged to have a session with her when i returned. something told me to stop and see her as i started out on my trip to kent. as i went to her bedside, judy opened her eyes, smiled, and reached for my hand. within minutes she died. although her life was short, she lived her final international journal of integrative psychotherapy, vol. 4, no. 1, 2013   63 years experiencing many moments of peace and joy. the use of erskine’s work in contact interruption and a focus on the therapeutic relationship was critical in judy discovering her story and remaining in therapy. not only did the concepts and constructs i used help her, they also helped me to stay connected with her and with my own internal experience. she taught me a lot about being present, not giving up on her, the struggles she had to stabilize herself, and as i am remembering her right now, her determination to live. today, i know i would have done some things differently. however, the basis of my interventions would not change. my interactions were founded on the theory and methods of integrative psychotherapy. one of the things that did change for me over the years has been a growing appreciation for the intricacy of the theory and methods. i continue to study, critique, and further the development of integrative psychotherapy. i have concern when someone has read a book or gone to a workshop and then believes he or she understands the theory – any theory. the richness of a theory and methods of psychotherapy is in its complexity. the effectiveness of the interventions and outcomes depends on an understanding of the intricacies of treatment. in conclusion, the theory and methods developed by richard erskine have persisted over four decades. the case study trilogy by richard erskine and the responses by james allen, grover e. criswell, ray little, and masa zvelc embody one of the criteria of both the international journal of the integrative psychotherapy association and the international integrative psychotherapy association (www.integrativeassociation.com) to provide exceptional works to the psychotherapy community. this particular case study trilogy has met this standard. it takes not only a lot of work to express ideas in writing, it also takes a willingness to share one’s self through the dialogue and to be willing to be open to others’ ideas. it is one thing to write an article; it is a whole different experience to have a discussion like the one that was done here. the process was deeply enriching for me due to description of a case and the interchanges that took place. my hope is that it has been so for you too. i leave you with this quote from a book i purchased on a recent visit to a museum in the us. i was surrounded by the works of cezanne, renoir, picasso, gauguin, van gogh, matisse, picasso, among others. this experience reminded me of my “visit” to theresa’s work with richard and the responses based on the case study. i have added the word ‘therapist’ in the citation below. a painter [therapist] is an artist … only if he is able to select from the work of his predecessors the forms which are adapted to his own designs, modifying international journal of integrative psychotherapy, vol. 4, no. 1, 2013   64 http://www.integrativeassociation.com/ international journal of integrative psychotherapy, vol. 4, no. 1, 2013   65 them as his individual needs require, and recombining them in a new form which represents his own unique vision. (barnes, 1990, p. 19). i see this case study trilogy like a painting. it is a portraiture of the theory and methods of integrative psychotherapy; richard erskine is the “artist”. author: marye o’reilly-knapp, rn, phd is a psychotherapist in private practice in nj. in june 2010 she retired from widener university school of nursing and was awarded emerita status. she continues to write and teach. marye is a teaching and supervisor faculty of the international integrative psychotherapy association references barnes, a.c. (1990). the art of painting. merion station, pa: the barnes foundation press. erskine, r.g. (1997). theories and methods of an integrative transactional analysis: a volume of selected articles. san francisco, ca: ta press. erskine, r.g. & moursund, j.p. (1988). integrative psychotherapy in action. newbury park, ca: sage publications. date of publication: 17.10.2013 41 international journal of integrative psychotherapy, vol. 12, 2021 internal criticism and shame, physical sensations, and affect: part 2 of a 5-part case study of the psychotherapy of the schizoid process richard g. erskine1 abstract this article details the unfolding of a relationally focused integrative psychotherapy in the treatment of relational withdrawal, self-criticism, introjected criticism, shame, and the disavowal of affect. keywords: lonely, loneliness, criticism, self-criticism, shame, relational withdrawal, schizoid, schizoid process, integrative psychotherapy, relational therapy, transference, case study it is a joy to be hidden and a disaster not to be found. — d. w. winnicott, 1965, the maturational processes and the facilitating environment during the summer recess, allan was periodically in my thoughts. i was not certain that he would return to the psychotherapy sessions we had scheduled for the beginning of september because i had often sensed that we had a tenuous interpersonal connection. allan was accustomed to doing things on his own. his quietness was illusive. he had occasionally commented about his internal criticism, and once in a while i heard a caustic remark about his coworkers or himself. i wondered about the extent of his criticisms, the history of his isolated attachment pattern, and the self-stabilizing functions of his relational withdrawal. i was pleased when allan returned. he was bustling with energy as he told me about his adventures in the arctic wilderness. i was touched by the little snippets of connection between us that were interspersed with the stories of his adventures. i still had a developmental image of allan as a lonely boy, hungry to be listened to 1 institute for integrative psychotherapy; deusto university international journal of integrative psychotherapy, vol. 12, 2021 42 and understood and at the same time deeply afraid of interpersonal contact (erskine, 2019, p. 14). in the midst of one of his stories, he made a tangential comment: “there were no women to look at.” i did not know what this meant, but i suspected that it was significant. it seemed important that i not comment on this remark while he was telling me lively stories about hiking and camping. when allan said, “there were no women to look at,” my first thought was, “of course there were no women to look at when camping alone in the wilderness.” i pondered what his words might mean. did i misperceive what he said? although i was a bit confused, i thought it wise to wait to raise the question until i sensed he was receptive to discussing it. among the important things that i learned from the writings of eric berne was to listen to every word the client says, particularly their parenthetical and tangential comments. it is in these utterances that the client reveals their unconscious organizing principles, which berne (1972) called script. i was confident that allan had inadvertently revealed something significant and made a note to investigate his comment once we had established a more trusting bond. during september, i continued to listen to allan’s stories about his camping adventures. i looked at his professional-quality photos of wild animals and waited for opportunities to inquire about his internal experiences. he seemed a bit more tolerant of my questions than he had been the previous winter and spring, but frequently there were long silent pauses or no answer. he remained reluctant to talk about his affect or family history. when i asked about possible sadness, fear, or shame, he seemed unable to relate it to himself. he understood the sensations of anger but said, “i do my best to purge my anger.” after a few sessions that seemed unproductive to me, i was frustrated with allan’s apparent lack of emotion and superficial conversation. i had been waiting for an authentic expression of his inner life. who was he under his social façade? what was the essence of allan? was his true self the man whose life was limited to work and hiking? was he hiding his vulnerability or some big secret? i discussed my confusion with a valued colleague who raised even more questions, and over the next several days i remained perplexed as i pondered them: • was allan actively avoiding letting me know about his inner process? if so, what was i doing wrong or failing to do? was i too focused on his accomplishing something in therapy? or would it be beneficial if i attended to the allan who learned to hide his vulnerability? 43 international journal of integrative psychotherapy, vol. 12, 2021 • was he so physically numb that he could not sense his affect? if so, it would be necessary for me to focus the therapy on his body and inchoate affect. was his noncommunication an expression of shame? • was he one of those children who had no one to help them identify internal sensations and provide a way to talk about subjective experience? if so, my task was to help him identify internal sensations and develop a vocabulary for talking about his affect. this approach included constructing a narrative about this life. i hypothesized that the direction i was looking for was embedded in the answers to these questions. it was clear to me that allan needed a good deal of security and sensitive guidance in order to become aware of his inner process. now it was necessary for me to address allan differently. i spent some time in each session bringing allan’s focus to the physical tensions in his body. i drew his attention to his tight chest and neck muscles and related the tensions to possible affect. at my initiation, we also spent a bit of time in each session taking about his “privacy.” he described how he had always been private, even in his earliest memories. i suspected that when he spoke of depression he was talking about the sensations of shame (erskine, 1994, 1995). he remained reluctant to talk about shame, but i returned to the topic for a few minutes in each session. he said that his depression (meaning shame) was “a great silencer.” i inquired about the nature of conversations he might have had with his mother when he was a young child. each time his immediate answer was “i don’t remember.” i pointed out that he knew his mother’s personality and that he could imagine the quality of their communication. in response, allan sarcastically said, “my mother knew nothing about me or my feelings.” in the next sessions, i tried to return to this topic, but allan responded, “i’ve said enough about her.” his reticence to talk about his relationship with his mother spoke louder than words. his pain and anger were palpable, even though he tried to keep them out of our conversation. i was willing to be patient, but i was also persistent in my focus on his feelings. i made a few inquires about his relationship with his mother in each session. a revealing dream two months into our second year, allan asked if we could talk about the following dream: “i am trying to get to the yukon. i rushed to the train station but the train to montreal was canceled. i kept looking for another train to take me to the wilderness, but none of the trains were running. i don’t want to stay in the city with annoying people.” i asked allan to tell the dream again, slowly, and add the international journal of integrative psychotherapy, vol. 12, 2021 44 following phrase to the end of each sentence: ”and this is my life.” as he retold the dream and added “this is my life,” we paused after each sentence for allan to sense the meaning of what he was saying. then i encouraged him to elaborate on each statement. with the first sentence of the dream he added, “i have no relationships. i am bothered, sad, and lonely, trying to go where there are no people to interfere with me. i am looking for quiet. … and this is my life.” he was then silent for several minutes. i watched the tension in his shoulders carefully even though he made no eye contact or acknowledgment that i was in the room. i remained observant and breathed deeply in order to remain present. i knew something important was happening within allan. after several minutes of silence, we continued exploring the meaning of the dream. his comment on the second sentence of the dream was, “i have no people in my life because i was just trying to survive, be safe, and wanting no one to bother me.” his voice became harsh: “relationships are a problem. i don’t need people. i get tired of people. and this is my life.” as he continued, he added, “something is missing in my life. i am empty. i don’t know what it is, but i can’t be with people.” i was amazed that he was telling me such a personally revealing dream. this is the first time he had spoken so pointedly about his internal experience. i asked him why he was telling me the dream that day. he said, “most of the time i don’t trust you, but today i wanted you to know my dream.” near the end of the session, i inquired about how he experienced me in that session. he said that he was relieved that i guided him to talk and added, “you didn’t make any interpretation. you allowed it to be my dream, my meaning.” i still did not have enough information about allan’s intrapsychic life to make a specific interpretation of his dream. yet, in asking allan to add “and this is my life,” i was making a subtle interpretation about how the dream represented the ways in which allan was living his life. i periodically use interpretation if i can sense the client’s developmental level of functioning and have an understanding of how they think and feel. if i do make an interpretation, it is usually about a child’s physical and relational needs and what quality of interpersonal contact may have been missing in the client’s significant relationships. often it is effective if i invite the client to decipher their own meaning. allan and i spent the next few weeks discussing the significance of the various elements in his dream, such as his yearning to be in the wilderness with “no one to interfere.” when i asked what he experienced when he said “no one to interfere,” allan had two memories of his mother “interrupting me when i was playing” and his older sister “bossing and controlling me.” i was elated because this was the first 45 international journal of integrative psychotherapy, vol. 12, 2021 time in a psychotherapy session that he had divulged an explicit childhood memory. in the next session i began by quoting allan’s statement that “i can’t be with people.” i asked him to explore what those words meant. i was again surprised when he offered a series of memories from when he was 9, 11, and 15 years old and wanted to be with friends. but he ended up disappointed and discouraged because they would tell him what to do. he said, “i hate people telling me what to do.” this was the first time since the previous spring that he provided an opening to talk about his anger. however, he said that he did not feel any anger and dismissed my inquiry with a scathing voice: “i just can’t be with people.” his selfcriticism was evident. i knew that we would soon have to address his self-critical comments because they were becoming more prominent in his conversations with me. i kept thinking about his statement the day we explored the meaning of his dream: “something is missing in my life.” i waited for some clue to investigate with allan what that meant and how it effected his life. i intuitively knew that the phrase was significant. i made a few inquires, but allan deflected my questions. i asked allan what he was feeling during his late night walks around the city. he had great difficulty describing his sensations, and i introduced the word “lonely.” at first he did not comprehend that there was such a feeling. he described it as “feeling empty.” in subsequent sessions, we used the words “empty” and “lonely” interchangeably to talk about what he was feeling during his nighttime excursions. i often thought that his lonely feelings might have been even more significant than what we were discussing. i made a note to come back to loneliness in future sessions. but for now, we were dealing with several entwined issues that had to be put to rest before we did any in-depth work on his unconscious pattern of isolated attachment. during this phase of the therapy, i periodically asked how allan perceived my behavior and my effect on him. he was usually slow to answer, as though he was struggling to comprehend something. for example, in one session he said that i was “kind” to him and that i did not “interfere” with what he was thinking. i asked him if my behavior was similar or different from his mother’s. with strain in his face he described the contrast between my “acceptance” of him and his mother’s “constant disapproval.” over the next few weeks i inquired more about his mother’s behavior, particularly his experience of her when he was young. he gave me little fragments of stories, and piece by piece the various stories began to form a picture of his mother dominating allan’s feelings and behavior. international journal of integrative psychotherapy, vol. 12, 2021 46 on some occasions when i inquired about allan’s mother’s behavior toward him, he gave his usual response: “i don’t remember.” i described how significant memories are stored in our body tissues and our emotional reactions and how unconscious relational expectations are formed in early childhood. whenever i talked about how people function, allan seemed captivated, like a little boy listening to an adult telling an exciting story. as we talked about ways of being in relationship, he said, “you don’t act like i expect. you’re interested in me.” i acknowledged his comment with a historical inquiry: “was anyone not respectful and not interested in you?” in the long silence that followed, i could see that he was struggling to answer. eventually he said, “she was unrelenting in her criticism.” then he looked away and was silent for the last few minutes of the session. although he said nothing, he looked sad. i wondered if he was trying to “purge” his anger. the flow of psychotherapy as i studied my notes to write this story of allan’s psychotherapy, i was aware that our therapy work progressed in a nonlinear way. i wish i could tell his story as a simple progression from one insight to the next, from one self-expression to the next, and how each phase of our work led directly to the resolution of another issue. but that is not the way it happened. rather, we recycled various issues several times. in writing this case study, i am organizing the story chronologically, but readers should keep in mind that what we was discussed in one session was often not mentioned again until much later. some of what i am reporting here may appear repetitive because, indeed, that is often how the rhythm and pattern of psychotherapy goes. usually, in each of allan’s sessions, we addressed a variety of topics, such as his walking the streets at night, hiking on the weekends, his internal criticisms, estrangement from his sister, his physiological reactions and feelings, and our relationship. early in our work i was quiet, attentively listening and acknowledging the significance of what allan was saying. as this second year progressed, i became more proactive and often made links to what we had discussed in previous sessions. i inquired much more about his phenomenological experience and his childhood. one of my therapeutic tasks was to gather and hold the diverse elements of allan’s story in order to help him construct a coherent narrative about his life. 47 international journal of integrative psychotherapy, vol. 12, 2021 self-criticism and shame during the next few sessions, i made several other inquires about allan’s mother’s disdainful attitudes toward him, how he coped with her criticisms, and how he perceived our interactions. by periodically focusing on the characteristics of our relationship, the juxtaposition of my behavior and his mother’s stimulated allan to recall several disheartening memories of how she had treated him (erskine, 2015, p. 17). over the next months, he had a number of additional memories of his mothers’s finding fault with him. often they were only fragments of a memory: an image, a body reaction, or the sense of repulsion that left him “feeling low down” and “empty.” these bits of memory provided an opportunity for me to engage further in both historical and phenomenological inquiry. we were slowly assembling various pieces of a puzzle about a little boy who learned to hide his loneliness and show the world that he was self-sufficient. our therapeutic dialogue now provided more openings for me to bring allan’s focus to his physiological reactions and what was happening in his muscles. we began to form a vocabulary to describe both the muscle tension in his back and some of his affects. in the first year and a half, he had been unable to talk about his feelings. now when he was occasionally feeling vulnerable, he made several attempts to verbalize his internal distress. my comments were aimed at increasing his awareness of physiological sensations and integrating his body reactions with his various affects. then the focus was on integrating his affect with understanding his motivations and behavior. this reflected a goal of integrative psychotherapy, which is the integration of the client’s physiology, affect, and cognition so that behavior is, by choice, in the current context and not activated by fear, compulsion, or conditioning. in some sessions, allan was now able to talk about being angry at his mother’s treatment of him. usually i encouraged him to look directly at me as he told me about his anger at her criticism and control. i wanted him to see my face and that i was taking his anger seriously. i also wanted him to see my sorrow about the way his mother had treated him. eventually, i asked him to close his eyes and talk to the image of the young woman who “criticized, manipulated, and controlled” him. at first, voicing his anger to an image of his mother was difficult, but after a couple of sessions he was able to vehemently express it. i pointed out how sad, even painfully lonely, it must be for a child to be constantly criticized. in one session, allan seemed amazed as i explained that it was emotionally confusing when a child was sad, angry, and scared at the same time, particularly if there is no adult to help them understand and express what they are feeling. he responded ironically, “my feelings did not matter to her.” i blurted out, international journal of integrative psychotherapy, vol. 12, 2021 48 “they matter to me !” he was quiet and his eyes were moist. in a soft voice he said, “thank you.” it was late november, time for the thanksgiving holiday, and allan had a week off from work. he went winter camping in the mountains. when he returned to therapy he surprised me by talking about how he missed me. i asked what he missed. he answered that i was “quiet, patient, not demanding like my mother. you never criticize me. i like coming here … some of the time.” i was amazed at what seemed like a transformative opening in our relationship. we went on to talk about other issues, and by the end of the session allan appeared to be withdrawn again. just as the session was finishing, i asked what he was thinking. he slowly answered, “i’m a fool for telling you. now you won’t want to work with me.” his selfcriticism had superseded all that we had talked about. i was reminded how people who use a schizoid process to manage their affect may feel a sense of attachment and affection with another person when they are physically distant but that they fearfully withdraw into hiding when in close proximity (galgut, 2010; yontef, 2001). after some sessions with allan, i reflected on the similarities between allan and harry heller, the schizoid protagonist in hermann hesse’s (1963) novel steppenwolf. hess artfully described the schizoid processes in his central character, who spends most of his time in an internal world of fantasized relationships while his actual life is devoid of interpersonal contact. guntrip (1968) referred to this as life half in relationship and half out—a stranger to intimate relationships except those that exist in the person’s mind. during these couple of months, i began to noticed a new pattern with allan. in the previous year, he had made several passing references to how he criticized himself after each therapy session. at that time i primarily listened rather than probed with questions. it seemed important that i observe his process and attend to resonating with allan’s affect or unarticulated relational needs. now some of our sessions began with allan describing how he chastised himself during the previous week. at first i assumed that he was replaying his mother’s criticisms, but i was surprised when he described the criticism as being his own voice. i wanted to know about the intensity and vehemence of his self-criticism. over the next few sessions, i encouraged him to let me hear what was happening inside him, even to shout the criticisms out loud. when he finally spoke, the forcefulness of his words was lethal: “i’m useless,” “i’m a weakling,” “no one’s interested in me.” my encouragement for allan to say the self-criticisms aloud was based on a fundamental gestalt therapy concept: intrapsychic conflict is diminished when it is externalized (baumgardner & perls, 1975; perls, 1973). i was certain that each criticism added to allan’s sense of feeling “low down” and “empty.” while 49 international journal of integrative psychotherapy, vol. 12, 2021 allan shouted his self-criticisms, i responded with empathy to the vulnerable part of him that was receiving the criticisms. i made sure that in each session i took some time to address these various selfcriticisms. it became clear to me that although allan wanted to talk to me each week, he was also disdainful of that wish. he rebuked himself for being “selfcentered” and for “talking about feelings.” he criticized himself and me for "talking about my mother and the past.” he was again retreating from contact with me. it took weeks of tentative inquiry and much encouragement for allan to tell me more of what was happening on the inside: “i’m a fool for going to therapy,” “i don’t have any needs,” and “i’m worthless.” eventually, i discovered that as he walked home from our sessions, he repeatedly told himself, “feelings waste mental energy.” we learned that he was most critical of himself when we had attended to his emotions or when i made reference to what children need from a sensitive parent. these brief moments of intimacy were discomforting for allan. he had no memory of anyone else being attentive to what he needed or felt. one day, as allan was leaving a session, he said, “when you are nice to me, the criticism begins.” as we addressed his internal criticism, it began to subside. allan was able to talk about his childhood, how his mother was “cold and rigid,” and that he sometimes felt “lost and low down.” when i periodically described what every child needs in a healthy child/parent relationship, he was astonished. in the next few sessions, he was vulnerable and described being sad about what was missing between him and his mother. i was feeling good about our work together because allan’s awareness of his body, affect, and anticipations seemed to be increasing. in each session, we were now talking about his continuing sense of shame and relating it to what he termed “turning inward.” with tears in his eyes, he described a deep sadness because he was not accepted by his mother and sister for “who i am.” he was afraid to express his uniqueness because “i know they will reject me.” we also talked about the necessity of hiding his anger “because they will overpower me with their nasty comments. mother was a controlling bitch.” he described how he would hide in his bedroom for several hours each day and watch nature shows on tv. he told me how he could hide even when he was at the breakfast or dinner table with his mother and sister: “it is simple. i just remain private, and they’re never curious about who i am. they tell me who they think i am and how i should be. but they don’t know the real me.” international journal of integrative psychotherapy, vol. 12, 2021 50 to trust or not to trust i was surprised when allan began a session by saying, “i know you criticize me when you go home. you’re nice to me in the office because i pay you. but you really don’t like who i am.” he was doubtful about staying in therapy. after listening to allan’s uncertainty for half an hour, i talked to him about how he had allowed himself to be vulnerable in my presence and how he had been sharing his emotional experiences with me. i suggested that sharing his internal processes may have disrupted how he had learned to manage his life and that terminating our psychotherapy sessions might restore an old perception of himself. although he did not immediately respond, allan seemed pensive. when the session ended, i assumed that my hypothesis had stimulated him to think about how he had been frightened of his increased awareness of his fear, sadness, and shame. early in the next session, allan said that when he was at home, he thought that he could trust me, but when he was walking to our sessions he was certain that i was not trustworthy, that i would eventually criticize him and he would have to quit the therapy. allan was actively transferring his emotional memories of his relationship with his mother into our relationship. i realized that it was his unconscious attempt to demonstrate his childhood relationship with his mother, the relational needs that were thwarted, and how he compensated for the damaging effects of his mother’s criticisms by imagining my potential criticisms (erskine, 1991). my task was to decode the unconscious childhood stories that were encoded in his transferential transactions, which were entrenched in his self-contained affect and embedded in his lack of relationships (erskine, 2009). this was a ripe opportunity for more inquiry about the internal effects of his mother’s criticisms and the various ways in which he could not rely on her. although some of the theme was the same, the details of his life kept unfolding. in the next session, i began by asking if allan had any memory of my criticizing him. he answered, “no. maybe you do it silently.” then, after several minutes, he said, “i’ll eventually hear some negative comment about me.” after a pause, “but you never do.” again we focused on the juxtaposition between my attitude and behavior toward him and what he had experienced with his mother. the contrast stimulated additional memories of his mother’s “despising behavior” toward him. now i was able to appreciate and modulate the responsive countertransference that had been engendered within me: i wanted to be a companion to him in the way that a 5to 7-year-old boy needs a father who listens, understands, and guides without any ridicule. 51 international journal of integrative psychotherapy, vol. 12, 2021 in one of the sessions during which he was imagining that i would reject him, i added my subjective experience by commenting, “i feel privileged to work with you. and your uncertainty about our relationships is central in the story of how you lived your early life.” after a pause in which we were both quiet, i added, “you needed security in your relationship with your mother and her criticisms interfered with that security.” his eyes teared up. he responded with, “my security was in my own room with my little tv. i watched the nature shows, over and over. they were my escape.” self-criticism: a distraction from criticism one day when he was paying for his therapy sessions, i was startled by his sarcasm directed toward me. when walking home, i recalled several occasions when allan had criticized his coworkers. his criticisms were often slight or parenthetical, but i now realized that his negative remarks were frequent. i was disappointed in myself because i had missed the significance of his various criticizing comments. but, unlike allan, i did not chastize myself. instead, i wondered what was happening within allan, what was unexpressed, and the functions of his criticisms of others. in looking over my notes for the first year of allan’s psychotherapy, i discovered that i had made only one notation regarding his derogatory comments about other people. i had presumed that his disparaging remarks were his attempt to express controlled anger. as i reflected on other snide comments that allan had made, i realized that i had disregarded my discomfort. clients’ sarcasm and ridicule usually put me on high alert because they may provide a momentary glimpse of the person’s internal organization. i was concerned: were his criticisms of people a projection and therefore a momentary relief from his own self-criticism? were the belittling comments an active expression of what he had introjected from his mother and sister? or did the criticisms he absorbed as a child activate his selfcriticism of others? i began our next session with a relational inquiry about how he experienced our interpersonal contact. a relational inquiry encompasses a series of questions about how the client perceives the psychotherapist and the quality of the mutual relationship, particularly what may be missing (erskine, 2021). relational inquiry is effective if the psychotherapist remains empathetic and is open to learning from the client’s perspective. at first allan did not recall his sarcastic comment. then he defended it as “normal” and said, “that’s just the way i talk.” i asked him to think about the effect his criticisms might have on both me and other people. he was international journal of integrative psychotherapy, vol. 12, 2021 52 pensive and then described how his mother’s remarks always left him feeling shame for being who he was. he realized that he was inflicting shame on others. we wondered together if this is how he avoided his own feelings of shame. it was evident that allan had a pattern of criticizing. in the following session i made an interpretation composed of three points: that he had been sarcastic with me, that he frequently criticized others, and that he criticized himself just like his mother had treated him. he immediately tried to apologize to me, but i suggested that there was something more important than an apology. what was most important was that he understood the functions of his criticism as the first step in changing what he had been doing. in that same session, i took the opportunity to talk to him about the concept of introjection and explained how children will unconsciously identify with the detrimental behavior of their parents as a way to not feel rejection, hurt, or shame. as a result, later in life they either treat themselves or others in the same way they were treated. allan grasped the concept quickly and told me some stories about how he acted with coworkers just as his mother had treated him. he was embarrassed by his behavior. i responded that i was more concerned about all the shame he had experienced over so many years because of his mother’s disdainful comments. in several sessions, i noticed that allan would sometimes hold his breath and then sigh. when i first asked about that pattern, he said, “it’s nothing, just the way i breathe.” however, i suspected that each sigh was a signal of some internal experience. i continued to inquire about his body sensations, and it became evident that each time he held his breath for a moment and then sighed that he had heard an internal criticism such as “you can’t do that” or “people don’t want you bothering them.” with several phenomenological inquiries, allan was able to tell me that it sounded just like his mother’s disapproving voice. we talked about how discouraging it was to constantly relive his mother’s criticism. i asked him to make those comments again and loudly, like he was talking to little allan. he repeatedly yelled his mother’s words, then he lowered his head and was silent for several minutes. when he again looked at me he had tears in his eyes. as our next session began, allan said that he had a profound insight. he was “not sure how it works,” but he was certain that his self-criticisms were his way of not remembering his mother’s criticisms. all week long he was able to remember his mother’s harsh tone. he said, “if i criticize myself, i don’t hear her.” he added, “now i realize that she ridiculed me all the time, even before i went to school.” we talked about how his self-criticism became more prevalent and vociferous than his mother’s and a distraction from the emotional pain of his mother’s words. his posture changed, and the tension in his face and shoulders relaxed as he cried. 53 international journal of integrative psychotherapy, vol. 12, 2021 we spent the next couple of sessions talking about his childhood and the effects of his mother’s criticisms and disapproval on him at each developmental age. he again cried about how he had “always tried to hide from her.” over the next few weeks, he reported that he “stoped criticizing myself” and added “i criticized myself to stop her from controlling me, but what i say to myself is much worse and more frequent. i feel a lot of what you call ‘shame.’ then i go to my private inner room.” i was curious about allan’s “private inner room” but i did not inquire. spring was in full bloom, and we had many loose ends of the work to deal with before the summer break. that spring we spent a good deal of time talking about allan’s shame and how shame was the result of both his internal criticism and the criticism he received in his family. back in september, when i had first used the word “shame,” he did not understand. later he realized that his feeling “low down” and “depressed” were the symptoms of shame. he said that when he was “low down” he had always known that “something is wrong with me.” he was now able to recall several incidents of his mother saying “what’s wrong with you, boy?” whenever he was playful or loud. he described how throughout his life he had held himself back in any situation in which someone might tell him he was wrong. he added, “i always go to my private inner room.” as he recalled these memories, he had an “empty feeling” in his belly and tension in his back. i had compassion for the loneliness of the boy who had such a mother. as we discussed his body sensations, he was able to talk about being sad for not being accepted for how he was and his fear of rejection if he said what he thought or felt. he talked about how he believed his mother and began to say to himself “something is wrong with me. i have to hide.” to protect himself from his mother’s ridicule, he spent most of his time in his room. i reminded allan that he had previously said that he “purged” himself of anger. we spent several sessions talking about how he worked to “keep silent,” “hide in my room,” and told himself “something’s wrong with me” every time he felt angry. “i refused to be angry like her. i purged my self of anger, but i was depressed instead.” allan was now actively telling me about his anger at his mother. on three occasions he grabbed a pillow and shook it with anger. he imagined it was his mother and that he was holding her by the neck. he shouted at her “nothing is wrong with me. i am a normal boy!” during those sessions, i encouraged him to physically express what he was feeling. i acknowledged his need to protest and validated the significance of both his anger and his sadness. it was again time for summer recess. he agreed to return to psychotherapy the first week of september. he was looking forward to two summer events: walking international journal of integrative psychotherapy, vol. 12, 2021 54 the appalachian trail with the hiking club he had recently joined and taking a month-long camping trip in the arctic. at the last session before the break, he expressed “a bit of worry” because last year he had felt “empty” when he was in the arctic. he did not want to feel that way again. i again translated allan’s word “empty” and offered the word “lonely” as a description of his visceral/affect experience. i knew we had more to discover when he returned in september. references berne, e. (1972). what do you say after you say hello? the psychology of human destiny. grove press. baumgardner, p., & perls, f. (1975). gifts from lake cowichan: legacy from fritz. science and behavior books. erskine, r. g. (1991). transference and transactions: critique from an intrapsychic and integrative perspective. transactional analysis journal, 21(2), 63–76. https://doi.org/10.1177/036215379102100202 erskine, r. g. (1994). shame and self-righteousness: transactional analysis perspectives and clinical interventions. transactional analysis journal, 24(2), 86–102. https://doi.org/10.1177/036215379402400204 erskine, r. g. (1995). a gestalt therapy approach to shame and selfrighteousness: theory and methods. british gestalt journal, 4(2), 107–117. erskine, r. g. (2009). life scripts and attachment patterns: theoretical integration and therapeutic involvement. transactional analysis journal, 39(3), 207–218. https://doi.org/10.1177/036215370903900304 erskine, r. g. (2015). relational patterns, therapeutic presence: concepts and practice of integrative psychotherapy. karnac books. erskine, r. g. (2019). child development in integrative psychotherapy: erik erikson’s first three stages. international journal of integrative psychotherapy, 10, 11–34. erskine, r. g. (2021). a healing relationship: commentary on therapeutic dialogues. phoenix publishing. galgut, d. (2010). in a strange room. mcclelland & stewart. 55 international journal of integrative psychotherapy, vol. 12, 2021 guntrip, h. (1968). schizoid phenomena, object-relations and the self. international universities press. hesse, h. (1963). steppenwolf. henry holt. perls, f. (1973). the gestalt approach: eye witness to therapy. science and behavior books. winnicott, d. w. (1965). the maturational processes and the facilitating environment: studies in the theory of emotional development. international universities press. yontef, g. (2001). psychotherapy of schizoid process. transactional analysis journal, 31(1), 7–23. https://doi.org/10.1177/036215370103100103 alcoholism is such a common condition that therapists must be exposed to clients who suffer from it, whether the therapist is phenomenological inquiry and self-functions in the transference-countertransference milieu richard g. erskine abstract: the article “balancing on the ‘borderline’ of early affect-confusion: part 2 of a case study trilogy” serves as the basis for this rejoinder and collegial discourse. the organizing-functions of reparation, stabilization, regulation, and enhancement are described and placed within the transferencecountertransference milieu. examples of bifurcating client’s questions to resolve transference are provided. key words: relational psychotherapy, transference-countertransference matrix, attunement, relational-needs, organizing-functions, phenomenological inquiry, self-functions. _______________________ response to ray little ray little begins his commentary on balancing on the “borderline” of early affect-confusion: part 2 of a case study trilogy by pointing out the importance of clear administrative contracts in managing the “boundaries” of psychotherapy. i offered to see theresa twice a week and the opportunity to talk on the phone “if necessary” for only 5 minutes and no longer. “if necessary” was defined as calling to extricate herself from an argument or “crying spell” and primarily to make an additional appointment for the following day. this strategy eliminated the late night phone calls. it provided protection from emotional escalations and offered a relational-stability that had been missing in her life. ray, you mentioned in this commentary, as you also did in part 1, that you would focus on the “present moment”, in the “transference-countertransference matrix, honoring the defenses”. you contrast this approach with how you imagine me as having a “focus on historical inquiry”. my focus with theresa was on the moment-by-moment dynamics between us and, simultaneously, her ever international journal of integrative psychotherapy, vol. 4, no. 1, 2013 19 emerging internal experience. working in the “present moment”, with full internal and interpersonal-contact, is pivotal in tailoring the therapy to the client and effecting lasting change. when we facilitate full contact, memories will emerge but these memories, or the painful reluctance to experiencing the memories, always occur in the “present moment”. we both seem to be stating that working in the here-and-now is indispensable. this is a central theme in beyond empathy: a therapy of contact-in-relationship (erskine, moursund, & trautmann, 1999). in re-reading my case study i can see how you may have arrived at the impression that i was primarily focused on historical inquiry when i said, “for many sessions she was reluctant (at times unable) to talk about her childhood”. although historical inquiry is a significant aspect of any effective psychotherapy, the majority of my inquiry in this second year of theresa’s treatment was phenomenological. perhaps i needed to emphasize that aspect more in my case presentation. if, for the purpose of illustration, i were to ascribe a ratio to the various forms of inquiry, the ratio would be approximately ten or fifteen phenomenological inquiries to one or two transferential/ historical inquiries, back to seven or eight phenomenological inquiries. then perhaps an inquiry or two about how she was experiencing our interpersonal relationship, another historical inquiry, more phenomenological inquiry, then two or three transferential/historical inquiries, and then one or two about how she coped, reacted physically, or what she concluded. perhaps we would then return to several phenomenological inquiries, then, if appropriate, another relational-inquiry, and the ratio would continue. these inquiries may also take us to inquiring about vulnerability and the client’s value of self. this is a constantly evolving co-creative progression. the process of staying in the “present moment” occurs when we re-circulate everything the client says (whether it be about feelings, expectations, transferential reactions, historical experience) back to phenomenological inquiry. interspersed with the many phenomenological inquiries about theresa’s affect, body sensations, fantasies, thoughts, associations, and how she made sense of her experiences, were inquiries about how she experienced our relationship. some examples include: “what is it like when i ask you about your feelings?”, “what do you experience inside when i look you in the eye?”, “how so you experience my quietness?” ray, i presume that these types of relational-inquiries are quite similar to what you might do. we use such relational-inquiries as we would use a delicate spice in cooking: in small portions to provide a subtle, penetrating flavor to the dish. if i understand your meaning of “honoring the defenses”, then i think i do what you are describing through acknowledgement and validation of the existence and importance of the client’s interruptions to contact (internal and interpersonal) and international journal of integrative psychotherapy, vol. 4, no. 1, 2013 20 the various habitual ways of resolving relational disruptions – the archaic struggles for self-reparation and self-stabilization. i would like to have heard both how you honor the client’s “defenses” and how you help them to dissolve those “defenses”. how do you conceptualize “defenses”, a psychoanalytic drive-theory concept, within the perspective of a relational psychotherapy? i wonder if the concept of “defenses” is incompatible with a developmental and relational understanding of human functioning. ray, you say that the “opening up of memories can be re-traumatizing, and make integration more difficult”. i believe that re-traumatization may occur when the psychotherapist takes a “stand opposite the client”. with an “opposite”, confrontative and, at times adversarial, stand the client is once again left alone in his or her re-living of overwhelming memories – there is an absence of an “us”. when we take a stand “alongside” the client we provide a new quality of a contactful relationship that strengthens internal security and allows for the traumatic memories to be integrated into a new sense of being and being-inrelationship. with clients as neglected and traumatized as theresa, my responsibility is to be an interested, involved, and caring psychotherapist who brings skills, commitment, and ethics to the therapeutic relationship. when i use terms such as “an alternative parent /object”, i tend to miss the significance of the reparative relationship that is so essential for the client’s healing from the wounds of cumulative neglect and trauma. it is important for me to remember that we are not merely an “alternative parent” or an “object”; we are real people involved in a healing process. that means being with and for our clients, respecting them, regarding them as valuable persons, supporting and celebrating them in their personal development, and loving them for who they are. i disagree when you say, “i believe i would need to be seen and experienced as a bad object to enable the client to work through her grief and separate from me”. grief is more fully resolved in the presence of someone who is empathetic, attuned, and patient. separation is much easier when there has been full interpersonal contact, a real sense of presence, and a celebration for what has been accomplished. if, in the separation, the client is experiencing the therapist as a “bad object” then something is amiss; either the therapist is out of contact with the client or the original relational disruption is not resolved. such negative transference is an unconscious call for help in resolving intrapsychic conflict and achieving intimacy. response to grover criswell grover, you raise some challenging questions in your commentary on part 2. the building of a constructive working alliance with theresa (i think this is international journal of integrative psychotherapy, vol. 4, no. 1, 2013 21 what you call “positive transference”) was a major accomplishment in the first seven months and so central to providing an effective psychotherapy for clients with early affect-confusion. in building an effective working alliance with theresa, i had two main focal points: security-in-relationship and affirming and valuing her. security-in-relationship requires more than verbal reassurance from the psychotherapist; it is in the client’s visceral experience of having her vulnerabilities respected and protected. respect and protection come primarily from sensing that the therapist understands (or at least tries to understand). i took the position that whatever theresa did had an important mental-organizing function or purpose, and, that the purpose was of value, worthy of my attention and our mutual exploration. the psychotherapist’s affirming and valuing the function of the client’s words, thoughts, feeling, and behaviors, without criticism or rejection, is central in accomplishing a constructive working alliance. i never provided theresa with a diagnosis but i did describe her affect experience and offered alternatives such as bringing her “troubled inner child” to therapy rather than crying helplessly or provoking conflicts with her coworkers and boyfriend. together, in the first seven months, we discovered that many of her conflicts were rooted in her early relational experiences. you say that she seemed “compliantly dependent”; i think that she was beginning to feel understood and respected. i have had many clinical experiences, as you no doubt had as well, where it is better to have a client temporarily depend on a caring and involved psychotherapist than being dependent on archaic coping patterns such as theresa’s engaging in conflicts at work, raging at her boyfriend, or collapsing into a sense of helplessness and long spells of crying. grover, i appreciate your comment: “my understanding of “interpretation” in psychotherapy is that the therapist gives explanations only when the client is on the verge of making that discovery or insight himself or herself. we want them to take existential ownership in the search for meaning. we are helping them take the next step rather than expecting them to leap in response to our expectations. this would seem to be an important part of attunement. otherwise, we may be experienced as giving them our version of the truth or to be imposing expectations of how they should view issues or be acting. this can place the client into the paradoxical dilemma of either being over compliant or defiant”. the avoidance of potential “insight robbery” is why i make extensive use of phenomenological inquiry and focus on working with the emerging experience between us rather than relying on interpretation. in responding to an inquiry the client is continually discovering previously unthought and unarticulated aspects of his or her own experience. in working with the emerging interpersonal experience we are co-discovering our mutual unconscious process. international journal of integrative psychotherapy, vol. 4, no. 1, 2013 22 you capture the essence of a relational and integrative psychotherapy when you say, “a key concept in the work is that of juxtaposition where the client is getting what she wants and needs but she is afraid to trust it. this was the springboard for much valuable work. while the work related to the mother’s criticalness was one level, simultaneously the therapist is relating with her in sensitivity and affirmation. her relational disturbances are being healed even as she has trouble trusting it. this is where i see the client moving from dependence toward interdependence, from affect confusion into self-acceptance”. grover, you end your commentary by wondering about the “five month break” in theresa’s psychotherapy. the summer recess was never longer than 12 weeks. after the initial seven months the client had no protest about the summer break because she had assumed that our therapy contract had come to an end. as our second year began we discussed my intended absence for the twelve weeks (she and her boyfriend were also going to be on an extended holiday) and she seemed comfortable. as the spring months approached the summer months theresa voiced her discomfort in my being away. she was worried about getting into conflicts again. we talked about what she had discovered in our therapy together and i assured her that she was “in charge of her own life” and that she had “choice” in how to behave. she now had the internal resources to engage with people in a new and different way. response to james allen jim, in your commentary you state, “we might speculate that by being a container for her troublesome projections, and an observing caring presence, erskine was a regulating process for her. by internalizing him, she contributed to her own self-regulating processes”. i think that an attuned, developmentally responsive, and involved parent provides a young child with several mental-organizing functions that are originally relational in nature: reparation, stabilization, regulation, and enhancement. over time, in the process of maturing and mastering developmental tasks, these mental-organizing functions gradually become autonomous self-directed functions. when there are cumulative relational disruptions in a child’s life, when relational-needs are continually not satisfied, and when there is unresolved trauma, the child’s sense of mental-organization becomes confused and disorganized and he or she prematurely learns to convert these relationalfunctions to self-functions. later in life the person may then rely on these prematurely learned archaic organizing forms of self-reparation, self-stabilization, self-regulation, and self-enhancement to habitually manage problem-solving, health maintenance, and relationships with people. a repeated reliance on archaically organized self-functions interrupts internal and external contact in the present moment and leads to a myriad of relational and behavioral difficulties. international journal of integrative psychotherapy, vol. 4, no. 1, 2013 23 i am constantly watching to see if my clients are using either contextually mature forms of mental-organization and/or significant relationships to repair, stabilize, regulate, or enhance their sense of self. or, are they relying on archaic forms of mental-organization? theresa’s helpless-crying and projections of abandonment are two examples of archaic attempts at self-reparation and self-stabilization. in an effective psychotherapy we create the quality of relationship wherein our clients can forgo using their archaic self-functions and temporarily transfer these organizing mental functions into the therapy relationship. i think this is what you are describing, jim, when you say, “by internalizing him, she contributed to her own self-regulating processes”. i wanted to engage theresa’s introjected mother in a serious psychotherapy similar to what i have described in other publications (erskine, 2003; erskine & trautmann, 2003; erskine & moursund, 2011; morusund & erskine, 2003). however, attending to theresa’s overwhelming sense of shame took precedence. theresa’s shame was the result of her mother’s constant criticism and ridicule that gave the injunction: “something is wrong with you”. it seemed essential that we resolve her fear of ridicule and abandonment, her immobilized self-expression, and her compliance with mother’s definition before i attempted any interventions with the introjected mother. i wanted to be sure that she felt secure in relationship with me and that she had a much more solid sense of mature self-regulation and self-definition before i addressed her introjected mother. response to masa žvelc maša, you point out what i consider to be an important component of working relationally with the client’s unconscious expression of affect-confusion when you highlighted the bifurcating of theresa’s direct questions. in an in-depth psychotherapy it is my responsibility to think beyond the apparent communication and have a broad-based perspective on the possible unconscious meanings in transactions and behaviors. with bifurcating theresa’s question, i focused on both her felt sense of being in relationship with me and her unconscious archaic experience that gave rise to the question, “what does it mean if i don’t believe your story about your mother hitting you, and what does it mean if i do believe you?” her answers to both parts of the question revealed her disavowed affect and script beliefs, “no one is there for me” and “no one understands me”. the bifurcated questions and her emotionally-laden answers expressed many implicit memories of neglect and relational deficits in her early childhood. this provided us the opportunities to explore how she coped, her body reactions, the conclusions she made, and the emotions she had in response to the ridicule, punishment, and emotional international journal of integrative psychotherapy, vol. 4, no. 1, 2013 24 abandonment. such work led us to explore the various ways in which she was still using archaic strategies of self-reparation and self-stabilization. maša, your sense that something was missing is an important asset in discovering what is not being talked about in the psychotherapy. you say, “i stopped a little and curiously explored my sense of missing… and questions started to emerge: “what else happened to her? is she avoiding something? what about her sexual experiences and development?” these are wonderful questions that represent your curious mind and capacity to discover the un-talked-about, an essential quality for doing in-depth psychotherapy. i too explored this theme with theresa through both circuitous and direct phenomenological and historical inquiries. there is no evidence of any childhood sexual abuse. she had a normal, but somewhat late, sexual development. there seemed no need to mention this in a case study that was already lengthy but i appreciate your raising such an important question. there is so much that i have not put into writing, such as several verbatim dialogues that would demonstrate our transaction-by-transaction interpersonal contact through which her unconscious experiences found verbal expression and meaning. you say that the case study had “no signs of uncovering and verbalizing transference-countertransference matrix.” prior to your writing this comment, your previous five paragraphs identified, detailed, and illustrated a relationalpsychotherapy that was a direct consequence of my careful attention to and use of transference and countertransference. this leaves me somewhat confused. i am always working within a transference-countertransference milieu; that is how i choose the nature of my phenonomological inquiries. for a more detailed example than what i provided in the written case of theresa, please see the article “integrating expressive methods in a relational-psychotherapy” (erskine, 2010). i would like to have heard more from you about how you would have uncovered and facilitated verbalization of the transference. central to my ethical commitment is a constant introspection: ‘what feelings, desires, history, or future dreams are being stirred within me? what are my own experiences as a parent and grandparent? what is the influence of all that i have read, films i have seen, and music that i know? what theories seem to be experience–centered rather than just speculation? how am i affected by other clients with whom i have worked?’ i judiciously use the answers to this private inner questioning, along with the client’s account, to form my series of inquiries. i have discovered that with constant phenomenological inquiry clients have much less need to enact childhood experiences. with inquiry we are constantly discovering the client’s inner process of affect, associations, implicit memory, past experiences, developmental needs that have been thwarted, and archaic organizing-functions that were formed to compensate for relational disruptions. international journal of integrative psychotherapy, vol. 4, no. 1, 2013 25 as i increasingly engaged theresa with phenomenological inquiry and attuned responses, she became less driven to enact unconscious interpersonal conflicts. i am constantly looking for the client’s expressions of unconscious processes and transferences, not only in the enacted behavior or transactions that may reveal expressions of early development, but also in their escalations or immunizations of emotions; in their physiology and body movement; in their stories and metaphors; in their fantasies, hopes and dreams; in both their internal and external interruptions to contact; and in the emotional and personal responses engendered in me. masa, your last long paragraph is intriguing and has stimulated soul-searching and memories of my many encounters with theresa. i think you may be reflecting a cultural difference and/or speculating from theory when you interpret the respectful phrase “it is my pleasure to be here for you” as inducing in the client the illusion “that he may be in love with her...this may be also mixed with sexual desires and fantasies”. nevertheless your confrontation is thoughtprovoking. in searching my own experience, i find that your comments do not reflect the quality of therapeutic relationship that i had with theresa. it was my intention to neutralize theresa’s experience of “no one is there for me”, and to convey to her that she is a person of value. seeing her on a sunday morning in an emergency session and saying those words was within the context of many months of theresa remembering her mother’s caustic comments and feeling worthless: “i’m unlovable”, “i’m a piece of shit”, “something’s wrong with me”. if there is any concern about a transference-countertransference merger it may well be that i, at times, felt like a protective father or good uncle to a neglected, ridiculed, and physically abused little girl. although i did not think it was pertinent to write about it in my case study, a couple of sessions later i asked theresa how she experienced my saying, “it is my pleasure to be here for you”. i inquired extensively about what she experienced inside when i greeted her with those words. in this session she was able to identify that her comment “you do it for the money” was because she was “feeling so scared and ashamed of needing anyone”. i made it a part of many sessions to inquire about how theresa perceived the intricacies of our relationship. this is the essence of a relational psychotherapy. a short conclusion this has been a thoughtful and exciting dialogue with each of you: ray, grover, jim, and maša. i wish we were face-to-face so i could feel your emotional reactions, share with you my thoughts and feelings, describe more detailed memories of my interactions with theresa, and hear much more from you about international journal of integrative psychotherapy, vol. 4, no. 1, 2013 26 international journal of integrative psychotherapy, vol. 4, no. 1, 2013 27 how you treat similar cases. i look forward to your reactions to part 3, relational healing of early affect-confusion. author: richard g. erskine, phd. is coauthor (with janet p. moursund and rebecca l. trautmann) of beyond empathy: a therapy of contact-in-relationship (1999, bruner/mazel: taylor & francis); a book that pioneered in articulating a relational perspective in psychotherapy. references erskine, r.g. (2003). introjection, psychic presence and parent ego states: considerations for psychotherapy. in c. sills & h. hargaden (eds.), ego states: key concepts in transactional analysis: contemporary views, (pp. 83-108) london: worth publishing. erskine, r.g. (2010). integrating expressive methods in a relationalpsychotherapy. international journal of integrative psychotherapy, 1, 55-80. erskine, r.g. & trautmann, r.l. (2003). resolving intrapsychic conflict: psychotherapy of parent ego states. in c. sills & h. hargaden (eds.), ego states: key concepts in transactional analysis, contemporary views, (pp. 109-134) london: worth publishing. moursund, j.p. & erskine, r.g. (2003). integrative psychotherapy: the art and science of relationship. pacific grove: brooks/cole-thomson learning. date of publication: 6.5.2013 alcoholism is such a common condition that therapists must be exposed to clients who suffer from it, whether the therapist is international journal of integrative psychotherapy, vol. 1, no. 1, 2010 41 relational needs of the therapist: countertransference, clinical work and supervision. benefits and disruptions in psychotherapy lindsay stewart abstract: relational needs are the emotional needs which underlie our social connectedness and help sustain and nurture our attachments to others. in doing psychotherapy, therapists must be attuned not only to the needs of the client, but also to their own relational needs. through self awareness and knowledge of healthy and appropriate boundaries, therapists can ensure the best interest of the client is kept foremost. in this article, the influence of the therapist’s own relational needs in the psychotherapy process is examined in terms of the possible benefits and disruptions to the client’s emotional growth. this is discussed in the context of the integrative psychotherapy model based on the core concepts of inquiry, involvement and attunement. clinical supervision is seen as an important part of working through counter-transference. ____________________________ the concept of relational needs has for some time been accepted as a useful clinical construct in guiding treatment interventions in psychotherapy (erskine, 1998). relational needs are different from the hierarchy of needs as defined by maslow (1970) which relate to survival and physical safety. relational needs emerge out of our social connectedness, and help sustain and nurture our emotional attachments to others (erskine, moursund, &trautmann, 1999). relational needs remain through the life cycle, although the intensity of certain needs may change as we mature. when these needs are not met, we experience psychological distress. if there is a chronic failure to get these needs met we are likely to experience disturbances in mood, thought, body and behavior – in other words, the type of symptoms that cause people to seek psychotherapy. the eight primary relational needs are: 1. need for security in relationship. 2.need to be validated and affirmed as significant. 3. need for acceptance by a international journal of integrative psychotherapy, vol. 1, no. 1, 2010 42 stable, dependable and protective other. 4. need for mutuality or confirmation of personal experience. 5. need for self definition. 6. need to make an impact on the other. 7. need to have the other person initiate. 8. need to express love. when we think of relational needs, most often we are considering the relational needs of our clients. that is how it should be if we are doing our jobs properly. however, we therapists are human and have the same relational needs as our clients. for most of us, there are times when our own relational needs do not get met, or when the urgency of unmet needs increases due to stress or losses in our personal life. all of us know of colleagues who have crossed boundaries and used clients to fulfill unmet relational needs. most of us will know of some blatant examples of this where the experience has been devastating for clients and they have been re-traumatized. again, their own needs have been missed by a trusted other and they feel used and betrayed. the experience is often devastating for the therapist as well, in terms of guilt, shame and loss of professional reputation. the examples of gross professional misconduct stand out for us and the boundary violation is really clear. there are many other ways for the therapist‟s relational needs to get tangled up in the therapeutic relationship through dynamics that are more subtle, less easy to label and often out of conscious awareness. as therapists, it is our responsibility to be aware of how our relational needs may be expressed overtly or covertly in the work with our clients. this is one reason it is important to do our own therapeutic work and get regular supervision throughout our careers so we have more awareness of how we may be using our clients to meet our own emotional needs. this is an aspect of countertransference that is often overlooked in supervision. it is inevitable that in a relationally focused therapy, our own needs will enter into the equation. in a therapy of inquiry, involvement and attunement, “involvement” requires that we bring our humanness to the therapy, and that includes our needs. in examining the ways in which our own needs might be met through the relationships with clients, i hope to convey this is not an issue that can be neatly divided into right or wrong. there will be a full spectrum of consequences to the client ranging from being powerfully affirming and validating to the client, to neutral, to a clearly destructive impact. being attuned to our own relational needs within the therapy relationship can also be diagnostic being aware of the ways clients try to meet our needs, or fail to be sensitive to our needs can tell us a lot about their history, the defensive systems in place, and how they relate to significant others in their lives. as with many aspects of doing psychotherapy, bringing the interface between our own needs and those of our clients into conscious awareness is the best strategy to avoid doing harm to our clients. at this point, i would like to note the distinction between current relational needs and archaic relational needs. current relational needs are those needs which can realistically and appropriately be met through our adult relationships. archaic needs relate to unmet relational needs from earlier developmental international journal of integrative psychotherapy, vol. 1, no. 1, 2010 43 stages. while it is possible to find relief from the symptoms of unmet archaic relational needs (e.g. profound feelings of emotional emptiness, confused sense of self, perceived powerlessness or crippling fears of abandonment) it is not possible as adults to fully meet those needs since the developmental window of opportunity has long since passed. we can respond to those needs by recognizing, empathizing, and validating them and helping our clients (or ourselves) finds ways to manage the pain and relinquish defenses which prevent current relational needs being met. we can also promote the emotional growth of our clients through many other different avenues, such as treating developmental fixations within the child ego state or mitigating the impact of destructive introjects. each of the eight relational needs will be discussed in terms of examples and implications of the therapists‟ needs being a dynamic part of the therapeutic relationship. need for security: having our physical and emotional vulnerabilities protected. (for a relationship to be secure, it must engender a sense of being protected and of safety to be open and vulnerable without ridicule or shame.) a situation where a therapist prolongs dependency of a client longer than necessary is one way a client might inappropriately be used to meet a current need such as financial security. if dependency is prolonged because the quality of the relationship with the client fulfills an archaic need of the therapist, then this would also be inappropriate and exploitive of the client. if a therapist brings his/her archaic needs for security into session, then there‟s a likelihood he/she will communicate in covert ways messages such as “i need to be taken care of”, or “i‟m overwhelmed by your needs.” for example, a therapist disclosed the presence of the sad and lonely little boy within himself to a client who then became obsessed with wanting to nurture and heal the therapist‟s wounded child. attempts by the therapist to redirect attention to the clients unmet childhood needs fueled an escalation of the client‟s obsession with the therapist‟s wounded child. the therapist was unable to resist the outpouring of nurturance and slipped deeper into his child ego state. the outcome was that therapy had to be terminated, and even after termination the client made calls and wrote letters attempting to heal and nurture the wounded therapist. in this example, the therapist thought that openly disclosing something about his unmet needs might fulfill the need of mutuality of experience for the client. because that wound was still very open and raw for the therapist it engendered an intense caretaking response from the client, which the child ego state of the therapist was unable to resist. on a personal level, i used to experience a sense of abandonment when clients terminated prematurely, cancelled sessions, or even came late for sessions. resolving my own abandonment issues and a pervasive script belief of “i‟m inadequate” has helped me be non reactive to perceptions of international journal of integrative psychotherapy, vol. 1, no. 1, 2010 44 abandonment, leaving me able to focus fully on the psychodynamics at play with the client. the therapist‟s experience of feeling abandonment or “i‟m not ok” in relation to clients seems to come up regularly in supervision. it is difficult to provide the secure base our clients need in order to let go and be vulnerable themselves if we aren‟t able to contain and then process our own insecurities away from the session. in other words, bringing our emotional fragility into session is not generally therapeutic. this doesn‟t mean that you can‟t be emotionally honest or vulnerable with clients but bringing our unmet archaic relational needs for security into the session can evoke a role reversal. in situations where a client is angry, threatening or overtly hostile towards us our sense of security is naturally affected. if we feel physically or emotionally unsafe, then our need for security is not being met. unless clear boundaries are established and the threat removed we are limited and compromised in our effectiveness. for example, a client once came and sat beside me and started rubbing my knee and suggesting sex. clear boundaries were established around this behavior in order for me to feel safe in continuing to work with this client, and for the client to feel secure that i would not replicate his previous sexual abuse. the incident also provided weeks of material to work with in therapy exploring the meaning of this „testing‟ behavior, eventually revealing his unconscious strategy to make me reject him and confirm his underlying script belief: “i will be abandoned”. need to be validated and affirmed as significant: confirmation that affect, fantasy and construction of meaning are significant. (this is the need to be appreciated, cared for and to be respected not only for what you can do, but for who you are. it is the need to be recognized and understood by others.) in an in-depth psychotherapy clients will project onto the therapist their unconscious transferential life story, therefore, it‟s not surprising that at times we might feel our clients don‟t see us, either in our therapeutic capacity or as real people. this can leave us as therapists feeling unappreciated or used which can become difficult to deal with when doing long term work. this is particularly true with those clients who, because of their characterological issues, may not have the capacity to have any empathy for us, or see us as anything other than a filling station for their need to be mirrored. if we are needing or expecting to be validated and the client fails to validate us, there is the risk of us being resentful and feeling wounded when it doesn‟t happen. if we are not conscious of our own process around this, there is the risk of retaliating in passive ways such as withdrawing emotionally. having a strong need for validation from our clients can stimulate caretaking from adaptive clients who try to meet our needs and thus win our affection or be special to us. if we have a blind spot in this area, we are reinforcing an old pattern of “other people‟s needs are more important than mine” for the client, perhaps missing the issues surrounding conditional acceptance international journal of integrative psychotherapy, vol. 1, no. 1, 2010 45 they have not yet dealt with. in addition, a strong need to be idealized may lead the therapist to set themselves up as “the expert” which can lead to misattunement to the client‟s rhythm, developmental level, cognitive style and affective processes. while being in the role of expert might fulfill the client‟s need for the presence of a powerful, protective other, leading to an idealizing transference, (erskine, moursund,&trautmann, 1999) it can work against the need for self definition. self definition demands careful introspection which can be hindered by the introjection of an idealized other. idealization of the therapist by the client is not uncommon and is an important dynamic to work through. if the therapist colludes with and reinforces being idealized to meet their own needs, the scope of therapy becomes limited and compromised. the therapist needs to keep in mind that idealization by the client is not about the therapist, but about the clients need for intrapsychic protection. in a similar vein, the need to feel validated can influence the therapist‟s response to gifts offered by clients. it can be important to graciously accept gifts from clients, within the guidelines of your professional body, from the perspective of the client‟s need to express love. however, a strong need to feel loved and appreciated may lead to the covert encouragement of gift giving to the therapist and the neglect of inquiry exploring the psychological significance of the gift. we can get powerful validation from our clients in many different ways. we see the changes people make in their lives; maybe they are less self loathing, maybe they are taking risks that were unthinkable before. some of the most powerful validation i‟ve received as a therapist has come from things clients have said. for example, a client once said to me “ of all the people in my life who might die, only my mother‟s death would affect me more than yours” which was a very sweet (and a bit sad), but was certainly a validation of the work we‟d done and met my need to make an impact. need for acceptance by a stable, dependable and protective other: encouragement, information and support that help create safety and protection from one’s own exaggerations, escalations, and intrapsychic conflicts. (this relates to the need to be able to look up to and rely on parents, teachers, elders, and mentors to gain protection, encouragement, and information from them.) if our archaic needs are brought into session we may indeed look to our client to provide acceptance and re-assurance. i am reminded of a therapist in training who was awed by a client who was powerful and healthy, and craved acceptance from the client. there was a sense for the therapist of wanting to bask in the aura of the client, which interfered with her ability to address and work with the narcissistic defenses the client presented. the therapist struggled with feeling inadequate and one down in comparison to the client. in a classic role reversal, the therapist craved acceptance from the client to soothe her own longings for an “ideal” other who was stable and dependable. this dynamic might be called an idealizing counter transference which could develop for the therapist while working with a client who is perceived to be one international journal of integrative psychotherapy, vol. 1, no. 1, 2010 46 up in terms power, status, talent, wealth or some other factor. these feelings need to be dealt with in the therapist‟s own supervision or therapy since they will interfere with effective attunement to the client‟s underlying vulnerabilities. there are certain circumstances where it might be therapeutic for the therapist to disclose feelings of idealization, in the form of admiration of a client. an example of this is when the therapist is responding to the client‟s need for validation and affirmation, or if the client has difficulty acknowledging and valuing their own areas of real competency and power. it might also be useful feedback for a client when they have little insight into the positive impact they have on others around them, or the positive impression they make. need for mutuality or confirmation of personal experience: (this is the need to be in the presence of someone who is similar to you – someone who understands because he or she has been there too. this person can understand your phenomenological experience without explanation.) sometimes we will have a client with whom we have an experience in common, perhaps who has an experience that nobody else in our life can relate to. there may be a parallel process as we treat someone who is going through something we are also struggling with. for example, one of my clients was dealing with her mother‟s failing health at the same time my own mother was in decline. just a few words now and then about my feelings of sadness, loss and helplessness regarding my own mother conveyed an understanding of what my client was going through and provided validation of her experience. in responding to any mutual experiences with a client, we need to stay attuned to what the client‟s relational needs are at that particular time. they may be at a point in their relationship with us when they don‟t want to know anything about our inner world. also, we can never assume that because a client has had a similar experience to us they will have had the same response to that experience. for example, as a gay therapist working with a gay client, i would never assume my client‟s internal experience of being a gay person in this world would overlap my own. i must patiently and conscientiously inquire again and again into my client‟s phenomenology in order to understand the world through his/her eyes. in a negative way, therapists may talk too much about their own personal experiences and unconsciously look to the client to satisfy their need for mutuality. the decision to reveal aspects of the therapist‟s feelings and experiences must be based on what the client‟s needs are in terms of knowing about those shared experiences. disclosing a little bit and observing the client‟s response will quickly help us gauge whether it is a therapeutic miss or an opportunity to strengthen the relationship. need for self-definition: acknowledgment and acceptance of one’s own uniqueness. (this need is in some ways the inverse of the need for mutuality. it relates to a need to have the other person recognize, accept and respect our uniqueness.) international journal of integrative psychotherapy, vol. 1, no. 1, 2010 47 clients teach us all the time about aspects of ourselves, of alternate values systems and of different ways of being in the world. in this way, they contribute to and enhance our developing sense of self. i know, personally, that listening to my client‟s stories over the years has helped me mature and develop a clearer sense of purpose and meaning in my life. i look at this as a byproduct of therapeutic involvement that benefits the therapist. one therapeutic outcome we hope for our clients is a stronger sense of self definition in their relationships. by this, i mean the client having better awareness of their own inner thoughts, feelings, hopes, fears, physical sensations and so on while relating to others. if the therapist has a strong sense of self in this way it can be a very positive force to bring into the therapy process. i see it as part of involvement – in order to share clear honest information when you process “i – thou” relationship issues, you need to know what your own thoughts, feelings and reactions are and be able to communicate them clearly. self definition in therapy for both therapist and client can be achieved through such things as therapeutic contracts, and an invitation by the therapist for the client to disagree with them. the therapist‟s clear sense of self is an important tool as we assist clients in dealing with their sometimes distorted views of us and the world, and helps us be clearer about our own boundaries and limits. role modeling can be a potent tool when clients see us able to connect easily with our own inner experience and share those experiences in a clear and responsible way. avoiding expressing self definition can lead to confluence in relationships with clients where we don‟t assert our differences from them (perls, hefferline, goodman, 951). asserting differences are important in transactions such as confronting a client‟s script bound belief system or self-destructive patterns of thinking or behaving. some other aspects of the therapists need for self definition which may hinder therapy include giving inappropriate or premature advice based on the therapist‟s world view, or being rigidly tied to a particular theoretical viewpoint or approach. similarly, a therapist‟s unconscious need to self define may cause them to be overly confronting or oppositional with clients leading to failures in empathic attunement. need to make an impact on the other: influencing and effecting a change. (this relates to the need to experience some potency in affecting or influencing another person in some way. that may be to influence their way of thinking, change a behavior, or to elicit an emotional reaction from the other.) we want to make an impact, and it feels good and is validating to us if we can make an impact. to need to make an impact can lead to therapeutic errors such as trying too hard and pushing our agenda, or trying to connect at a level of intimacy the client is not yet ready to tolerate. in other words, we may miss the current relational needs of our clients by becoming too focused on change rather than inquiring and connecting . international journal of integrative psychotherapy, vol. 1, no. 1, 2010 48 it is common for less experienced therapists to be discouraged and feel inadequate because a client seems stuck and not changing. this relates sometimes to unrealistic expectations of change, but can also relate to the therapist‟s need to make an impact not being met. it is important to have the capacity to tolerate the feeling that we are not having an impact (often for a very long time) and be okay with it, and accept the fact this relational need may never be met at all by some clients. clients may leave therapy without acknowledging or being aware of the impact we have had on them until much later. i am always touched, and often surprised, when someone contacts me several years after they have finished therapy and tells me how significant the work was to them. to have the other person initiate: (the need to have the other person reach out and initiate contact. any relationship where we always have to take the first step, always initiate, always be the one to approach will eventually become frustrating and dissatisfying.) if we are unable to initiate interpersonal contact, if we aren‟t able to take the risk to reach out and connect in a deep emotional way then we aren‟t ready to practice a relational therapy. it is important to be aware of the dynamics of initiating since sometimes it is clinically astute to wait until the client initiates reaching out to us. this is particularly important when the client needs the safety of having total control over how, when, and where they make contact and deepen the intimacy of their relationship with us. this is an area where clinical judgment comes into play in terms of when and how the therapist should initiate, and how much should be left to the client. if we need the client to initiate because of our own issues, whether that be fear of rejection, fear of intruding into the clients psyche, theoretical orientation or some other reason, our ability to work deeply with clients can be seriously limited the presence of the therapist‟s need to have the other initiate might be felt as a longing for the client to reach out to them, and a disappointment when they don‟t. for example, a colleague remarked on his longing for certain ex-clients or supervisees to stay in touch, perhaps just with a christmas card. on a personal level, when i return from vacation and a client doesn‟t ask “how are you?” or “how was your holiday?” i‟m aware of a mild disappointment. in saying this, i‟m not suggesting the client should initiate, just that therapists be mindful of their own need in this regard and not make it an expectation of clients or withdraw when it‟s not met. need to express love: (we all have the desire to express love and caring towards another, and to have this accepted and valued by the other. love may be expressed in many ways such as gratitude, giving affection, gift giving, doing something for the other). here is an opportunity to role model for clients how to appropriately express caring and the capacity to be loving. it is also an expression of our involvement and willingness to be impacted by our clients. international journal of integrative psychotherapy, vol. 1, no. 1, 2010 49 the therapist‟s expression of affection, caring or of being loving can be a potent validation and antidote to feelings of worthlessness and self loathing in clients. this can be a healing and corrective emotional experience for clients at a point in therapy where there is trust and potency invested in the therapist. timing, attunement and therapeutic judgment all come into play in expressing these sentiments. when your heart opens as you witness the vulnerability and despair of the hurt child in your client, showing this openly may be threatening or overwhelming – it may be premature if your client is not ready to receive it. the expression of caring needs to be titrated and delivered in a way that is fully attuned to the capacity of the client to receive and assimilate these feelings. in this way, expressing love is no different than any other form of self disclosure on the part of the therapist – attunement to the client‟s need is the first priority. the therapist might suppress expressing caring or affection for a variety of reasons such as fear it might be misinterpreted as seduction or an invitation to stay dependent. actions can speak louder than words sometimes, so expressing love through our dependability, presence and concern is often enough. for other clients, the caring and communicative hug at the end of a significant piece of work will be more meaningful. on the negative side, unmet needs to express love can lead to the therapist misinterpreting or reacting inappropriately to the client‟s transference feelings, possibly adding a romantic or erotic undertone to the relationship. these dynamics need to be addressed in the therapist‟s own supervision or therapy. conclusion: the issue of the therapist‟s relational needs being met through the psychotherapeutic process has not been widely addressed in the literature. we need to provide the information, permission and constructs necessary to support therapists in achieving full awareness of their own relational needs within the context of the therapeutic relationship. taking this issue “out of the closet” in individual or group supervision can be beneficial both in addressing feelings such as confusion and shame experienced by the therapist and gaining clarity on appropriate boundaries. this would be especially important for therapists with the script belief of “i don‟t need” where there may be significant denial of their relational needs being part of the intersubjective field with their client. sharing, in supervision or with our own therapist, the ways we get our relational needs met through our work with clients helps normalize the existence of this dynamic and support the positive aspects of it. transparency with colleagues creates the opportunity for feedback if the therapist‟s needs are being met inappropriately through their clients. this helps identify blind spots, confronts denial, and works towards protecting our clients from the potentially destructive aspects that can occur. if an error has been made it can usually be repaired if acknowledged, owned and worked through with the client, often strengthening the relationship in the process (guistolise,1997). international journal of integrative psychotherapy, vol. 1, no. 1, 2010 50 through heightened awareness of how we get our own relational needs met, we become more conscious and consistent in attuning to our own process. this enhances our clarity around appropriate boundaries and clarity in how we need to be with the client to create optimal conditions for their emotional growth. author: lindsay stewart is a registered clinical social worker in vancouver, canada. lindsay has been using the integrative psychotherapy model since 1986 and is a founding member of the iipa and a trainer/supervisor with the organization. lindsay sees individuals and couples in his practice in addition to doing process group work and clinical consultation. references erskine, r.g. (1998). therapeutic response to relational needs. international journal of psychotherapy, 3, (3), 234-244. erskine, r.g., moursund, j.p., & trautmann, r.l. (1999). beyond empathy: a therapy of contact in relationship. philadelphia: brunner/mazel guistolise, p. (1997). failures in the therapeutic relationship: inevitable and necessary? transactional analysis journal, 4, 282-288 maslow, a. (1970). motivation and personality. newyork: harper & row perls, f.s., hefferline, r.f., & goodman, p. (1951). gestalt therapy: excitement and growth in the human personality. new york: crown publishers. international journal of integrative psychotherapy, vol. 13, 2022 15 integrative trauma treatment: expanding the psychoanalytic frame gregory d. carson 1, lcsw, sep, peggy reubens 2, lcsw sandra shapiro 3, ph.d. abstract psychological trauma is a human condition that has been much addressed in psychoanalytic theory and clinical practice both historically and contemporaneously. our purpose in discussing extra-analytic ideas and techniques and presenting clinical examples of their use is to introduce recently developed efficient and effective ways to resolve traumatic experiences that can be readily incorporated into psychoanalytic/psychodynamic practice. eye movement desensitization and reprocessing (emdr) and somatic experiencing (se) are the two primary modalities described in the two integrative trauma treatment cases presented. both of these modalities utilize focused points of entry into implicit memories and self-states and both offer a significant expansion in clinical effectiveness to the authors’ shared relational psychoanalytic orientation. the cases, which include process notes, illustrate two different ways of moving patients along a trajectory to trauma resolution and post-traumatic growth. accepted in publication: the final version of the article will be published soon ______________________________ 1 the national institute of the psychotherapies, clinical affiliate program faculty, the national institute of the psychotherapies 2 integrative trauma program, the national institute of the psychotherapies faculty, integrative trauma program, the national institute of the psychotherapies 3 integrative trauma program, the national institute of the psychotherapies associate professor emeritus, psychology department, queens college, cuny international journal of integrative psychotherapy, vol. 13, 2022 16 the case for extra-analytic techniques psychoanalysts from many schools have published accounts of successful resolution of traumatic experiences beginning with janet and freud on through to today. e.g., boulanger, 2007, howell, 2005, krystal, 1968, and stolorow, 2007, to name but a few. why then do we see an advantage to integrating extra-analytic techniques into clinical practice? there are at least four reasons for doing so. one) traumatized people may be incapable of verbalizing their experience. this may be because they are dissociated, because trauma occurred before they had language, because language and narrative areas of the brain were rendered dysfunctional by cortisol released under stress, and/or because traumatic memories were encoded into somatic, motoric, or imagistic form (van der kolk, 2014). since psychoanalysis privileges verbal communication, extra-analytic approaches may be preferable or required in these cases. two) integrative treatment assumes, as does psychoanalysis, that the past informs the present. in psychotherapy, and particularly when using emdr or se, earlier memories may emerge quite dramatically and with intense emotional arousal. this evocation may exceed the analyst’s capacity to regulate affect through relational presence and the treatment frame and may result in destabilization, dissociation, or even retraumatization. specific affect regulation techniques are often employed to prevent these unwanted effects. a deepening of resourcing may also provide for a more thorough reprocessing of traumatic material (lepak & carson, 2021). three) the patient’s traumatic experience may remain inaccessible because it either doesn’t show up in discourse or become enacted in the transference. extra analytic technique can help to identify such aspects of implicitly-held traumatic memory and bring them forward. four) extra-analytic techniques accelerate the process of trauma resolution. learning to utilize them, or refer out to clinicians who do, therefore, becomes an ethical consideration. considerations when working with trauma traumatized individuals have unique clinical requirements. those of us working with this population need to recognize and address the following five features. psychoeducation the use of psychoeducation, usually at the outset of treatment, helps the traumatized patient to understand the nervous system’s unique and specific response to trauma. we frame ptsd symptoms as adaptive strategies in response to threats to survival, whether they are physical, emotional, or related to attachment. as people come to realize that their responses are understandable, common, and biologically-based, they are usually profoundly relieved; they are not “crazy,” and there is nothing inherently wrong with them. they are also reminded that they did indeed survive and that the therapy will help them to return to their pre-traumatic baseline. this international journal of integrative psychotherapy, vol. 13, 2022 17 reframing is an often important first step towards greater affect regulation, a reduction of shame, and the establishment of a therapeutic alliance. dissociation dissociation, the hallmark adaptation to traumatic experience, is understood in two different ways: first related to arousal level and second to structural changes in personality. in the first usage, dissociation refers to an extreme physiological state which occurs during the traumatic event or while recalling the memory. for traumatized individuals, it is often a chronic state of daily life. patients may be hyper-aroused (anxious, agitated, or frantic), or may be hypoaroused (disconnected, numb, or shut down). the traumatized person may also experience dissociation as either depersonalization or derealization. while in these states, either they or the world do not feel entirely real, respectively. the second use of the term refers to structural dissociation (van der hart, et al., 2006). this occurs when the traumatic event is so disturbing that the nervous system’s defense is to compartmentalize. this may include memory gaps, dissociated elements of traumatic experience, isolated self-states, or more serious splits in the structure of personality, as in dissociative identity disorder (did). dissociated elements may include sensations, images, behaviors, affects, or meanings, which we conveniently refer to by the acronym sibam (levine, 2008, 2010). any of these may reappear decontextualized as flashbacks, intrusive thoughts, wordless images, sensations, or movements. which form of dissociation we refer to will be evident from its context. catastrophic isolation catastrophic aloneness and helplessness are inevitable components of traumatic experience, even if others were physically present (herman, 1992, van der kolk, 2014). integrative trauma treatment and psychoanalysis share a relational focus which counters this. witnessing the patient’s traumatic narrative with empathic attunement disconfirms their expectations of continued aloneness and otherness. when the patient has suffered abuse or neglect at the hands of an attachment figure, these forms of relational contact are particularly vital. in cases of attachment trauma, relational repair may need to be addressed before focusing on specific traumatic experience. where there have been overwhelming attacks on one’s sense of identity and safety, particularly when the source of trauma was an attachment figure, a sense of a reliable, trusted other needs to be restored or even developed for the first time. specific extraanalytic techniques designed for this purpose may also prove useful, e.g., dyadic resourcing (manfield, 2010), developmental needs meeting strategy (schmidt, 2004). in addition, trauma-oriented group therapy can significantly augment individual treatment by developing the patient’s sense of societal and familial/cohort belonging in ways that one-on-one individual psychotherapy, with a more parental transference, may not (carson, 2020). as a unique therapeutic modality, group treatment provides myriad opportunities to disconfirm relational international journal of integrative psychotherapy, vol. 13, 2022 18 expectations about self and other that traumatized patients hold, in particular, as regards their sense of aloneness, relational safety, and belonging beyond dyadic interactions and relationships (carson, 2020; erskine, 2009; herman, 1992). resourcing resourcing is the technique of invoking the patient’s own capacities, positive memories, and associations in order to develop the resiliency needed to facilitate memory reconsolidation. resourcing may be used during the preparatory phase before reprocessing or at various times during processing to enhance clinical effectiveness. physiological and affective dysregulation affective dysregulation refers to both hyper-arousal or hypo-arousal. states of hyper-arousal often lead to impulses to fight or flee whereas hypo-arousal often leads to freeze or collapse responses. in cases of ongoing relational trauma, collapse may take the form of an impulse to submit and attach, often with a pathological attachment to the traumatizing figure (shaw, 2014). the optimal range of affective arousal, i.e., the window of tolerance (siegel, 1999) is one in which the patient is neither hyper-aroused nor hypo-aroused and is sufficiently alert to be both readily grounded in the present and able to access the past. by helping patients to remain within their window of tolerance, the therapist can facilitate the patient’s processing of traumatic memory without their becoming unduly affectively dysregulated or potentially retraumatized. any need for upregulating or downregulating the patient’s arousal level is addressed prior to trauma processing, using various guided suggestions of imagery, postural adjustments, or movements to either calm or enliven. additionally, we gauge the patient’s present-orientation throughout treatment, continuing to employ these techniques as needed. it is worth noting that successful trauma treatment often strengthens a patient’s affect tolerance thereby expanding their overall window of tolerance. as a result, the patient can both experience and tolerate a greater range of emotional arousal, both negative and positive, which greatly benefits the quality of their lives outside of the treatment setting. accessing traumatic experience in order to determine the best point of entry into a particular patient’s traumatic memory network, we first explore and assess the dimensions of the patient’s experience using the sibam outline referenced above (levine, 2010). our goal is to determine which elements hold the most salience and/or valence to serve as a nodal point which other dissociated elements of experience will be reconnected to through exploration. emdr and se differ in their approach to this assessment. somatic experiencing, utilized in the case of carol, finds the entry point into traumatic memory by guiding the patient into their felt sense experience (gendlin, 1964). the therapist actively tracks physiological responses, and, in doing so, helps the client to discover, reintegrate, and process, hitherto dissociated dimensions of traumatic experience. if the client is hyper-activated, the international journal of integrative psychotherapy, vol. 13, 2022 19 therapist may intentionally separate over-associated dimensions of experience to allow for effective processing within the patient’s window of tolerance. in the emdr protocol, utilized in the case of mary, the patient and therapist select an aversive memory that best captures the patient’s chosen issue (a traumatic event, phobia, negative belief about oneself, etc.). the patient is then asked to go back to the remembered scene (image) and identify and/or rate other elements of sibam according to the emdr protocol. m (meaning) is accessed by formulating the subjective negative belief about oneself (nc) and the world in the present tense when the remembered image is brought to mind, e.g., “i am unsafe”. asked what they would like to believe instead, the patient provides a pc or desired positive belief (also a dimension of meaning) and a rating from 1-7, e.g., “i am safe now.” the patient then identifies the emotion (affect) and bodily experience (sensation and behavior) that arises when accessing the memory, and also rates the overall disturbance of the memory from 0-10. bilateral sensory stimulation (bls) is next introduced. this may include guided alternating side-to-side stimulation via eye movements, beeps in headphones, hand taps, etc. bls activates explicit and implicit components of the memory network as well as associated networks that contain positive memories and beliefs. during the pause between bls sets, the patient is asked to relate their preceding experience, and the therapist can gauge progress and monitor arousal level. often, these sets will advance the patient’s own trajectory towards trauma resolution. other times, judicious interventions are required. a full description of the protocols, processes, and underlying adaptive information processing model (aip) can be found in shapiro (2018). introducing extra-analytic techniques trust and confidence in the therapeutic relationship supports the patient’s willingness to try a new approach. this often involves a significant change in discourse and sometimes includes changes to the physical arrangement of therapist and patient in the room. the therapist becomes more directive in instructing the patient what to do than in psychoanalysis. at the same time, the therapist remains receptive to the patient’s experience of as well as to any negative reactions to the new technique. this may include feelings about the modality or negative reactions to the therapist in this new role. every step forward is necessarily collaborative and the patient is never coerced into working in a new way. when patients are ready to proceed, the active choice and collaborative engagement in these new techniques can itself begin to counter the sense of powerlessness and helplessness that is embedded in traumatic experience. it is important to note that the trauma therapist needs to be alert to the possibility of command compliance as a potential habituated relational defense on the part of the patient (cole and eldredge, 2008). bringing this very common survival strategy for traumatized individuals into the light of treatment can often offer a rich vein of exploration in its own right. international journal of integrative psychotherapy, vol. 13, 2022 20 transference/counter-transference considerations when we have isolated a specific symptom or issue and are preparing to use an extra-analytic technique, we address transference and countertransference issues only when they appear to be impediments to processing the traumatic issue. in the two cases that follow, transference and countertransference responses were mutually generally positive and facilitating. had it been otherwise, there would be two options. first, we could address the issues within our primary relational therapeutic modality, or we might also invite the patient to explore their transference using the extra-analytic modality. it is important here that we take great care to determine whether the patient is able to engage their observing capacity or whether we need to take a more experience-near approach (kohut, 1977) so that the primary focus becomes the patient’s feeling blamed for their reactions. in this way we can avoid the pitfall of unwittingly facilitating relational re-traumatization. memory reconsolidation once the patient is sufficiently stabilized, resourced, and comfortable enough to try a new modality, we enter the heart of the work. our goal is to facilitate memory reconsolidation. this refers to the process in which the traumatic experience or symptom-producing learning is elicited, transformed, and then returned to memory in an updated form. this process is distinct from memory extinction in that the old learning is not merely subordinate to the new learning but actually replaces it on a neurobiological level rendering the patient with symptom cessation that remains stable and enduring over time (ecker, 2012). it is important to note here that the resolution of transference, intimated in the preceding paragraph, also carries out memory reconsolidation and is a, if not the, fundamental strength of relational psychoanalysis. we understand symptoms to be expressions of originally adaptive emotional learnings that are at odds with current phenomenological reality (carson, 2020). these emotional learnings are usually unconscious and non-verbal and are often referred to as schemas, implicit knowledge, or implicit relational learnings (lyons-ruth, 1998). to the person, these feel emotionally true and operate like facts: about the way things are, the way the person is, other people are, or the world is. when learned in the context of abuse, neglect, misinformation, or a lack relevant information, they become harmful. patients then misperceive what present day stimuli actually signifies. for example, they may fear that intimacy is life-threatening, or that expressing their feelings means that they will be retaliated against, etc. the process of memory reconsolidation (mr) begins by reactivating the implicit traumatic memory or implicitly-held learnings about oneself, others, and the world (ecker, 2012, schiller et al, 2010). this needs to occur within a vividly-felt emotional context. at the same time, an experience or learning that strongly varies from or directly opposes these beliefs is simultaneously accessed and brought into conscious awareness. (ecker, b., 2010). simply stated, the heart of mr is the experiential disconfirmation of learned expectations, and as a result of successful mr, international journal of integrative psychotherapy, vol. 13, 2022 21 there is a permanent reorganization to the way that the patient engages with situations and responds to stimuli. it is important to note that mr does not erase episodic memory. for instance, a patient may remember that she was sexually abused as a child, and even recall that she once had nightmares and was terrified of men. however, she no longer has bodily activation in sexual situations and no longer believes the trauma-induced prediction that all men are dangerous. equally important, she is no longer filled with shame stemming from the belief that she was somehow responsible for what happened. barring another sexual assault, her symptoms (sensory, semantic, and procedural memories of the events) are erased and/or revised, even though the factual narrative memory of the events are not. we assume that all higher order memory changes in neurologically normal individuals involves mr although the precise turning point for mr may or may not be directly identified/observed in session. for a more in-depth discussion of mr and how it may appear across various modalities, please see ecker (2012). additional extra-analytic modalities we are aligned with erskine’s view that integrative psychotherapy brings together elements of sibam within our patients' lived experiences (erskine, 1996). the domain of our paper, however, is limited to consideration of those integrative approaches which have been particularly formulated for trauma treatment, carry out mr, and integrate well with a relational orientation. in addition to somatic experiencing (levine, 2010) and eye movement desensitization and reprocessing, (shapiro, 2018), these include sensorimotor psychotherapy (ogden et al., 2006), internal family systems (schwartz, 1995), accelerated experiential dynamic psychotherapy (fosha, 2000) coherence therapy (ecker & hulley, 1996), and presence psychotherapy (lepak & carson, 2021). while a further discussion of these modalities is beyond the scope of this paper, familiarity with several of them is desirable in order to better match one’s therapeutic approach with each patient’s way of organizing and expressing their traumatic experience. the clinical presentations that follow demonstrate how various therapeutic modalities can be used not only to achieve mr but also to restore and enhance each patient’s sense of self. the case of carol (psychotherapist: greg carson) carol, a caucasian heterosexual woman in her mid 40’s, reported an uncanny feeling as though someone was going to hit her from behind with a 2x4. however, whenever she turned around, nobody was there. this repeated experience, which occurred primarily in the stairwells at work, confounded her and was causing her mounting anxiety. it seemed that her problem could be best understood as the result of an interruption to her natural defensive orienting response and that somatic experiencing would most effectively address her symptoms. carol presented as intelligent, courteous, punctual, and engaged. she was in a good marriage, related well to her adolescent daughter, enjoyed her full-time career, and had a robust and international journal of integrative psychotherapy, vol. 13, 2022 22 satisfying social life. she also reported a regular meditation practice. this led me to believe that she would be able to tolerate the emotional intensity of trauma reprocessing after some initial work was done to diminish her chronic anxiety. inasmuch as carol was initially overly solicitous toward me, i kept in mind that she might have an anxious/preoccupied attachment style. if this proved to be an impediment to trauma processing, we would have addressed this issue first. if not, we might address her interpersonal style after the trauma work, depending on her goals for therapy. carol’s transference and my countertransference remained positive and facilitative during her year-long treatment. carol’s initial idealization of her early family life soon yielded to a more distressing narrative. her sunny picture of being her mother’s confidante gave way to underlying feelings of resentment from believing that she needed to be her mother’s caretaker. her initial description of her father as a handsome, hardworking athlete and a successful physician transformed into a picture of a moody, agitated, self-involved, and socially awkward man who drank too much. carol felt that she constantly worried about both of her parents but that no one seemed to worry about her. this manifested in the present with a preoccupation of imagining bad things happening to those that she loved. carol had been in a prior talk therapy in which her therapist had diagnosed ptsd stemming from a serious car accident, but this trauma had not been addressed. during college, while in a car with friends, one of whom was driving, she had impulsively grabbed the steering wheel when she imagined that another car was heading towards them. the car flipped, which resulted in serious injuries to herself and others. afterwards, she was required to wear a halo brace and undergo neck surgery. i considered this experience a likely contributor to her fear that she would be attacked from behind. additionally, the disastrous consequence of her mistakenly grabbing the steering wheel resulted in a deep mistrust of her own judgment which thereafter contributed significantly to her anxiety. my attempts to attune to the nature of carol’s experience guided my choice of modalities. in this paper, i will focus on my use of somatic experiencing; however, i also incorporated systems centered therapy (sct), coherence therapy (ct), and internal family systems (ifs). these will be briefly described and referenced in the bibliography. to bind carol’s anxiety, i employed techniques from systems centered therapy (ladden et al., 2006). because much of her anxiety stemmed from negative predictions of the future, i helped her to develop a here & now orientation, and to be curious about whatever might happen next. i then normalized carol’s fear of attack from behind, employing psycho-education to teach carol how the body responds to traumatic events, and i used somatic experiencing to build her capacity for observing her felt-sense experience. in sum, these methods helped carol to come into the present moment, calm her nervous system, and help her remain present and within her window of tolerance when her somatic experiencing entered the territory in which her threat responses would be re-evoked. international journal of integrative psychotherapy, vol. 13, 2022 23 a brief word about somatic experiencing. se conceptualizes trauma as the result of disruptions to one’s automatic sequence of defensive orienting to threat (levine, 2010). in cases of posttraumatic stress disorder, the sequence hasn’t been completed successfully, e.g. the person is overpowered, rendered helpless, or flight from the relationship or situation is impossible. se intervenes at the point at which the impasse(s) occurred, allowing for the natural release and completion of thwarted defensive responses via sensory tracking, and use of imaginary or symbolic motor actions. i began by inviting carol to attend to her sense of threat from behind by guiding her to explore the space 360˚ around her. i was looking for unprocessed memories of rupture to her peripersonal space either from the car accident, her subsequent neck surgery, or from something else that both carol and i might not yet be aware of. the body will often reveal what cannot be accessed through words. i guided carol to look for changes in tension, sensations, emotion, images, meaning, etc. while i looked for changes in her posture, the bracing or relaxing of musculature, or changes in facial expressions that indicated her having located something. i also attended to my somatic countertransference, for the possibility of resonances that might suggest what carol was experiencing. throughout, my main task was to keep her within her window of tolerance so that she could effectively reprocess whatever she encountered. as session time wound down, i gently reoriented her back to the here and now. somatic experiencing requires that the therapist refrain from sharing interpretations or hypothesized narratives and rather to trust that tracking nonverbal experiences will lead to both trauma resolution, and very often, the reformulation of relevant narratives. in carol’s case, i assumed that a “clamping down sensation” she reported in her neck was likely connected to her car accident and/or surgery. interestingly, this proved incorrect. what emerged instead was a physical representation of holding back and keeping things to herself to avoid being shamed or abandoned. the somatic approach revealed another layer of carol’s relational adaptation, and i utilized coherence therapy to bring into awareness carol’s implicitly-held belief for the emotional necessity of clamping down. the experience of identifying and openly sharing this early pattern, with an attuned listener, served to disconfirm her implicitly-held belief that no one would ever stay present with her in her underlying vulnerability or negative affect (ecker & hulley, 1995; ecker, ticic, & hulley, 2012). carol was able to both observe and experience the genuine felt sense that her experience mattered to me and that she didn’t need to “hold back” by keeping everything to herself. this empathic attunement, a bedrock of psychoanalysis, helped to further carry out memory reconsolidation. returning to se, we tracked discrete sensations along carol’s forehead which led her to recall a previously dissociated felt-sense memory of wearing a halo brace and being told by doctors not to move for risk of causing irreparable damage. she remembered her shock at being alone when she was informed that she would need emergency neck surgery. the sense of threat from behind (stairwell anxiety) was, at least in part, related to feeling overwhelmed at having to make such a consequential decision by herself. carol’s mother claimed to be too upset to visit and her father international journal of integrative psychotherapy, vol. 13, 2022 24 was, as usual, largely absent. here, our therapeutic relationship proved crucial. again, carol was able to experience my presence and empathic attunement as an experience that disconfirmed her sense of insignificance, aloneness (fosha, 2000), and the implicit belief that no one “had her back”. as a result, we were able to work with neck sensations that related to childhood experiences of aloneness, vulnerability, unmet need, and resulting shame as well as those related to her surgery. experiences that occur under general anesthesia often remain alive in the body and require somatic expression (osterman, j. e. & van der kolk, b. a. 1998). as we continued to explore the space around her, carol reexperienced the nervous system activation associated with her neck surgery. this arousal was the result of thwarted survival responses related to peripersonal boundary violations including intubation and being placed face down on the operating table with her spine exposed. i believe the presence of these unprocessed traumatic experiences in carol’s nervous system expressed themselves on a somatic level as significant elements of her underlying paradigmatic anxiety and bodily tension. in session, we were able to discharge1 the feeling of powerless subjection to invasion from intubation as well as the successful completion of an adaptive defensive sequence through an imagined flight from the imprisonment of the strapped-down surgery. in the sessions that followed the reprocessing of her intubation and surgery, carol came in reporting feeling lighter, happier, and freer. in subsequent sessions, self-states holding traumatic experience (both relational and situational) would emerge non-sequentially, (bromberg, 1996). these were addressed in whatever order they arose: being taped to a board at the crash site, negotiating with herself immediately after the crash whether things were really that bad, a thwarted startle response during surgery, being in traction post-surgery, anger at her father for burdening her further when she was helpless in the hospital, freezing before the other car’s impact, the collapsing of space around her during impact, recognizing implicit family messages that promoted keeping family emotional truths hidden from oneself and others, the car rolling after impact, being an 8-year old un-seat-belted passenger in the car while her father drove home drunk from holiday parties, fears of losing consciousness/control (perhaps under general anesthesia), etc. following these sessions, carol reported being able to express her needs and differences more often and more easily (including disagreeing with her father), and being free from anxiety in situations in which she formerly would have felt fearful. from an ifs perspective (schwartz, 1995), carol’s difficulties could be seen as stemming from self-protective parts that on face, appeared to be destructive. through incorporating an ifs approach, i was able to help carol’s adult observing self compassionately recognize that her anxious self-doubting part and her hypervigilant self-critical part both served vital functions. by bringing her to focus to what she lacked, they each effectively distracted and protected her from re-experiencing her underlying sense of feeling out of control, helplessness, and subject to serious danger that resided in her traumatic memories. these unconscious protective strategies were rooted in implicitly-held learnings which originated in her family-of-origin and which were reinforced by the car accident, her subsequent surgery, and frightening post-operative time spent alone in the hospital. international journal of integrative psychotherapy, vol. 13, 2022 25 at one point, carol wondered aloud if she might be under-worrying. when i invited her to explore what now resided in the bodily space her worry used to inhabit, she described a new and novel experience of pleasurable spaciousness and playful rejuvenation. i understood this as a direct outgrowth of feeling safe in a body now freed up from containing thwarted and trapped survival responses and one in which she could now expand her ability for positive affective states (leeds, 2007) and the engagement of her seeking and play systems (panksepp, 2004). it is not always necessary to verbally formulate implicit trauma memories in order to resolve them. an example of this occurred when, ten months into therapy, we processed newly occurring uncomfortable and puzzling sensations that extended down the left side of carol’s body. although no verbal narrative emerged during se processing, in her next session, carol reported that she was now able to walk in the stairwells at work without any distress. carol’s sense of danger had been resolved through working with its somatic representations. after just over one year, carol successfully terminated treatment leaving the door open to future work should she so wish. at termination, carol had cleared her sense of threat from behind, evidenced significantly improved capacities for self-trust, self-expression, relaxation, and joy, and she possessed a far greater facility for being present-oriented and curious in the moment. carol now saw others as having their own perspectives and reported marked differentiation from her lifelong role of caretaker. this stood in beautifully stark contrast to her anxious preoccupation with bad things happening to loved ones either through either her impulsivity or lack of vigilance which comprised so much of her experience at the outset of treatment. the case of mary (psychotherapist: sandy shapiro) the case of “mary” which follows illustrates the integration of emdr into a long-term relational psychoanalytic psychotherapy. treatment resolved specific childhood traumas, dissociation among self-states, and achieved a degree of maternal attachment repair. mary, a 64-year-old caucasian, heterosexual, single woman, spent a chaotic and unhappy childhood in an isolated rural area with an older brother and their suicidally-depressed mother. their father was unreliable, alcoholic, and left the family when mary was 11 years old. when she was less than 14, her mother committed suicide. this was followed by mary being shuttled among unwelcoming family members. mary had a lifelong history of major depression, including one hospitalization for suicidality and a chronic reliance on a variety of antidepressant medications. she had a succession of female therapists throughout her adult life, including a long-term treatment with me. while mary’s symptoms of major depression were finally treated successfully with electroconvulsive therapy (ect) and maintenance-level anti-depressants, residuals of her traumatic childhood remained unresolved, and these were targeted throughout treatment with emdr. my countertransference tended towards the maternal, and in retrospect, my desires to be a positive maternal object for mary may have potentially inhibited her from needed expressions of international journal of integrative psychotherapy, vol. 13, 2022 26 forbidden affect. fortunately, by being able to reprocess early traumatic memories with emdr, most importantly the kitten trauma which follows, i was able to facilitate mary’s expression and resolution of lifelong guilt in relation to murderous wishes. when mary was about 4 years old, she discovered a feral cat with a litter of kittens and took a favorite kitten for a pet. she left the kitten in her closed toy box in the garage. at least a day passed before she remembered the kitten and found it dying. mary hoped that emdr, which she had previously experienced with success, would resolve this hauntingly painful memory. mary vividly, tearfully, imagined the kitten’s terrible suffering and felt hateful and without compassion for her child self. mary was generally able to be in a present-oriented adult self state in therapy. however, while processing the kitten episode, the dissociative splits amongst several self-states were clearly reflected in her changing use of different personal pronouns (“i”, “she”, “we”). these fluctuations in mary’s use of personal pronouns suggest changing identifications with her mother as abuser (when mary blames herself for harming the kitten), and with herself as an abused child/abused kitten. i hypothesized that mary had harbored hateful fantasies of her mother’s death, but that these fantasies were caught in the insoluble bind of being attacked, abandoned, and then losing any possibility of being loved, if expressed. rather, mary, enacted the moral defense (fairbairn, 1943), preserving her relationship with her mother by enacting her own badness in holding her child self responsible for killing the kitten. a month-long course of emdr (including extended sessions) was aimed at helping mary to resolve her intense feelings about the unintended death of the kitten, but as we will see, this opened up the more fundamental issue of maternal attachment. session one mary’s initial emdr focus was on the image of finding the kitten “not asleep”. we co-constructed her negative cognition/self-belief (nc) as, “i am dangerously careless”. her desired, positive cognition/self-belief (pc) was, “i can take responsibility and learn to forgive myself” which mary rated as a modest credibility of 3 on a scale of 1-7. emotions: “guilt, shame, great sadness.” body sensations: “discomfort, from the top of my head to the base of my spine”. during bls sets, mary imagined how the kitten felt, “crying and screaming,” until it became exhausted. she then reflected, “my own mother could do that to me” (treat her as she had treated the kitten). session two mary reported that her somatic symptoms from the previous session had disappeared and she attributed their dissolution to emdr. she now reported experiencing “a massive clump of major depression”. when we returned to the kitten trauma, mary engaged her adult self in the international journal of integrative psychotherapy, vol. 13, 2022 27 reprocessing of traumatic memory, saying “we needed to bury the kitten and put a cross on the grave in the back yard”. at this point, i suggested a parallel by saying, “yes, and the right kind of mourning didn't happen with your mother either. that, too, has yet to be resolved”. session three enacting the cycle of her ambivalence, mary returned to a more familiar self-state, “i have no compassion for myself as a child”. in response to mary’s shift back to self-blame, i encouraged mary to re-engage her adult self to accompany this child in whatever way felt authentic. mary: “i ended up taking the kitten into the house. i fed it from an eye dropper, with a mixture of sugar water and a pinch of salt, and sent the child off to see if she could find the mother cat. i told the child what i was doing, keeping it warm, giving it fluid, but that if we couldn’t find the mother, it probably won’t live; it’s too young. (when it died), we dug a hole, and i told her that everything that is born and lives ends up going back into the earth, making it better for things to grow. i told her this kitten died too soon, and i’m not allowed to take a kitten from its mother. that was a mistake, but it was a bad mistake… she was still responsible for the mistake.” i contrasted mary’s respectful stance with her mother’s cruel verbal treatment. i supported a differentiation between adult mary and child mary by asking “so, how does this child feel after being shown how to try to save a life, being given a role in trying to save it, and then burying the kitten when it died?”. i then resumed bls to facilitate mary’s formulation and expression of her own reactions to this question. mary (standing in the spaces (bromberg, 1996) and speaking for the child): “i still feel shame, but i feel more respected”. then immediately, mary (as adult): “i’m glad there was not an erasure of responsibility. there was a mistake, but a bad one”. i saw this as progress towards mary resolving her self-hatred. the child felt less shamed. the adult mary still felt strongly about responsibility but was less blaming and emerged into a nascent self-state of a kinder mother. and finally, there was a shift to “we” as mary joined with her child self to plan a memorial ritual for the kitten. significantly, mary later reported that her recent depression had lifted after this session. and at the end of this session, mary reported greater conviction in her positive belief, “i can learn from my mistakes” (now a 5, on a scale of 1-7). session four in this session, mary wanted to shift to her feelings about her mother’s death. she knew intellectually that she didn’t kill her mother, but she still felt guilty knowing that, at the funeral and thereafter, she had felt relieved and even glad about her mother’s death. i asked “could you ever have been the perfect, good child who healed her or stopped her suicide?“ international journal of integrative psychotherapy, vol. 13, 2022 28 mary: “no!” this intervention probed mary’s felt sense of responsibility for her mother’s ill-treatment of her. her response clarified that her previously implicitly-held belief that she was to blame had been disconfirmed. session five mary’s choice of emdr target image changed to putting the kitten in the toy box. she recalled “i felt then, this is naughty, not right”, and that feeling naughty was a pleasure. i suggested that she wanted to be naughty but not to kill the kitten. mary: “yes. i never felt like i murdered the kitten. being stupid and killing the kitten, yes. negligent…” therapist: the act was intentional, but the death was unintentional.” a set of bls followed in which mary was able to convey this distinction in an imagined interaction with her child self. as dissociation between child and adult self-states diminished, mary’s implicitly-held belief that she is bad was further changed in favor of compassionately understanding that she was only a child. this new view of self was then reconsolidated into a revised memory of the kitten’s death. session six as evidence of mr, mary began the next session reporting that the kitten scene had lost most of its associated distress (now a 2 on a scale of 0-10 and by session’s end a 0). her thoughts next turned to her mother’s chronic depression and suicide attempts, “i finally have come up with a logical reason that will filter down to my heart and stomach. the 13-year-old wasn’t guilty about her suicide. those suicide attempts were hers, not mine, not my father’s. yes, i was an obnoxious, nasty, brilliant 13-year-old, but… i didn’t kill the kitten. and much less did i kill my mother… which makes me think, how do i mourn the woman whom i loved and hated equally?” mary’s open question marked a profound change in stance from the self-hating, traumatized woman whom she had been. she had traveled far: from resolving a concrete, single-episode (kitten) trauma to uncovering her core issue of ambivalent attachment (ainsworth et. al., 2015, bowlby, 1988). although i had understood that emdr could facilitate the exploration of mary’s attachment trauma, mary had not expected her conflict with her mother to emerge, no less to be resolved. mary said “yeah, who’d have thought the kitten memory would go to this?” international journal of integrative psychotherapy, vol. 13, 2022 29 mary had now learned that positive change can come from negative experiences. with additional sets of bls, mary rated her pc, “i can learn from my mistakes” at the maximum value of feltsense credibility (7, on a scale from 0-7). the trauma of the kitten’s death has remained resolved thereafter. when trauma involving a death is resolved, authentic grief and mourning often follow and need to be processed. mary was able to reimagine her mother’s funeral during sets of bls without undue arousal. she no longer felt the shock from her mother’s suicide, responsible for her mother’s death, or guilty for feeling relieved at her mother being gone. mary planned and subsequently carried out a number of her own creative and meaningful rituals which allowed for her to accommodate this early and traumatic loss. mary and i agreed that her hospital-based ect for her life-long treatment-resistant depression was a crucial prerequisite for her successful trauma treatment. flooding depressive affect is enervating, places the person outside of their window of tolerance, interferes with clarifying sources of their depression, and precludes one’s fully experiencing other emotions. ect’s resolution of mary’s depressive disorder, however, did not in itself resolve either the kitten trauma or her core attachment trauma. mary & i agreed that is was emdr which had facilitated their resolution. mary’s life became much more expansive after this phase of treatment. she traveled, reached out to friends, and she opted for continued recovery and growth in joining a group led by a therapist who works with trauma. in the end, mary was able to risk intimacy, enjoy the benefits of being with others, and see herself as a member of shared humanity. discussion the case of carol represents an integrative treatment in which a number of modalities were woven together to address and resolve striking somatic symptoms, a problematic developmental history, implicitly-held situational and relational trauma, and a lifelong defense of anxious preoccupation. her presenting complaint of feeling the threat of attack from behind offered a clear pathway into her underlying and implicitly-held experience. somatic experiencing, which i initially used to explore boundary ruptures to her peripersonal space, opened the door to related developmental and relational issues of invasion, abandonment, dependency, and trust. the use of system-centered psychotherapy early in her treatment helped carol to sufficiently manage her anxiety, and the later integration of coherence therapy and internal family systems helped carol deepen her awareness of and bring compassion to the various unconscious protective strategies that kept her underlying traumatic experience at bay. i combined these approaches with an empathic attunement born from a long-standing relational psychoanalytic psychotherapy practice. this allowed for in-vivo and felt-sense disconfirmation of implicitly-held memories which contained relational and somatic aspects of trauma from carol’s childhood, the car accident, her subsequent surgery, and her post-surgical time alone in the hospital. working in this manner allowed for the further disconfirmation of her implicitly-held beliefs of needing to hold herself back and attend to others which was learned in childhood and reinforced throughout much of her life. carol’s relatively rapid alleviation of trauma sequelae as well as the international journal of integrative psychotherapy, vol. 13, 2022 30 deeper and more fundamental reorganization of how she viewed herself and others strongly support the choice of an integrative, multi-modal approach in this treatment. in mary’s treatment, the integrative approach of emdr and psychodynamic psychotherapy resolved the specific kitten trauma, but it also brought into awareness and resolved her ambivalent maternal attachment. while the question of whether she could now actually forgive her mother remained, it did not impede mary’s emergence into a freer and more expansive life and sense of self. although mary’s treatment with me ended with my retirement from clinical practice in 2018, she was very pleased to participate in follow-up communications. she reported that five years after the emdr phase of therapy had ended, she evidenced continued resolution of guilt and shame, improvements in self-compassion, and the valuable ability to hold ambivalence without dissociation. further evidence of the clinical effectiveness of our work emerged more recently after a depressive episode during the coviod-19 pandemic, which she attributed to her persisting post-virus symptoms and to social isolation. this latest recurrence, however, neither reversed nor destabilized the treatment gains she made via emdr-facilitated memory reconsolidation. conclusion emotionally meaningful learning and relearning in all effective psychotherapies involve memory consolidation (in treating developmental deficits) and memory reconsolidation (in the unlearning and relearning that is central to therapeutic reprocessing). both of these may be achieved through the use of a variety of therapeutic approaches (carson, 2020; erskine, 1996; frank, 2020). as analysts, we focus on the story of our client’s lives as worded, meaningful narratives and typically co-create new versions in the course of psychotherapy. words are a powerful form of symbolic encoding. they enable us to create emotionally explicit, labeled, and semantically nuanced categories of experience (bucci, 1997). these consolidated encodings may express our truths on the one hand or rigidly maintain our protective strategies on the other. by integrating experiential modalities such as emdr and se, we can facilitate the revision of one’s life narrative beyond semantic memory to include the reprocessing of somatic/sensory and procedural/motoric memories. these may not emerge or be processed in a less experiential verbal psychotherapy. in addressing these other dimensions of implicitly-held experience, we can help clients shift their narratives in ways that are not possible otherwise. both cases presented demonstrate the importance of nonverbal processing without sacrificing the patient’s capacity to put their newly recognized and/or newly created experiences into words. there is presently no convincing prescriptive indication for the choice of treatment modality for specific trauma symptoms. it is our contention that competency in a variety of modalities considerably facilitates the clinician’s ability to address and resolve a variety of traumatic sequelae. we hope that these case examples and our prior argument supporting the use of extraanalytic techniques have served to demonstrate both the advantages of an integrative approach and the need for special considerations in working with those affected by trauma. international journal of integrative psychotherapy, vol. 13, 2022 31 notes on authors gregory d. carson, lcsw, sep gregorycarson.lcsw@gmail.com program chair, the national institute of the psychotherapies, clinical affiliate program faculty, the national institute of the psychotherapies faculty, the institute for contemporary psychotherapy associate instructor, the coherence psychology institute certified somatic experiencing practitioner, the somatic experiencing trauma institute certified consultant in emdr, emdr international association certified consultant in presence psychotherapy, presence psychotherapy institute peggy reubens, lcsw peggyreubens@gmail.com founding clinical director, integrative trauma program, the national institute of the psychotherapies faculty, integrative trauma program, the national institute of the psychotherapies sandra shapiro, ph.d sandrashapiro42@gmail.com founding director, integrative trauma program, the national institute of the psychotherapies associate professor emeritus, psychology department, queens college, cuny none of the authors have any real or potentially perceived conflict(s) of interest, including financial, personal, or other relationships with other organizations or companies that may inappropriately impact or influence the research and interpretation of the findings. mailto:gregorycarson.lcsw@gmail.com mailto:peggyreubens@gmail.com mailto:sandrashapiro42@gmail.com international journal of integrative psychotherapy, vol. 13, 2022 32 references ainsworth, m.d.s., blehar, m.c., waters, e., & wall, s.n. (2015). patterns of attachment: a psychological study of the strange situation. taylor & francis. boulanger, g. (2007). wounded by reality. analytic press. bowlby, j. (1988). a secure base: parent-child attachment and healthy human development. basic books. bromberg, p. (1996). standing in the spaces: the multiplicity of self and the psychoanalytic relationship. contemporary psychoanalysis, 32:509-535. bucci, w. (1997). psychoanalysis and cognitive science: a multiple code theory. guilford press. carson, g. d. (2020). greater than the sum of its parts: the value of co-led trauma group psychotherapy. in wise, s. & nash e. (eds.) healing trauma in group settings: the art of coleader attunement. routledge. carson, g. d. (2020, may 7). memory reconsolidation and the therapeutic reconsolidation process: the linchpin of psychotherapeutic change. national institute for the psychotherapies. https://us02web.zoom.us/rec/share/wpfzfr_uymxixj3uq0frvp8empyit6a81iifqabbze8koioqlx uc7z_mbz3ytltk ecker, b. & hulley, l. (1996) depth oriented brief therapy: how to be brief when you were trained to be deep and vice versa. jossey-bass. ecker, b., ticic, r., & hulley, l. (2012). unlocking the emotional brain: eliminating symptoms at their roots using memory reconsolidation. routledge. ecker, b. (2018). clinical translation of memory reconsolidation research: therapeutic methodology for transformational change by erasing implicit emotional learnings driving symptom production. international journal of neuropsychotherapy, 6(1), 1–92. ecker, b., & bridges, s.k., (2020). how the science of memory reconsolidation advances the effectiveness and unification of psychotherapy. clinical social work journal. eldrege, c. & cole, g.w. (2008). learning from work with individuals with a history of trauma: some thoughts on integrating body-oriented techniques and relational psychoanalysis. in anderson, f.s. (ed.) bodies in treatment: the unspoken dimension. analytic press. erskine, r. g., & trautmann, r. l. (1996). methods of an integrative psychotherapy. transactional analysis journal, 26(4), 316–328. https://doi.org/10.1177/036215379602600410 https://us02web.zoom.us/rec/share/wpfzfr_uymxixj3uq0frvp8empyit6a81iifqabbze8koioqlxuc7z_mbz3ytltk https://us02web.zoom.us/rec/share/wpfzfr_uymxixj3uq0frvp8empyit6a81iifqabbze8koioqlxuc7z_mbz3ytltk https://doi.org/10.1177/036215379602600410 international journal of integrative psychotherapy, vol. 13, 2022 33 erskine, r. g. (2009, april 17). relational group psychotherapy [keynote address]. 4th international integrative psychotherapy association conference, lake bled, slovenia. fairbairn, w. r. d. (1943). the repression and the return of bad objects. in psychoanalytic studies of the personality (pp. 59-81). london: tavistock, 1952. fosha, d. (2000). the transforming power of affect: a model for accelerated change. basic books. frank, k. a. (2020). an integrative approach to relational psychoanalysis. psychoanalytic inquiry, 40:6, 448-460, doi: 10.1080/07351690.2020.178214 gendlin, e.t. (1964). a theory of personality change. in p. worchel & d. byrne (eds.), personality change, pp. 100-148. john wiley & sons. grand, s. (2013). the reproduction of evil: a clinical and cultural perspective. routledge. herman, j. (1992). trauma and recovery: the aftermath of violence-from domestic abuse to political terror. basic books. howell, e. (2005). the dissociative mind. taylor & francis. kohut, h. (1977), the restoration of the self. new york: international universities press. krystal, h. (1968) integration and self-healing. routledge. ladden, l. j., gantt, s.p., rude, s. & agazarian, y. (2006) systems-centered therapy: a protocol for treating generalized anxiety disorder. journal of contemporary psychotherapy. doi 10.1007/s10879-006-9037-6. lepak, m. m., & carson, g. d. (2022). presence psychotherapy: a novel integrative trauma treatment model for thorough memory reconsolidation. journal of psychotherapy integration, 32(4), 426– 442. https://doi.org/10.1037/int0000273 levine, p. (2008). healing trauma: a pioneering program for restoring the wisdom of your body. sounds true. levine, p. (2010). in an unspoken voice: how the body releases trauma and restores goodness. north atlantic books. lyons-ruth, k. (1998). implicit relational knowing: its role in development and psychoanalytic treatment. infant mental health journal, 19(3). 282-289. manfield, p. (2010). dyadic resourcing: creating a foundation for processing trauma. on-demand publishing. international journal of integrative psychotherapy, vol. 13, 2022 34 nader, k., schafe, g.e., and ledoux, j. (2000). fear memories require protein synthesis in the amygdala for reconsolidation after retrieval. nature, 406, 722-726. najavits, l.m. (2002). seeking safety: a treatment manual for ptsd and substance abuse. the guilford press. ogden, p., minton, k., & pain, c. (2006). trauma and the body. w.w. norton & co. osterman, j. e. & van der kolk, b. a. (1998). awareness during anesthesia and post traumatic stress disorder. general hospital psychiatry, vol 20, 274-281. panksepp, jaak, (2004). affective neuroscience: the foundations of human and animal emotions. oxford university press. przybyslawski, j., roullet, p., & sara, s. j. (1999). attenuation of emotional and non-emotional memories after their reactivation: role of beta adrenergic receptors. journal of neuroscience, 19, 6623–6628. pmid: 10414990 schiller, d., monfils, m.h., raio, c.m., johnson, d.c., ledoux, j.e., & phelps, e. preventing the return of fear in humans using reconsolidating update mechanism. nature, vol. 463, january 7, 2010. pp. 49-53. schmidt, s. j. (2004). developmental needs meeting strategy: a new treatment. the journal of trauma & dissociation of trauma & dissociation. haworth press schwartz, r. (1995). internal family systems therapy. the guilford press. shapiro, f. (2018). eye movement desensitization and reprocessing, (edmr) therapy, (3rd ed.). the guilford press. shaw, d. (2014). traumatic narcissism: relational systems of subjugation. routledge. siegel, d. (1999). the developing mind: toward a neurobiology of interpersonal experience. guilford press. stolorow, r. (2007). trauma and human existence. analytic press. van der hart, o., nijenhuis, e., & steele, k. (2006). the haunted self. w.w. norton & co. van der kolk, b. (2014). the body keeps the score: brain, mind, and body in the healing of trauma. penguin. watkins, j. & watkin, h. (1997). ego states: theory and therapy. w.w. norton & co. international journal of integrative psychotherapy, vol. 13, 2022 35 winnicott, d. (1953). transitional objects and transitional phenomena, international journal of psychoanalysis., 34:89-97. international journal of integrative psychotherapy, vol. 4, no. 2, 2013 1 vulnerability, authenticity, and inter-subjective contact: philosophical principles of integrative psychotherapy richard g. erskine abstract: the philosophical principles of a relationally focused integrative psychotherapy are described through the concepts of vulnerability, authenticity, and inter-subjective contact. eight principles or therapist attitudes are outlined with clinical examples that illustrate the philosophy. these philosophical principles provide the foundation for a theory of methods. this article is based on a keynote address given at the 6th international integrative psychotherapy association conference, grantham, uk, july 11-14, 2013. key words: philosophy of psychotherapy, integrative psychotherapy, intersubjective contact, vulnerability, authenticity, interpersonal contact, relationship, interdependent, physis, psychopathology, relational-disruptions, relational psychotherapy. ______________________ vulnerability, authenticity, and inter-subjective contact are three words that reflect several philosophical principles of a relationally focused integrative psychotherapy. in the process of writing about and teaching integrative psychotherapy, i have frequently demonstrated and refer to various philosophical assumptions that are the foundation for working relationally and integratively. on the occasion of this 6th biannual international integrative psychotherapy association conference i want to address the theme of this conference by articulating some of the philosophical principles inherent in a respectful, coconstructed, and interpersonally focused psychotherapy. in several publications i described and illustrated various methods of facilitating our clients’ integration of physiology, affect, and cognition. with such integration, the individual’s behavior becomes a matter of awareness and choice and is not stimulated by compulsion or fear. in rereading the books, integrative psychotherapy in action (1988/2011), beyond empathy (1999), and the art and science of relationship (2004), i realize that i have not specifically identified or clearly articulated the core philosophical principles of therapeutic practice. this conference address is intended to remedy that oversight and provide an outline and synthesis of the philosophical principles and central assumptions of a relationally focused integrative psychotherapy. the core principles and assumptions listed in this article are the foundation for our therapeutic interventions when we engage in a relationally focused psychotherapy -a psychotherapy that holds the relationship between the therapist and client as central to a process of healing and personal growth. i have not listed these principles in any specific order. most likely this list is not complete and there may be other important principles that you want to add. the following are the philosophical assumptions that influence my therapeutic outlook, attitude, and interactions with clients: all people are equally valuable this seems like such a simple statement yet the concept is profound. many of our clients have grown up in homes and school systems where they were treated as though they had no value as a human being. they, like us, attempt to protect themselves from being vulnerable in the presence of neglect, humiliation, or physical abuse. it is our responsibility to find ways to value every client even if we do not understand their behavior or what motivates them. this involves respecting their vulnerability, as well as their attempts at being invulnerable, while we maintain a therapeutic relationship that fosters a sense of security. we manifest this principle of equality when we treat our clients with kindness, when we provide them with options and choices, when we create security, and when we accept them as they present themselves rather than looking for a possible ulterior agenda. when we are truly in interpersonal contact, we create a secure environment where our clients are free to be vulnerable with us and we with them. this is an enlivening sense of vulnerability. vulnerability can be healing when there is an opportunity to express one’s physical and relational needs and to be valued just as one is while remaining interpersonally secure. vulnerability includes being open to any interpersonal encounter with an absence of defenses. metaphorically, vulnerability is like a naked baby -a baby free of any defenses -seeking contact and need fulfillment, open to being cared for, and susceptible to potential harm. i remember one particular incident where valuing the other’s experience was so important. the husband of a client came charging into my office accusing me of destroying his marriage. he raged at me, cursed me, and threatened to do bodily harm because his wife had changed as a result of our therapy. there was no opportunity for me to speak. i started to defend against his rage. i wanted to tighten my body to make myself invulnerable. instead, i sat still, breathed deeply, listened carefully to his anger, took his concerns seriously, watched for international journal of integrative psychotherapy, vol. 4, no. 2, 2013 2 international journal of integrative psychotherapy, vol. 4, no. 2, 2013 3 his hidden vulnerability, and valued the various relational-needs embedded in his rage. i responded to his need to make an impact, to define himself, and to have security in his marriage. he softened his voice when i spoke of his needs as normal and valuable. i told him about my fear of his rage. we were vulnerable together. he ended by agreeing to attend a couple’s session the next day. all human experience is organized physiologically, affectively and/or cognitively our biological imperatives require that we make meaning of our phenomenological experiences and that we share those meanings with others. people are always communicating a story about their life either consciously or unconsciously. our clients’ unconscious communication is embodied in their physical tensions, entrenched in their emotional reactions, encoded in the way they make visceral and cognitive sense of their current and past situations. therefore, our therapeutic task is to observe, inquire, listen, and decode our clients’ many unconscious attempts to communicate their life story and to seek a healing relationship. this requires us to decenter from our own perspective and to experience the client through his or her own way of being in the world. a middle-aged female client did not allow me to inquire. she would become physically tense with each phenomenological or historical inquiry and either became silent for a few minutes or responded with “i don’t know.” i could see the intense body tension that seemed to increase with each inquiry. i realized that her body was unconsciously communicating an important story about her life experiences. i stopped inquiring and instead made statements - statements that reflected her body tensions, posture, and silence. such statements included “it seems important to remain silent” and “perhaps by holding your muscles tight you do not have to feel.” after several sessions in which i only used descriptive statements she began to talk about the sexual abuse in her family and the lack of opportunity to talk to anyone who would be protective. her story was embodied in her physical tension and communicated through her silence. our authenticity is in our awareness that “i know nothing about this client’s internal process, therefore i must continually inquire about his or her phenomenological experience”. authenticity is also expressed when we speak truthfully from our heart -when we make genuine heart-to-heart contact. the healing of psychological confusion occurs through a sustained contactful therapeutic relationship -a relationship that involves two individuals in full interpersonal contact -vulnerable and authentic. even when we speak heart-to-heart the therapeutic relationship is not the same as a friendship. as psychotherapists we bring our interest, commitment, skill, and ethics to each therapeutic encounter. our inquiries and responses are always determined by the needs and welfare of the client. we seek to provide a relationship that allows each client to fully express their life story to a respectful and involved other person. all human behavior has meaning in some context it is our therapeutic task to help our clients become aware of and appreciate the various meanings of their behaviors and fantasies. this includes a therapeutic involvement of normalizing their behaviors by helping them understand the contexts in which their behaviors, beliefs, or fantasies were derived. all problematic behaviors and interruptions to internal and external contact serve some psychological function such as reparation, prediction, identity, continuity, stability, or enhancement. before focusing on behavioral change in therapy it is essential to know and appreciate our clients’ phenomenological experiences and various psychological functions. one young client repeatedly burned herself with cigarettes. on many occasions her family had tried to stop her but she continued to burn herself. i focused our therapy on the functions of her self-harm and we discovered that the aim in burning herself was “to feel real” instead of desensitized and dissociated. resolution of both current and archaic conflicts occur when the client becomes conscious of implicit relational patterns, the psychological function of those patterns, and how those implicit and procedural memories effect current relationships. part of our therapeutic task is to explore with the client the multiple psychological functions underlying such dynamics as fixated script beliefs, repetitive fantasies, and/or internal criticisms. internal and external contact is essential to human functioning many of our clients have lost proficiency or even the capacity to maintain internal and/or interpersonal contact. in a relationally focused psychotherapy we are always inviting the client into full contact -contact with his or her internal processes of body sensations, affect, memories, and thoughts. and, we also invite them into external contact -to communicate interpersonally with awareness and intimacy. in an integrative psychotherapy, one of the definitions of psychological health is the capacity of an individual to shuttle between internal and external contact. we make use of an inter-subjective process to identify interruptions to external contact. such interruptions in interpersonal contact may represent significant internal interruptions to contact with physical sensations, affect, memory, or reasoning. we also invite our clients to consistently engage in intersubjective contact. i frequently engage in a relational-inquiry wherein i ask the international journal of integrative psychotherapy, vol. 4, no. 2, 2013 4 international journal of integrative psychotherapy, vol. 4, no. 2, 2013 5 client how he or she experiences our relationship. i ask about his or her experience of my tone of voice, what it is like to have me point out a behavior or gesture, or to sit in silence. such relational-inquiry either leads to further phenomenological inquiry or to a sharing of my personal experience of our relationship. inter-subjective contact involves that vulnerable process of each person authentically expressing his or her own unique feelings, fantasies, thoughts, and relational-needs while also allowing the other’s feelings, thoughts, desires, and perspectives to make an impact on him or her. with such inter-subjective contact a new sense of understanding and appreciation is co-created and each person develops as a result of the encounter. all people are relationship-seeking and interdependent throughout life many of the difficulties that our clients describe are based on repeated disruptions in their relational systems and their resulting inability to depend on significant others when it was developmentally necessary. as a result, they are unconsciously inhibited by archaic internal working models of relationship that influence the development of a sense of self and the quality of interpersonal relationships. through psychotherapy we provide the authenticity of the intersubjective contact that may challenge our clients’ old script beliefs and dysfunctional patterns of behavior. we offer a new inter-subjective relationship that provides emotional security, validation, and dependability. as we effect a change in one aspect of our clients’ relational systems we influence their other relationships as well. when we affectively, rhythmically, and developmentally attune to our clients, consistently inquire about our clients’ experience, and when we are authentically involved with our clients, we change their perspectives of what is possible in inter-subjective contact and we open new possibilities to being vulnerable and authentic with other people in their lives. the healing power of inter-subjective contact is illustrated in the cases of elizabeth and kay. both entered therapy depressed and lonely. by the time the therapy ended elizabeth had changed her appearance, she no longer compulsively searched for her mother, and she had achieved intimacy with her husband (erskine, 2010). kay entered therapy angry at many people in her life. she had a deep sense of being neglected. consistent attunement to her level of development, validation of her affect and needs, and reparative responses to her traumas produced a transformation in her personality. after terminating therapy kay began to volunteer at a hospital where she loved working with the children (erskine, 2008). humans have an innate thrust to grow the ancient greeks use the term physis to describe the vitality and psychic energy that is invested in health, creativity, and the expansion of our personal horizons. physis is the source of our internal thrust to challenge acquiescence, to explore different ways of doing and being, to have aspirations, and to develop our full potential. as a psychotherapist, it is my commitment to engage each client in a contactful relationship that vitalizes this innate thrust to grow. such a therapeutic relationship: • enhances each client’s understanding of his or her history and inner experience; • furnishes each client with a sense that his or her behavior has an important psychological function; • fosters the capacity for full internal and external contact; • provides the opportunity for each client to experience being seen as a unique and valuable human being; • explores creative options and outlets, and • nourishes the possibility of pleasure in relationships. i am reminded of a young woman i saw once a week for over a year. she used most of the time in session to talk about films, social events, and the lives of actors and singers. no matter how skillfully i inquired about her own experiences she would turn the conversation into talking about anything but herself. she told me that she had “nothing to say” when i asked her about her life. i wondered what unconscious story she was telling me when she talked about films and the lives of famous people. was she telling me about her early family life in some encoded form or was she living a vicarious life through these stories? after the summer holiday she arrived in her first session feeling much more lively and energetic. she looked more attractive. she enthusiastically told me that over the summer she had decided to change her life. she left her previous partner, got a new job, and bought new clothes. i asked her what prompted the big changes. she responded, “i talked to you for a year. you never acted like anything was wrong with me. so i decided it was time to grow up and change the way i live my life.” although i listened to her stories with interest and presence, attempted to establish full contact, and tried to inquire about her inner experiences, the actual changes in her life emerged from her innate thrust to grow. our relationship provided a foundation for growth but it was her psychic energy -physis -that propelled her to develop her potential. she added, “if nothing’s wrong with me i am free to live my own life”. international journal of integrative psychotherapy, vol. 4, no. 2, 2013 6 international journal of integrative psychotherapy, vol. 4, no. 2, 2013 7 humans suffer from relational-disruptions not “psychopathology” a relationally focused integrative psychotherapy emphasizes a nonpathological perspective in understanding peoples’ behavior. discomforting physiological and emotional symptoms, entrenched belief systems, obsessions and compulsive behaviors, aggression or social withdrawal are all examples of creative attempts to satisfy relational-needs and resolve disruptions in interpersonal contact. when we view someone as “pathological” we lose our awareness of the person’s unique creative accommodation and their attempts to manage situations of neglect, ridicule, and/or abuse. we also lose a valuable opportunity for interpersonal contact when we mistakenly focus on an individual as a “personality disorder”, or view people as either passive or manipulative, or even define them as playing psychological games. yes, people can be passiveaggressive, manipulative, game playing; they can be cruel; they can lie and cheat -we would be foolish not to recognize such behavior -but our therapeutic advantage is in our understanding our client’s creative accommodation, their internal working models, core beliefs, and their desperate attempts to resolve intrapsychic conflicts. tasha was a thirty year old woman who had been in a previous therapy where her therapist had diagnosed her as “borderline” and had repeatedly told her that she would never be “fully sane”. he insisted that she change her “crazy behavior”. throughout the early stages of our therapy together she continually referred to herself as “crazy”, “incurable”, and “borderline”. with each selfdeprecating comment i focused on how her bodily reactions, emotions, and behaviors were an attempt to describe how she managed an early childhood family environment that was affectively confusing and traumatic. an important element in the healing of emotional distress, intrapsychic conflict, and relational disruptions involves the psychotherapist’s authentic communication to the client that his or her psychological accommodations were creative attempts to solve relational ruptures. we protect our clients’ sense of vulnerability and open an opportunity for healing when we perceive our clients’ defenses, inhibiting beliefs, and problem-making behaviors as developmentally appropriate, normal reactions to previous disruptions in relationships. it is in authentically recognizing and appreciating the other person’s emotional vulnerability, relational-needs, and desperate attempts at self-reparation, selfregulation, or self-enhancement that we create the possibility for full intersubjective contact a contact that heals old psychological wounds. the inter-subjective process of psychotherapy is more important than the content of the psychotherapy inter-subjectivity refers to the synthesis of two people sharing an experience together. each person brings to any interpersonal encounter his or her own phenomenological experience. the inter-subjective process involves the melding together of each person’s subjective experience, his or her affects, belief systems, internal relational-models, implicit and explicit memories, and relationalneeds. effective psychotherapy emerges in the creation of a new perspective and understanding -a unique synthesis. a new psychological synthesis occurs when there is authentic and open contact between two people. each is influenced by the other; the therapy process is co-created. therefore, no two psychotherapists will ever do the same psychotherapy -each of us is idiosyncratic in how we interact with our clients. the important aspects of the psychotherapy are embedded in the distinctiveness of each interpersonal relationship, not in what we consciously do as a psychotherapist, but in the quality of how we are in relationship with the other person. the therapist’s attitudes and demeanor, the quality of interpersonal relationship and involvement, are more important than any specific theory or method. an effective healing of psychological distress and relational neglect occurs through a contactful therapeutic relationship -a relationship in which the psychotherapist values and supports vulnerability, authenticity, and intersubjective contact. thank you to paul stein, md and members of the professional development seminar of the institute for integrative psychotherapy, 1989 to 1994, for their contribution in the development of these philosophical principles. author: richard g. erskine, phd is the past president of the international integrative psychotherapy association and the training director of the institute for integrative psychotherapy, vancouver, bc, canada. he conducts workshops and training programs in several countries. he can be reached through the web site: www.integrativepsychotherapy.com copyright march 13, 2013 by richard g. erskine, phd. and the institute for integrative psychotherapy, vancouver, bc, canada references erskine, r.g. (2008). psychotherapy of unconscious experience.transactional analysis journal, 38:128-138. international journal of integrative psychotherapy, vol. 4, no. 2, 2013 8 http://www.integrativepsychotherapy.com/ international journal of integrative psychotherapy, vol. 4, no. 2, 2013 9 erskine, r.g. (2010). life scripts: unconscious relational patterns and psychotherapeutic involvement. in r.g. erskine (ed.), life scripts: a transactional analysis of unconscious relational patterns, (pp.1-28). london: karnac books. erskine, r. g., & moursund, j. p. (2011). integrative psychotherapy in action. london: karnac books. originally published 1988. newbury park, ca: sage. erskine, r. g., moursund, j. p., & trautmann, r. l. (1999). beyond empathy: a therapy of contact-in-relationship. philadelphia: brunner/mazel. moursund, j.p. & erskine, r.g. (2003). integrative psychotherapy: the art and science of relationship. new york: thompson/wadsworth (brooks/cole). date of publication: 26.11.2013 international journal of integrative psychotherapy, vol. 8, 2017 79 a psychotherapist’s exploration of clinical intuition: a review of the literature and discussion margaret arnd-caddigan marilyn stickle abstract: the psychoanalytic and psychotherapy literature, including transactional analysis and integrative psychotherapy, have long acknowledged the role of intuition in clinical work. more recently, cognitive psychology researchers have begun to explore the phenomenon in a more general sense. this article presents an overview of the concept of clinical intuition, and a case study that demonstrates some ways that clinical intuition may be a valuable tool in psychotherapy. in keeping with the relational emphasis in integrative psychotherapy, the clinical example explored in this article both arises out of and strengthens the therapeutic alliance and contributes to positive treatment outcomes. the increased awareness of the potential benefits of the phenomenon of clinical intuition suggests the advantages of further legitimizing its use and training thereof. key words: clinical judgement, therapy process there is a small but growing body of research on intuition from the perspectives of cognitive psychology. this work investigates intuition across contexts (see sinclair, 2011). in addition to this more general research, there is a small corpus of research that focuses specifically on clinical intuition therapists’ international journal of integrative psychotherapy, vol. 8, 2017 80 use of intuition in the treatment process. there are also a number of schools of psychotherapy that have produced theoretical treatments of clinical intuition. noteworthy among these works is that of eric berne from the perspective of transactional analysis (berne, 1949/1977). integrative psychotherapy represents an expansion and refinement of the early core concepts of transactional analysis (o’reilly-knapp & erskine, 2003), and so perhaps not surprisingly one may conclude that clinical intuition is acknowledged as an important element in the clinical process. this becomes clear in a close reading of the importance of the therapeutic relationship and attunement. following an overview of the concept of clinical intuition in psychotherapy and the research on the topic, the authors present an example from a larger multiple case study on boundary dilemmas. this example demonstrates how one intuitive therapist used her ability in a clinical encounter. three issues emerged as important in this case. first, those who have studied clinical intuition have found that research participants report that intuition emerges from a deep connection with the client (charles, 2004; jeffrey & fish, 2011; petitmengin-peugeot, 1999), a theme that is front-and-center of integrative psychotherapy (moursund & erskine, 2004). the case example presented here suggests that the use of intuition may also enhance the therapeutic alliance. the second point is that intuition is not antithetical to, nor employed as a substitute for, solid clinical judgment. it can be, in fact, a valuable tool in the psychotherapy process. indeed, in some cases intuitively derived insights may contribute to a successful treatment outcome. finally, the therapist in the case example reveals some uneasiness in discussing her use of intuition. as the concept of intuition gains legitimacy in psychotherapy, the authors hope to mitigate such uneasiness and help therapists use intuition ethically and successfully in their professional work. the growth of interest in intuition while intuition has always seemed to lurk at the edges of the psychotherapy literature, based on the material explicated in this literature review, it would seem that in the past twenty years this interest has expanded. different perspectives represented in this literature review share some common, as well as divergent, features regarding how intuition is defined, how it operates, and the legitimacy of intuitively derived information. one of the most notable differences between international journal of integrative psychotherapy, vol. 8, 2017 81 existing models is in the definition of intuition. arguably the most commonly agreed upon definition is “knowing without knowing how you know” (radin, 2006, p. 142). perhaps one of the reasons this definition is rejected in some circles is because it is so nebulous. however, a glimpse at the use of the term in the literature reveals that this vague definition may be as close as one can get to agreement on what, exactly, intuition is. cognitive psychology research on intuition in the past several decades cognitive psychologists have productively researched intuition. psychologists who have studied intuition hold nuanced differences in how they define the term yet they agree on several key points. one notable feature of their definition is that they limit the use of the term to the decisionmaking processes. this point differentiates intuition from insight (hogarth, 2010; lieberman, 2000). in other words, one must decide on a preferred course of action in order for the experience to qualify as an intuition (betsch, 2008), whereas an insight is simply acquiring some knowledge. for example, to tie this to clinical experience, cognitive psychologists would not classify a therapist sensing that a client may have been abused in childhood as intuition. rather, they would describe the intuitive aspect of the experience as the automatic judgment to employ a specific course of action; to react, or decide not to react, in one way or another in response to the felt sense that the client may have been abused. additionally, cognitive psychologists hold that intuition is a separate phenomenon from instinct or innate reaction (hogarth, 2010). hogarth (2010) has used the example of the professional tennis player who decides to swing his racket at a specific speed and angle in relation to an oncoming ball. this is not an innate reaction or reflex, nor is it instinctual or in-born. instead, it represents true intuition in that the professional is automatically applying a complex mixture of information, resulting in a splitsecond decision-making process. this highlights an aspect of intuition on which all of those who study the phenomenon agree: intuitive responses are reached with apparently no conscious effort. there is little or no awareness of deliberation (hogarth, 2001). this does not vitiate the fact that intuition is a legitimate cognitive process, different from, yet related to, what is traditionally understood as “thinking”. as gore and sadler-smith (2011) wrote: system 1 thinking and reasoning [intuition] is hypothesized as evolutionarily the more ancient of the two systems… its core international journal of integrative psychotherapy, vol. 8, 2017 82 processes are rapid, parallel, and automatic, permitting judgment in the absence of conscious reasoning… system 2 [deliberative problem solving] is more recent, its core processes are slower, serial, and effortful, permitting conscious abstract reasoning and hypothetical thinking (p. 304). the fact that one cannot typically analyze the cognitive processes that lead to an intuitive conclusion may be one of the reasons the vague definition of intuition as, knowing without knowing how you know, crosses disciplinary lines. while there is some accord among the cognitive psychology researchers concerning intuition, there is a great deal of disagreement about the phenomenon as well. they agree that intuition is the non-conscious processing of information, but they dispute the nature of that process. one hypothesis is a model premised on “the role of resemblance in prediction” (kahneman, 2011, p. 6). that is, one uses simplifying shortcuts or heuristics to find a pattern from past experience that matches the current situation in order to draw conclusions. kahneman (2011) has suggested that one of the most common short-cuts used in the intuitive process is to replace the actual problem at hand with one that is more readily solved. such cognitive shortcuts are highly biased, as they are based on the ease of retrieval of variables against which one matches the current situation (kahneman, 2011). this renders the resulting judgment vulnerable to emotion-based biases. thus, kahneman and other heuristic-model advocates believe that intuition is unreliable in many, if not most, circumstances. kahneman has noted that the unreliability of the heuristic model seems to fall away in the special condition of experts using intuition in their specific field. so-called “expert intuition” (p. 11) is based on situationally triggered cues that allow information stored in the memory to tacitly supply a heuristic. this recognition is very much in keeping with the learning theory model of intuition. there are actually several different learning theory models of intuition (see for example, plessner, betsch & betsch, 2008, for several such models), but they all share the point that intuition is the product of implicit learning. the proponents of this approach tend to give a positive valence to emotions. rather than being a source of unwanted bias, as the heuristic approach suggests (kahneman, 2011), those who forward a learning theory perspective suggest that emotions allow one to bypass the process of scanning memory. “[i]mmediate feelings can reflect the sum of experiences made with an attitude object” (betsch, 2008, p. 13). those who endorse this model tend to emphasize the reliability of intuition rather than its pitfalls, although they warn that intuitive judgments are best double-checked. international journal of integrative psychotherapy, vol. 8, 2017 83 one aspect of the cognitive models of intuition that may be quite important to the application of these research findings to clinical conditions, is the use of experimental protocols in which the participants must make decisions that are centered on impersonal issues. chief among these are probabilistic inferences. for example, perhaps the most widely used protocol requires the research participants to quickly determine such information as whether or not a city is the state capital (glockner, 2008). such judgments have limited relevance to a clinical context, where a therapist is experiencing intuition about another person with whom they are closely involved. perhaps due to the impersonal nature of the research protocols the cognitive psychologists employ, intuition from this perspective is understood to arise from within the individual. in this research, the process of arriving at the judgment is understood to be interior to the person having the intuitive experience. that is, there is no discussion of the possibility that the subject of the intuition plays any role in the process. in a clinical context, two subjectivities may operate in relation to each other, rendering it a different phenomenon from that studied in either the heuristic or learning theory models of intuition in which there is an intuiting subject and the object of intuition. psychoanalysis and psychotherapy: theoretical treatments of intuition and therapy within the history of psychotherapy, beginning with freud, intuition was a concept that received some attention. not all of this attention was positive. throughout the history of psychoanalysis, attitudes regarding the use of clinical intuition span the spectrum of outright rejection, to endorsement of its use. in some texts freud overtly eschewed intuition. he related intuition to occultism, religion, and other forms of extra-sensory perception, which he soundly devalued (reiner, 2004). for example, in beyond the pleasure principle (1920/1989), freud clearly rejected the role of intuition in the clinical process. in the question of a weltanschauung (1933/1989), he affirmed his position that psychoanalysis is a science, and therefore distinct from lower forms of religious thought. he asserted that, as a part of the scientific project, psychoanalysis should be grounded in empirical research. thus, it should admit “no knowledge derived from revelation, intuition or divination” (freud, 1933/1989, p. 784). while it is clear that freud shunned intuition, there is also a good bit of international journal of integrative psychotherapy, vol. 8, 2017 84 evidence that he changed his mind regarding intuitive knowing as a form of telepathy over the course of his career. in fact, there is some compelling evidence that freud had a personal telepathic experience that reversed his position (radin, 2006). ernest jones (1957), a student of freud, documented his teacher's foray into the world of "occultism." perhaps made clear by the use of this terminology, jones (1957) was not approving of freud's apparent shift in perspective. nonetheless, he presented a persuasive case that such a shift indeed occurred. for example, in 1921 freud wrote in a letter to the psychic researcher hereward carrington, “if i had my life to live over again, i should devote myself to psychical research rather than psychoanalysis” (jones, 1957, p. 392). in 1932 freud declared in his new introductory lectures, that "telepathy might be the kernel of truth that had become surrounded by fantastic occult beliefs" (jones, 1957, p. 405). jones appears to suggest that freud wrestled with the conflicting need to root his new therapy in science, as understood in the early part of the 20th century, in addition to acknowledging his personal experiences of the capacity to “know” through means other than the five orthodox senses. as psychoanalytic thinking has continued to evolve over the past century, some of its schools have softened considerably regarding freud’s original position about the role of intuition in the clinical process. brown (2009) observed that freud’s suggestion to use one’s unconscious as an instrument of analysis was inspirational to bion’s (1970/1977) development of the importance of intuition in analysis. bion stated the physician can see and touch and smell. the realizations with which a psycho-analyst deals cannot be seen or touched… for convenience, i propose to use the term ‘intuit’ as a parallel in the psycho-analyst’s domain to the physician’s use of “see,” “touch,” smell,” and “hear” (bion, 1970/1977, p. 7). following bion (1970/1977), jarreau (2012) has elaborated on the use of intuition in the psychoanalytic encounter. like bion, he equated the phenomenon with listening with the unconscious mind. he stressed that one must stop thinking, or at the very least not pursue more formal forms of theoretical cognition, in order to fully experience emotions that arise during time with a patient. in this state, free of memory and desire, one is able to apprehend the patient’s emotional experience. for jarreau, intuition brings insight into important aspects of the patient’s unconscious gained through unconscious communication. international journal of integrative psychotherapy, vol. 8, 2017 85 contemporary analytic literature of diverse schools has suggested that two human minds are capable of interpenetrating and reciprocally influencing each other. one person can “know” both some of the content as well as processes of another’s mind without explicit verbal communication or deductive reasoning based on observable evidence (see bass, 2015; beebe, knoblauch, rustin, & sorter, 2005; campbell & pile, 2015; sands, 2010). that is, one person can come to know the subjective experience of another without explicit communication or even the overt intention to acquire that knowledge. in addition to its presence in contemporary analytic thought, intuition is a cornerstone concept in jungian psychology (pilard, 2015). pilard (2015) has noted that there is widespread popular recognition that jung postulated intuition to be among the capacities that constitute psychological types. jung’s treatment of this conscious level of intuition represents, however, the tip of a proverbial iceberg. …intuition in jung’s theory comes from the abysses of the deepest unconscious of psychology… intuition is present everywhere instead of just in types and functions. to try to untangle all the forms of intuition present in jung’s writing is to expose its central and pivotal position in his psychology” (pilard, p. xiii). because of the centrality and complexity of jung’s treatment of intuition, a full explication of his theory is beyond the scope of this article. the interested reader is directed to pilard’s text. the important point here is that for jung and jungians, intuition is an important component of clinical method. carl rogers (1980) also recognized the role of intuition in the clinical process, although he did not formulate an explicit theory of the phenomenon. it appears from the quote below that rogers understood intuition to be part of a transcendent core, and a well-spring of healing. when i am at my best, as a group facilitator or as a therapist, i discover another characteristic. i find that when i am closest to my inner, intuitive self, when i am somehow in touch with the unknown in me, when perhaps i am in a slightly altered state of consciousness, then whatever i do seems to be full of healing. then, simply my presence is releasing and helpful to the other. there is nothing i can do to force this experience, but when i can relax and be close to the transcendent core of me, then i may behave in strange and impulsive international journal of integrative psychotherapy, vol. 8, 2017 86 ways in the relationship, ways which i cannot justify rationally, which have nothing to do with my thought processes. but these strange behaviours turn out to be right, in some odd way: it seems that my inner spirit has reached out and touched the inner spirit of the other. our relationship transcends itself and becomes a part of something larger. profound growth and healing and energy are present (rogers, 1980, p. 129). eric berne (1949/1977), the creator of transactional analysis, gave a prominent role to the concept of intuition. he defined the phenomenon as “knowledge based on experience and acquired through sensory contact with the subject, without the ‘intuiter’ (sic) being able to formulate to himself or others exactly how he came to his conclusions” (berne, 1949/1977, p. 4). he suggested that this knowledge can arise out of a number of different processes. the first process is the application of logic to conscious perception. the second process is through “unverbalized processes and observations based on previously formulated knowledge which has become integrated … through long usage… below the level of consciousness” (berne, 1949/1977, p. 1). the third process occurs through implicit cues. lastly, he described a process that is “quite unexplainable by what we know at present concerning sense perceptions” (berne, 1949/1977, p. 3). berne (1949/1977) focused primarily on process number three implicit cues. he postulated that this implicit knowledge leads one to perceive another based on patterns developed early in life. as schmid (1991) observed, “berne assumed that people react to their intuitive perceptions by alterations in their experience and behavior” (p. 145). by interacting with the other in a way that is consistent with this patterned perception, one elicits a response from the other that indeed repeats the pattern. berne (1949/1977) suggested that for intuitive judgments to be accurate, an “intuitive mood” (p. 22) must be present. “the intuitive mood is enhanced by an attitude of alertness and receptiveness without actively directed participation of the perceptive ego. it is attained more easily with practice; it is fatigable, and fatiguing” (berne,1949/1977, p. 25). the intuiter should be free of pressure to perform. he also noted that intuition seems to be enhanced once one has established “proper rapport” (berne, 1949/1977, p. 22) with the subject of the intuition. schmid (1991) has broadened berne’s (1949/1977) definition of intuition. he has given a decidedly constructivist interpretation of the process. based on the international journal of integrative psychotherapy, vol. 8, 2017 87 work of jung (1921/1972) and the jungian theorist von franz (von franz & hillmann, 1980), he suggested that intuition is not simply the application of a predetermined template onto the current situation, but an ability to apprehend what could be, what is possible, or potential. in keeping with berne’s (1949/1977) understanding of intuition existing outside of conscious awareness, schmid (1991) suggested that while a therapist may not be consciously aware of what they know, they nonetheless communicate in a way that actualizes the potential growth in the client. it is this unconscious communication that embodies and constitutes the content of the therapist’s intuitive process. he also suggested that this capacity may be relevant to the therapeutic alliance. the work of eric berne provided a foundation upon which integrative psychotherapy was built (o’reilly-knapp & erskine, 2003). yet, as central as the concept of intuition is to transactional analysis, there are few direct references to the word in the integrative psychotherapy literature. there are, however, two very important direct references to intuition in erskine’s work. in his 2008 article on unconscious experience, erskine directly referenced berne’s use of the term, and defined the phenomenon as “the therapist’s unconscious connecting with the client’s unconscious communication” (erskine, 2008, p. 129). prior to this insight, moursund and erskine (2004) referenced intuition in relation to attunement. attunement is perhaps one of the most prominent concepts in integrative psychotherapy (erskine, moursund, & trautmann, 1999). moursund and erskine (2004) differentiate attunement from empathy: they define the latter term as “vicarious introspection” (p. 98). in distinction from this activity of imagining how one would feel if one were in another’s place, attunement involves using both conscious and out-of-awareness synchronizing of therapist and client process, so that the therapist’s interventions fit the ongoing, moment-to-moment needs and processes of the client. it is more than simply feeling what the client feels: it includes recognizing the client’s experience and moving— cognitively, affectively, and physically so as to complement that experience in a contact-enhancing way (p. 98). the relationship between attunement and intuition is then explicated by moursund and erskine (2004). in discussing developmental attunement, the authors stated that an awareness of child development is crucial in order to attune to the client’s developmental level. but, they also cautioned that this form of attunement is also premised on intuition. international journal of integrative psychotherapy, vol. 8, 2017 88 probably the most important set of guidelines, though, comes from our own intuitive, emotional response to the client’s behavior… we are often able to pick up tiny cues, cues for which we are consciously unaware, from the nonverbal behavior of our clients; such cues can aggregate out of our awareness and make themselves known as a general hunch about how to respond most effectively (moursund & erskine, 2004, p. 105). thus, one may conclude that in integrative psychotherapy intuition is understood to be identified with attunement. marks-tarlow (2012), in her treatment of clinical intuition, also viewed intuition in terms of attunement. marks-tarlow (2012) has championed the use of intuition in psychotherapy. she argued that clinical work that is not informed by intuition is ultimately unethical. this is because theory-driven work, what she referred to as “top down” (markstarlow, 2012, p. 8) processing, biases a clinician to see whatever the theory posits, rather than the client’s experience. marks-tarlow suggested that clinical intuition is the result of right-brain to right-brain unconscious communication, as described in the work of the affective neuroscientist allan schore. schore (2005) has studied the right hemisphere of the brain for several decades. while his research was originally aimed at mother-infant interactions, he has stated that his work has direct relevance for therapist-client interactions. through the use of positron emission tomography (pet scans) and functional magnetic resonance imaging (fmris) to study brain functions that occur in time frames beneath conscious awareness, schore has documented, . . . bidirectional implicit affective communications embedded in proto-dialogues… [c]oordinated visual eye-to-eye messages, tactile and body gestures, and auditory prosodic vocalizations [serve] as a channel of communicative signals that induce instant emotional effects… the dyadic implicit processing of these nonverbal… communications of facial expression, posture, and tone of voice are the product of the operations of the infant’s right hemisphere interacting with the mother’s right hemisphere. (p. 833). international journal of integrative psychotherapy, vol. 8, 2017 89 thus schore, like other infant researchers, merges intuition with the non-conscious communication of micro-expressions and other non-verbal behaviors (see the boston change process study group, 2010). research on clinician use of intuition in the therapeutic encounter there is a limited but growing body of research on therapists’ use of intuition in clinical practice. in 1999, petitmengin-peugeot undertook a broad-based study of intuition that included non-clinical contexts. however, within this study, she examined a subsample of psychotherapists. these therapists discussed intuition as part of their concerted efforts to connect with their clients. they reported how focusing on specific parts of clients’ bodies generated a visual, kinesthetic, or auditory image of connection, such as a channel of light or energy vibration that created a bridge between the therapist and the client. charles (2004) has also explored clinical intuition. she gathered her information from two sources of data: a focus group of psychotherapists who selfidentified as intuitive, and the diaries of therapists who self-identified as intuitive. the focus group participants discussed the irrational nature of the experience, which rendered it difficult, if not impossible, to explain. they reported that the resultant understanding seemingly comes from nowhere. as in the petitmengin-peugeot (1999) study, the self-reported intuitive clinicians in the charles (2004) study also discussed the importance of the connection between themselves and the client. they suggested that there must be some “accord between the therapist and client” (p. 71) in order for the connections between the pieces to emerge. the participants also discussed the need to validate their clinical intuitions by checking with clients for accuracy and appropriateness. as charles (2004) stated, “subjective certainty does not guarantee veracity” (p. 71). jeffrey and fish (2011) undertook a qualitative study of marriage and family therapists in which the participants described their understanding of intuition, its function in their clinical work, and how they experienced the phenomenon. their findings fell into five basic categories: a) the nature of clinical intuition in marriage and family treatment; b) intuition and the therapist-client relationship; c) the spiritual dimensions of intuition; d) intuition and clinical training; and e) the felt resistance to recognizing the role of intuition from within the discipline. international journal of integrative psychotherapy, vol. 8, 2017 90 in the first category, participants described the affective and sense-centered experience of knowing about their clients. the second category involved the relationship between the clinician and the client, again suggesting that intuition is not a “one person” phenomenon. the research participants discussed the role of the client in facilitating or disrupting the intuitive process, thus suggesting that the client is clearly a co-participant in the process. the respondents elaborated on the topic of the connection between the client and the therapist by endorsing the belief system that there is a force that connects everything. intuitive therapists seemed clear that they drew upon this connection in order to allow for an intuitive understanding with a client. the fourth category was training. the respondents were clear that when they observed the use of intuition as modeled by supervisors, they were more comfortable using it in the clinical setting. some of the respondents elaborated on the sense of frustration they experienced because intuition was not taught in their curricula. they felt that the de-valuation of this important clinical tool was a deficit in their education as therapists. three theories regarding intuition in general, the literature cited above highlights three different theories regarding the nature of intuition. certainly, general theories and clinical theories need not be mutually exclusive, as intuition in general and clinical intuition specifically may be more than a singular phenomenon. nonetheless, the three theories currently represented in the literature include two cognitive theories: 1) the heuristic model, which purports that intuition is a “quick and dirty” problemsolving strategy that is highly prone to error due to retrieval bias (kahneman, 2011); and that, 2) intuition is the implicit application of tacit learning (plessner et al, 2008). an alternative explanation, that intuition may be a form of unconscious communication, is represented in the work of analysts and psychotherapists, including the integrative psychotherapy theorists. this theory suggests that the unconscious communication may be based on subliminal micro-expressions and non-verbal cues (schore, 2005), or that it is the result of a basic connection between people (jeffery & fish, 2006). an important difference between the cognitive psychologists’ theories of intuition and those of the psychoanalysts and psychotherapists is the degree to which clinical intuition may be interactive. the former posits a one-person model, or a process that occurs in the mind of the intuitive. the latter suggests that intuition can be a two-person phenomenon in which the intuitive clinician is engaged in a international journal of integrative psychotherapy, vol. 8, 2017 91 specific type of relationship with his or her client, and that intuitive knowing is the result of some type of communication. to further elaborate on the ideas discussed thus far, a case example follows that demonstrates how one therapist used her intuition to make an important clinical decision. julie’s intuition – an example of the use of clinical intuition this case material was collected during a multiple case study on boundary dilemmas as experienced by therapists. the study received institutional review board approval, and the participants provided informed consent. participants engaged in a recorded semi-structured interview, which was transcribed. the material presented here has been altered by moving chunks of data to give the piece narrative coherence. that is, the words are the actual words of the participant, excepting those in brackets. the bracketed information is supplied for clarity. the re-arrangement is supported in constructivist research (see rodwell, 1998), in which the inquirer is encouraged to use narrative and creative non-fiction techniques necessary to tell a story. as the nature of narrative data is such that any given event or topic may arise repeatedly in different parts of the interview, rearrangement renders the narrative more cohesive. “julie” (a pseudonym) identified her approach to treatment as, “humanistic, probably a little existentialism, problem solving, acceptance and commitment therapy and… cognitive behavioral therapy, solution focused. it’s fairly humanistic, as integrated, relying most heavily on humanist theory”. she is in private practice as a contractual employee of a psychiatric practice and had been licensed for twelve years at the time of the interview. she is a licensed clinical social worker. she became a psychotherapist somewhat later in her career, having worked as a non-clinical social worker since the 1990’s. one day i disclosed to [a client who was struggling with alcoholism] that a member of my family is an alcoholic and i had had some experience with various treatment centers and this is what i knew. now why did i disclose that, why did i tell her that? my gut. just my gut. that intuitive feeling. it should-of been the code of ethics. i’ve since gone back and reviewed the code of ethics. i didn’t consult, i didn’t evaluate, i didn’t do all of the process thinking. it was more or international journal of integrative psychotherapy, vol. 8, 2017 92 less intuitive and from my gut. i had a feeling that it would be okay. i was comfortable with that. i know i should have consulted a colleague. even more important than that i think i should have followed up with her… i missed the boat on that one. i consult with my colleagues i do, i don’t hesitate. i didn’t do it on this one, why? i didn’t consult, i didn’t evaluate, i didn’t do all of the process thinking. it was more or less intuitive and from my gut. i had a feeling that it would be okay. i thought about [why i disclosed] when i was thinking about this on the way over [to the interview]. i did think of the word credibility. i wanted her to see that i just might have an understanding of her perspective, i might have an understanding, a better understanding. this might put me in a position to have a better understanding of what she could be going through. her struggle was known to me. credibility, but a different kind of credibility from a more personal perspective i think. i disclosed that information, she was surprised that i had. not surprised at my disclosure but surprised to learn that i had dealt personally with this issue. i do think it helped her to understand that this had touched my life personally in a very meaningful way. just as it was touching her life as well. perhaps it was to lend itself to that, i’m not sure. it would do no harm, but there was a potential that it could do some good. i thought my disclosure would help her to understand as i said that maybe i do have the knowledge to think that maybe i do have a different kind of understanding about what she’s going through. i wanted her to see. i wanted to if there was any barrier there where she felt you don’t understand, you don’t get what i’m going through. i guess the fact that she disclosed [her drinking] at all said something about the level of trust in our relationship. that was important to me and the fact that i disclosed to her said something about the level of trust i had in the relationship, i think. [i]t maybe lent itself to her feeling that i really could empathize with her. i mean really could empathize with her. it took empathy maybe to another level, maybe i don’t know. maybe that’s what it did. i had international journal of integrative psychotherapy, vol. 8, 2017 93 hoped that and i do hope that it inspired her in some way to perhaps towards going to detox. to joining a group, to admitting to a group of women that she is an alcoholic. maybe it just helped to move her a little farther along. that it just crosses, alcoholism crosses all lines. it was an equalizer. before i made that disclosure i certainly thought about her ego strength, what about her developmental history, what about this, what about that. i think maybe i had those things in my… those issues wrapped up somewhere else. yes, i certainly thought about her ego strength and i thought about her history. i thought about her situation, i thought about the context of her life and the context of how our relationship fit into that context. i guess context is very important to me. the context, what’s going on in a client’s life, what’s going in mine that makes me maybe compelled to share this. all these things were going on in my head and i hadn’t shared it with her. i’d been working with her for a long time and we had consistently talked about inpatient treatment and whether or not she felt she needed that and how i could be helpful in this process. i think the reason why i disclosed to her, one of the reasons again not somebody else—other people i worked with similar problems is that i felt something for this woman. there was a real connection there. i knew her, i felt i knew her as much as i could and felt safe. i felt safe in making that as safe as i could in making that disclosure. it was a good relationship. there was something else with this particular there was a closeness. i want to make room i want to preserve the connection but make room for growth and the connection. i don’t want to do anything because of my own self-interest known or unknown to jeopardize the potential that’s in that connection. that potential for change in a client that’s in that connection. [the disclosure] solidified [the connection]-not “solidify.” what’s the word i’m looking for? i can’t think of essence. adds an essence, something more. i guess i really felt it would lend itself to the therapeutic relationship. i really liked this woman; i really respect her. i want the very best for her in terms of helping her to make better, healthier choices for herself. i felt i guess, one of the things i felt was that she was asking for help. i mean she was desperate, she was asking for help and i felt an international journal of integrative psychotherapy, vol. 8, 2017 94 obligation to do what i could to help her make different choices, to get on track again. the client was absolutely desperate. she was drinking quite a bit, excessively at night again. [she felt] guilt, shame, remorse, self-hatred. yeah, all of that, some of the same emotions that i have felt in my personal experience with this family member, but from a different angle. i no longer see her privately. i assisted her in getting into detox for about a week. then she came out and then she saw me one other time before she could meet with the other therapist in town [who is an addictions specialist]. she is now engaging in group therapy and individual therapy with this other agency and seems to be doing well. now i do see her once every other week, i do a woman’s support group where i am, and the beautiful thing is that she was able to disclose just only recently to the other women that she is an alcoholic. it just was wonderful. discussion this example of a therapist’s use of intuition illustrates three important points regarding clinical intuition that were noted in the literature review. given the emphasis in integrative psychotherapy on the relationship (o’reilly-knapp & erskine, 2003), perhaps the most important point the case illustrates is that the use of clinical intuition is a relational phenomenon. the second point is that the use of clinical intuition is so closely associated with good clinical judgment that the two are indistinct. finally, julie anticipated that she would be criticized for using her intuition. the first point focuses on the therapist’s intuition as a relational experience. from the perspective of integrative psychotherapy, the importance of the therapeutic relationship cannot be understated (erskine, 2011; erskine & trautmann, 1996; o’reilly-knapp & erskine, 2003). erskine and trautman (2003) have noted that the importance of relationship to human well-being is widely recognized by various schools of psychotherapy, and thus can form the foundational construct for integrating different theories and types of therapy. integrative psychotherapy in particular, stresses the need for contact-in international journal of integrative psychotherapy, vol. 8, 2017 95 relationship (erskine & criswell, n.d.) as the centerpiece of the therapeutic process. erskine (in erskine & criswell, n.d.) stated: the quality of the relationship we build becomes the heart of everything else that happens in the therapy… it is not the techniques that heal… it is the contactful (sic) therapeutic relationship that heals our clients’ relational wounds. our therapeutic involvement is honed by the way in which we understand the client’s experience and how we bring our own experience into the therapeutic relationship: (para. 1-5). julie’s narrative speaks directly to this quality of relationship. her decision to act on her intuition was premised upon her profound contact with her client and the client’s situation: i think the reason why i disclosed to her, one of the reasons again not somebody else other people i worked with, with similar problems is that i felt something for this woman. there was a real connection there. i knew her, i felt i knew her as much as i could… there was something else with this particular there was a closeness. the therapists who participated in the studies cited in the literature review, above, suggested that they actively generated and/or held in high importance a sense of connection between themselves and their clients during their use of clinical intuition. julie’s case takes this information a step further since it suggests that not only was the relationship between the therapist and client an important prerequisite for clinical intuition, but the use of knowledge gained through intuitive means deepened the therapeutic alliance. as julie noted, “[i]t maybe lent itself to her feeling that i really could empathize with her. i mean really could empathize with her. it took empathy maybe to another level…” julie’s motivation to use her intuition to make a clinical decision was based on her desire to deepen the existing connection. she wished both to “even the playing field” in terms of enhancing the felt sense of mutuality and also be seen as human. thus, julie’s use of intuition did not simply emanate from the therapeutic alliance but may have enhanced it by communicating her “contactful psychotherapeutic presence” (erskine, 2011, p. 10). the second point, regarding how clinical intuition is so closely associated with good clinical judgment that the two are often indistinct, is more complex. it international journal of integrative psychotherapy, vol. 8, 2017 96 involves three related points: 1) that julie used intuition to make an important treatment decision, 2) that the intuitively derived decision is enmeshed with solid clinical judgment based on clinical data, and 3) that this use of intuition was both ethical and successful. first, it came as a surprise to the researcher who gathered this data, that the therapist freely revealed that the means by which she resolved a boundary dilemma was intuition. julie is clear that the decision was based on intuition. she used the word “intuition” explicitly and referred to her “gut.” this information appears to have remained on an implicit level: “i think maybe i had these things… wrapped up somewhere else.” indeed, the explicit knowledge appears to have surfaced only as she contemplated participating in the interview: “i was thinking about this on my way over.” it must be immediately noted that the use of intuition was not a departure from solid clinical judgment but was so interwoven with clinical data that the two cannot be distinguished. julie had a great deal of information about her client’s functioning. her intuitive decision was based on a nuanced understanding of what the client needed and what was in the best interest of the client. in describing her process in this particular case, she demonstrated a broad understanding of several important clinical factors, specifically identified as ego strength, developmental history, and context. in addition, she brought in her own life experience that informed her professional decision-making. thus, her intuitive decision was wellgrounded in a thorough knowledge base regarding herself and the functioning of her client. it was not a substitute for, nor antithetical to, appropriate clinical judgment. one may question the ethical aspects of basing therapist self-disclosure on intuition. clearly, julie placed the welfare of her patient at front and center. she stated, “i don’t want to do anything because of my own self-interest known or unknown… i want the very best for her in terms of helping her to make better, healthier choices for herself.” in the face of her client’s pain, julie stated, “i felt an obligation to do what i could to help her make different choices, to get on track again. the client was absolutely desperate”. even though her focus was to lessen her client’s pain, julie questioned if her actions could in any way serve her own needs. she believed that if the client was aware of the degree to which this therapist could relate to her experience, it may lessen the client’s shame-response and mobilize her ability to enter into a treatment program. confident that ultimately, she was serving her client’s best interest, julie acted on her intuitively derived decision. after the fact, she reviewed the national association of social workers’ international journal of integrative psychotherapy, vol. 8, 2017 97 code of ethics (national association of social workers, 1999), and was “comfortable” with her decision. finally, julie’s clinical acumen, which included the judicious use of her intuition, contributed to a successful outcome for this case. julie had hoped that her disclosure would help the client seek appropriate treatment, including detox, and the client did so. subsequently the client entered detox with on-going treatment and appears to be past her shame, as she has disclosed to group members her status as an alcoholic. the third point illustrated by this case is that while this clinician’s use of her intuition was an integral aspect of her practice, she anticipated criticism for using it, and a general negative valuation of her use of clinical intuition. therefore, she was conflicted over her use of intuition in making an important clinical decision. although she affirmed that she felt comfortable with her decision, she secondguessed her use of intuition. in an almost confessional tone she suggested that she should have consulted a colleague, or she should have looked at her professional code of ethics sooner. the “shoulds” appear to undermine her confidence in her professional mastery, in spite of the successful outcome. in response to this common dilemma, the authors are in agreement with the jeffrey and fish (2011) participants: had this therapist been exposed to the value of clinical intuition during her education and socialization as a therapist, she may have been spared some stress. in the ever-evolving attempt to find what works in psychotherapy, researchers have determined that there is a vast and complex set of factors to consider. the question of which of the nearly infinite factors to consider, in conjunction with how they are likely to interact, requires clinicians to individualize treatment. the american psychological association has suggested that relationship factors are at the heart of this process (norcross, 2011). this case demonstrates the clinician’s individualization of treatment and her ability to use the relational context of psychotherapy was enhanced through her use of intuition. in a deep state of connection and empathy that is at the very core of integrative psychotherapy (o’reilly-knapp & erskine, 2003) the psychotherapist in the case example was able to go beyond treating symptoms. by connecting at a deep human level she enabled her intuition to inform her on how to best reach the treatment goals. international journal of integrative psychotherapy, vol. 8, 2017 98 conclusion there is a modest but growing body of literature about intuition in general, and clinical intuition specifically. research in academic and non-academic settings has focused on defining what intuition is, how it operates, and the legitimacy of intuitively derived information. while there is widespread disagreement concerning these questions, there is also a significant core of agreement between the different perspectives. one possible source of disagreement is perhaps that what we refer to as “intuition” is actually several distinct phenomena, indicating the need for further research and investigation. julie’s case demonstrates important aspects of intuitive decision-making in the clinical context. perhaps the most obvious, yet also the most important point to understand, is that therapists in fact use intuition to make clinical decisions. however, it is important that they do so as part of an overall understanding of individual clients’ functioning and needs and are able to use intuition ethically and effectively. this case also illustrates that clinical intuition is in some cases derived from a strong connection between the therapist and client and is also a source of potential enhancement of this connection. as is highlighted in integrative psychotherapy, this relationship is at the very core of the healing process (o’reillyknapp & erskine, 2003). thus, intuition should be taken very seriously as an important therapeutic tool. finally, this case illustrates that the current negative climate regarding the use of clinically based intuition by psychotherapists may be doing a disservice to clinicians, as well as their clients, by ignoring or even denigrating the importance of clinical intuition. it is the authors’ sincere hope that this topic may be openly discussed and studied among our colleagues, for the benefit of our clients. author: margaret arnd-caddigan, phd, lcsw, is an associate professor at east carolina university school of social work. she is the director of the greenville psychoanalytic study group, associate faculty of the psychoanalytic center of the carolinas, and has a small private practice in greenville, north carolina. she and the co-author are currently researching the use of intuition among licensed clinical social workers. marilyn stickle, lcsw, bcd has worked in a state psychiatric facility, community mental health, and private practice with children, adolescents, and adults. active international journal of integrative psychotherapy, vol. 8, 2017 99 in the clinical social work community for over 35 years she has served on several boards, has been a faculty member at the clinical social work institute, is a seminar and meditation group leader, and has presented papers nationally and internationally on intuition and spirituality. she is currently in private practice in arlington, virginia. references bass, a. (2015). the dialogue of unconsciousness, mutual analysis and the use of self in contemporary relational psychoanalysis. psychoanalytic dialogues, 25, 2-17. beebe, b., knoblauch, s., rustin, j. & sorter, d. (2005). forms of intersubjectivity in infant research and adult treatment. new york, ny: other press. berne, e. (1977). the nature of intuition. in p. mccormick (ed.), intuition and ego states: the origins of transactional analysis (pp. 1-31). san francisco: ta press. (original work published in 1949). betsch, t. (2008). the nature of intuition and its neglect in research on judgment and decision making. in h. plessner, c. betsch, & t. betsch (eds.) intuition in judgment and decision making. (pp. 3-19). new york, ny: lawrence erlbaum associates. bion, w. r. (1962). learning from experience. lanham, md: rowman and littlefield. [reprinted in 1977 in seven servants. new york, ny: jason aronson.] bion, w. r. (1970). attention and interpretation: a scientific approach to insight in psycho-analysis and groups. london: tavistock. [reprinted in 1977 in seven servants. new york, ny: jason aronson.] boston change process study group (2010). change in psychotherapy: a unifying paradigm. new york, ny: w. w. norton. brown, l. j. (2009). from “disciplined subjectivity” to “taming wild thoughts”: bion’s elaboration of the analyzing instrument. international forum of psychoanalysis, 18, 82-85. campbell, j. & pile, s. (2015). passionate forms and the problem of subjectivity: freud, frau emmy von n. and the unconscious communication of affect. subjectivity,8, 1-24. charles, r. (2004). intuition in psychotherapy and counselling. london: whurr. erskine, r. g. (1998). attunement and involvement: therapeutic responses to relational needs. international journal of psychotheray, 3, 235-244. international journal of integrative psychotherapy, vol. 8, 2017 100 erskine, r. g. (2008). psychotherapy of unconscious experience. transactional analysis journal, 38, 128-138. erskine, r. g. (2011). attachment, relational-needs, and psychotherapeutic presence. international journal of integrative psychotherapy, 2(1), 10-18. erskine, r. g. &criswell, g. e. (n.d.). psychotherapy of contact-in-relationship: conversations with richard. integrative psychotherapy articles. retrived from http:// www. integrativetherapy.com/en/articles.php?id=100. erskine, r. g., moursund, j. p., & trautmann, r. l. (1999). beyond empathy: a therapy of contact-in-relationship. philadelphia: brunner/mazel. erskine, r. g. & trautmann, r. l. (1996). methods of an integrative psychotherapy. transactional analysis journal, 26, 316-328. ferro, a. & basile, r. (2009). the universe of the field and its inhabitants. in a. ferro and r. basile (eds). the analytic field: a clinical concept. (pp. 5-29). london: karnac. freud, s. (1920/1989). beyond the pleasure principle. p. gay (ed). the freud reader. new york, ny: w. w. norton. freud, s. (1933/1989). the question of weltaschauung. p. gay (ed). the freud reader. new york, ny: w. w. norton. glockner, a. (2008). does intuition beat fast and frugal heuristics? a systematic empirical analysis. in h. plessner, c. betsch, & t. betsch (eds.) intuition in judgment and decision making. (pp. 309-325). new york, ny: lawrence erlbaum associates. gore, j. & sadler-smith, e. (2011). unpacking intuition: a process and outcome framework. review of general psychology, 15, 304-316. hogarth, r. m. (2001). educating intuition. chicago: university of chicago press. hogarth, r. m. (2010). unpacking intuition: a process and outcome framework. psychological inquiry, 21, 338-353. jarreau, a. (2012). intuiting the unknown: listening with the unconscious mind. modern psychoanalysis, 37, 66-81. jeffrey, a. j. & fish, l. s. (2011). clinical intuition: a qualitative study of its use and experience among marriage and family therapists. contemporary family therapy, 33, 348-363. jones, e. (1957). the life and work of sigmund freud, volume 3 the last phase. new york, ny: basic books. jung, c. g. (1972). typologie. olten: walter verag ag. (original work published 1921). kahneman, d. (2011). thinking, fast and slow. new york, ny: farrar, straus and giroux. international journal of integrative psychotherapy, vol. 8, 2017 101 lieberman, m. d. (2000). intuition: a social cognitive neuroscience approach. psychological bulletin, 126, 109-137. marks-tarlow, t. (2012). clinical intuition in psychotherapy: the neurobiology of embodied response. new york, ny: w. w. norton. moursund, j. p. & erskine, r. (2004). integrative psychotherapy: the art and science of relationship. pacific grove, ca: thomson brooks/cole. national association of social workers. (1999). code of ethics of the national association of social workers. washington, dc. nasw press. norcross, h. (2011). conclusions and recommendations of the interdivisional (apa divisions 12 & 29) task force on evidence-based therapy relationships. retrieved from http://societyforpsychotherapy.org/evidence-based-therapy-relationships/ o’reilly-knapp, m, & erskine, r. (2003). core concepts of an integrative transactional analysis. transactional analysis journal, 33, 168-177. petitmengin-peugeot, c. (1999). the intuitive experience. journal of consciousness studies, 6(2-3), 43-77. pilard, n. (2015). jung and intuition: on the centrality of forms of intuition in jungian and post-jungians. london: karnac. plessner, c. betsch, & t. betsch (eds.) (2008). intuition in judgment and decision making. new york: lawrence erlbaum associates. radin, d. (2006). entangled minds: extrasensory experiences in a quantum reality. new york, ny: simon & schuster. reiner, a. (2004). psychic phenomena and early emotional states. journal of analytical psychology, 49, 313-336. rodwell, m. k. (1998). social work constructivist research. new york, ny: garland publishing. sands, s. h. (2010). on the royal road together: the analytic function of dreams in activating dissociative unconscious communication. psychoanalytic dialogues,20, 357-373. schore, a. n. (2005). a neuropsychoanalytic viewpoint: commentary on paper by steven h. knoblauch. psychoanalytic dialogues, 15, 829-854. schmid, b. (1991). intuition of the possible and the transactional creation of realities. transactional analysis journal, 21, 144-154. sinclair, m. (ed.). (2011). handbook of intuition research. cheltenham, uk: edward elgar. von franz, m. l., & hillman, j. (1980). zur typologie c.g. jung tellbach-oeffingen: verlag adolf bonz gmbh. http://societyforpsychotherapy.org/evidence-based-therapy-relationships/ international journal of integrative psychotherapy, vol. 8, 2017 102 character adaptation systems t...doc (883 kb) international journal of integrative psychotherapy, vol. 11, 2020 85 the role of shame in the development of the schizoid process lynn martin1 abstract the author considers the role of shame and the response to it, which she describes as self-protective avoidance of relationship, in the development of a schizoid process. she proposes that the intention and action of suicide may in some cases be the ultimate schizoid withdrawal. she describes her work over 10 years with a young woman who required a gentle, attuned, relational process to help her heal a relational split. keywords: schizoid process, schizoid compromise, shame, suicidal ideation, suicide, somatic, psychogenic pain, script beliefs, attunement, relational needs the referral some years ago, i received a call from a woman who was desperate for me to work with her adult daughter, carmen, who had just been discharged from a psychiatric unit. normally i would expect an adult client to make their own contact and request for therapy, but the desperation in her mother’s voice convinced me to make an exception. it was also clear that her daughter did not have the capacity to make the request herself because of her deeply depressed state and inability to connect with the world in any meaningful way. carmen’s medical and psychological history carmen had made several attempts to take her own life and had a history of chronic abdominal pain dating back to adolescence, the cause of which could not be established despite seven exploratory laparoscopies. a small amount of endometriosis had been found but not nearly enough to justify the level of pain that carmen experienced. 1 e-mail: lyn44martin@gmail.com international journal of integrative psychotherapy, vol. 11, 2020 86 carmen had first engaged in counseling for 2 years at school when she was between 14 and 16 years old. she had more counseling during her university years followed by three blocks of cognitive-behavioral therapy (cbt) through her doctor’s surgery in her twenties. none of the therapy so far had been useful. carmen was in her early thirties and on long-term sick leave from her work in the pharmaceutical industry when we began our work together. her therapy continues as i write this article, and we have talked about the potential impact of my writing, including the possibility that her agreement to my using her material came from a compliant, transferential place. we have considered that we might use this article in her ongoing therapy, slowly exploring and dealing with the inevitable shame that is stimulated through our exploration of her therapeutic journey thus far. the etiology of pain at the beginning of our work, carmen was taking 11 types of prescribed medication, including two antidepressants and an antipsychotic, high doses of opiate medication and other analgesia, hormone treatment, and a nerve block every few months. none of this appeared to have any impact on her level of physical pain or her depressed mood. whether the physical pain was a manifestation of her psychological pain or vice versa was an important consideration for me. the word pain comes from the latin poena, meaning punishment or penalty, so i wondered if carmen’s physical pain was a form of unconscious self-punishment or a kind of self-destructive behavior, although she described it to me during a session as “a big hug.” we discover that in the course of the child’s development, pain and relief of pain enter into the formation of interpersonal (object) relations and into the concepts of good and bad, reward and punishment, success and failure. pain becomes par excellence a means of assuaging guilt and thereby influences object relationships. (engel, 1959, p. 899) although the link between somatic and psychogenic pain has been well discussed in the psychiatric literature for many years (bass, 1990; blumer & heilbronn, 1982; engel, 1959; tyrer, 2006), carmen’s physical pain and depressive symptoms had been treated individually and separately since their onset in adolescence, without success. her pain and suicidal intent always increased when the status quo was threatened and especially if anyone suggested that she was getting better. when i suggested to her that taking international journal of integrative psychotherapy, vol. 11, 2020 87 responsibility for the management of her medication represented a step forward, she described my comment as a “slap in the face.” this was an example of my misattunement to her relational needs (erskine et al., 1999) in that moment. i believe that she needed to continue to define herself and for me to be accepting of her without judgment instead of validating her change in behavior, which meant that i was defining her. the beginning of therapy my first impression of carmen was that she was overweight, unkempt, and older than her years. much of the excess weight was a side effect of her medication. through her heavy sedation, she found coherent thought difficult, and her ability to verbalize was initially exceedingly difficult, at times impossible. as an intelligent woman, this inability to articulate her thoughts and feelings stimulated her shame and reinforced her script beliefs of being “useless, worthless, and unable to do anything right.” during this first phase of therapy my task was simply to be a stable, dependable other who had no agenda and no expectations of carmen. i imposed no time scale for her to be well and return to work. my focus was on careful rhythmic attunement, not too fast so that she felt overwhelmed and not too slow so that she felt abandoned. it took many sessions of my sitting and waiting for her to feel safe enough in our relationship for her to begin to emerge. all of the psychological assessments and offers of therapy from the psychiatric services, none of which carmen had found helpful, simply increased her shame and belief that everything was her fault. she told me that her husband had constantly shamed her for not being able to do anything right. if she vacuumed the carpet, he found pet hair that she had missed; if she chopped vegetables, he claimed they were the wrong size. he told her that it was her fault that their marriage had failed. at work, if she was summoned to her manager’s office, she always assumed that she had done something wrong. carmen’s final attempt to hang herself came after a failed attempt by hospital staff to perform a nerve block. she naturally believed that its failure was her fault, and coinciding with my absence at a conference, it overwhelmed her. suicide seemed to be the only way she could withdraw far enough. as yontef (2001) wrote: international journal of integrative psychotherapy, vol. 11, 2020 88 suspended in the death-level conflict between total isolation and being swallowed up, these individuals often feel tired of life and the urge for temporary death. this is not active suicide, just exhaustion from living a life with insufficient nourishment. (p. 11) for carmen, after so many years of a battle to which she could see no end, it was another active attempt at ending her life. carmen’s early life and relationship with her parents fairbairn (1952) suggested that people who develop a schizoid process are bought up by parents who were unable to demonstrate tender, loving emotions, causing the child to experience rejection and to withdraw into an inner world that is safer but lonely. carmen was the only child of professional parents whom she experienced as having no time for her. she had a clear script message that she was always in the way. both masterson (1988) and yontef (2001) described the cold, disconnected childhood experience of someone who develops a schizoid process, and on several occasions carmen told me that her father’s view of children was that they were a “sexually transmitted disease.” when she first told me this, there was no feeling in her voice, as if she had just told me that it was raining. over time, with each new telling of this story, the distress and shame that this view of herself caused her became more apparent. eventually she was able to connect with an appropriate angry response to being defined in this way by her father. each new appropriate expression of affect, especially anger, coincided with an improvement in her mood and a decrease in her physical pain. through careful attunement to carmen’s capacity to connect with her own outrage, my role during this time was to assess what would be an appropriate response from me. if i had expressed my own indignation too soon, i would have been at odds with carmen’s response, and offering my judgment on the parents whom she still relied on so heavily would have been counterproductive. i attempted to obtain a picture of carmen’s childhood and early adult life through historical inquiry, which was difficult because of the heavy doses of medication that made her barely able to stay awake in our first year or so of therapy. i felt as though i was just holding a space where there were no demands, criticisms, or definitions. international journal of integrative psychotherapy, vol. 11, 2020 89 the first real breakthrough came after nearly 2 years when she said, “i’m not worth anything.” then, immediately, without being prompted by me, she changed her statement to, “i don’t believe i’m worth anything.” this showed that her selfdefinition was changing, and she was becoming more aware of the script decisions that she had made early in her life. supervision and shame often during the first few years of therapy with carmen, i would think to myself that we were just chatting. we chatted about birds, gardening, wildlife—anything provided it was a safe subject that did not require any deep self exploration or expression of affect. i took this to supervision regularly and always felt criticized by my supervisor’s response, which was to question my lack of working at depth with and challenging carmen. this, of course, paralleled the criticism, both real and imagined, that carmen experienced from her husband, parents, and managers at work and that left her feeling that she could never be good enough. this parallel process stimulated my own shame for not being a good enough therapist, which in turn caused me to distance myself from my supervisor. with hindsight, it might have been more helpful to explore with my supervisor my countertransference, which made me very protective of carmen. her transference invited me to be the idealized mother who had been missing all her life, which was vital during the years in therapy when she was actively suicidal. she needed a mother who would validate her internal experience and be stable and dependable (erskine et al., 1999). i always returned from my supervision sessions resolved to challenge carmen to go deeper and to express more of what she was experiencing phenomenologically. i was aware that sometimes i felt irritated by her inability to work at greater depth. i was at risk of projecting my shame onto my client and blaming her for her lack of progress in the therapeutic work—a blame, of course, that was familiar to carmen throughout her life and would have confirmed her script that it was all her fault. however, by continuing to work within the transference, i chose not to challenge but to support, validate, and nurture so that carmen began to develop a sound sense of who she might be as an adult. working with the schizoid process from what i now know about working with someone who has such a profound schizoid process, my intuitive way of working was exactly what carmen needed, and it provided an attuned, holding environment (bowlby, 1969). this was international journal of integrative psychotherapy, vol. 11, 2020 90 something she had never experienced as an infant, which resulted in her never developing an emotional attachment to her mother or father. my aim was to encourage a healthy attachment to me that would act as a template for developing other healthy emotional attachments. i believe that what appeared to be somewhat superficial conversation also had a protective function. it kept us away from any deep connection that might have allowed an exploration of affect that was deeply buried for fear of the impact it might have on her ability to manage relationships within which she experienced a considerable amount of ambivalence. these relationships included her parents, her husband, and possibly me. it also reflected guntrip’s (1962) schizoid compromise, whereby we could be in relationship as long as the level of intimacy was superficial. another profoundly harmful script belief for carmen was that she was “in the way.” as mentioned earlier, both her parents were successful career people, and toward the end of her primary schooling, they both were appointed to new posts in a different town. carmen was left at the family home during the week and cared for by a neighbor while her parents worked away. they returned each weekend, but carmen’s memory is that they made no attempt to engage with her needs but expected her to fit into the activities in which they engaged. it was only later in her therapy that carmen connected with intense rage toward both her parents and her husband. however, as a child, she relied entirely on her parents. she rarely mentioned extended family, and as an only child they were all she had. at the beginning of her therapy, she continued to rely on them because they held her medication, delivering one day’s supply at a time, so she was unconsciously replaying her childhood dependence. as she began to get in touch with her anger toward her husband, she realized that he had never made her a priority. for example, he refused to take a day off work when carmen needed to go into hospital for a surgical procedure. she would not be able to drive herself home again, and the anesthetic meant that she was advised not to be alone for 24 hours after the operation. he arranged for someone to pick carmen up from the hospital and drop her at the door to their house. sometimes, as i reflected on our work, i noticed the changes that she was making and found it hard to understand how “chatting” could have possibly helped to facilitate those. now i understand that the importance of our chatting was that it enabled our secure bond to form with no threat to carmen’s integrity. just to sit in silence with carmen would have been shaming to her because she international journal of integrative psychotherapy, vol. 11, 2020 91 would have believed that she was bad for not being able to fill the silence. instead, our therapy sessions became a place where there was no risk of her being shamed, and our interactions provided a relationship in which she felt accepted and respected, where nothing harmful was demanded of her. shame and the schizoid withdrawal nathanson (1994) described a number of defenses against shame, including withdrawal and attacks on the self. with carmen, i had to learn the importance of both rhythmic and affective attunement in avoiding a schizoid withdrawal when making phenomenological inquiry. her inability to express her phenomenological experience would lead to shame, the defense against that being the denial of the need for relationship and consequent withdrawal (erskine, 1995). erskine suggested that “shame is a complex process involving (1) a diminished selfconcept, a lowering of one’s self worth in confluence with the external humiliation and/or previously introjected criticism; (2) a defensive transposition of sadness and fear; and (3) a disavowal and retroflection of anger” (p. 109). disavowal of anger carmen’s disavowal of anger was absolute, and i realized that part of my role was to help her to reconnect with her retroflected anger at a pace that was tolerable and acceptable within her script beliefs. in the first few years of her therapy, any mention of anger would send carmen into a defensive withdrawal because she experienced anger as shameful and leading to conflict. if i mentioned anger, she would always say, “i don’t like conflict.” with her parents, carmen would go to any length to avoid expressing her anger toward them, sometimes cutting her legs with scissors as a way of retroflecting her anger, particularly toward her mother. in the early years of her therapy, any attempt at phenomenological inquiry would result in carmen looking frightened. being unable to answer my questions about what she was experiencing internally led to her feeling shamed because she thought that she “ought” to know. so, in those days, when i noticed the tension in carmen’s body and the darkness of her frown, i would tentatively say, “as you say that you sound angry.” her response would be to twist her fingers, her feet would point inward and raise up to give the impression that she was so small that her feet could not reach the ground, and she would respond with “but i don’t feel angry” in the high pitched voice of a young child. the obvious defensive position that she adopted at those times was a clear message that i had international journal of integrative psychotherapy, vol. 11, 2020 92 overstepped the mark in noticing the anger that terrified her and that had been disavowed. it was a clear misattunement on my part that resulted in a schizoid withdrawal. however, without those gentle invitations to notice her anger, no progress would have been made. over time, through my noticing when either her tone of voice or her body language suggested that she was experiencing anger, she slowly began to recognize her affect and gradually learned to express her feelings more authentically. working in conjunction with other psychological professionals because i was working in conjunction with local psychiatric services, i attended carmen’s case reviews at her request. i met with her psychiatrist and community psychiatric nurse, and her general practitioner and parents were initially also present. at these meetings, i received a good deal of criticism for not working in a more solution-focused and time-limited way. the written reports following those meeting continually reiterated that open-ended therapy was not effective and that “a planned and managed ending that is a focus from the onset is of most therapeutic value.” throughout our work, any suggestion that her therapy needed to be time-limited would stimulate a schizoid withdrawal and an increase in physical pain for carmen. as guntrip (1962) wrote, “there is certainly no quick and easy way of making a stable and mature adult personality out of the legacy of an undermined childhood” (p. 273). carmen’s psychiatric diagnosis was avoidant and dependent personality disorder with recurrent depression. it reminded me of johnson’s (1994) view of the continuum from schizoid personality disorder at one end to avoidant style at the other. in his description of the early development of the schizoid process, johnson suggested that the hatred of the caretaking parent will be introjected and will begin to suppress the life force of the organism, such that movement and breathing are inhibited and there develops an involuntary tightening of the musculature to restrain the life force. (p. 75) the dilemma of challenge whenever carmen felt any challenge from me, no matter how small or gentle, her breathing would become seriously restricted. and when she began to feel tears pricking behind her eyes, she became so overwhelmed that she would international journal of integrative psychotherapy, vol. 11, 2020 93 completely stop breathing and tense her whole body as if she were trying to disappear. for a long time, i had to gently remind her to breathe whenever she began to cry. initially, her crying was silent and clearly painful because it resulted in a tensing of every muscle in her body in an attempt to prevent the tears from flowing. reminding her to breathe resulted in a huge intake of breath followed by a loud, body-wracking sob. throughout the first few years of therapy, carmen would panic at any suggestion that she was getting better. it would send her into a spiral of increased physical pain and suicidal thoughts. her pain and incapacity had become part of her identity, without which she said that she did not know who she was. she saw herself not as someone who was experiencing pain but that she was the pain. she also said that she was afraid that if she got better, no one would like her. working with calculated risk during the first phase of therapy, when carmen was still taking large doses of medication, she made collections of her tablets as insurance that if life became too unbearable, she could end it with certainty. initially, i talked with her about giving me her medication collection to dispose of, which she agreed to do. the second time she created a collection, she agreed to take it to her doctor’s surgery. relinquishing this “insurance” increased her anxiety, and after she had surrendered her second collection, i was greatly concerned about her physical safety. as i reflected on our work, i realized that i was not attuning to carmen’s needs. in telling me about her medication collection, she was trying to paint a picture for me of the existential dilemma of someone who has developed a schizoid process. my focus had been much more on what i considered to be my ethical duty to keep my client safe and prevent her from killing herself. in fact, i recognized that my oversimplistic method of keeping carmen safe by removing the lethal medication was similar to how her parents would respond rather than offering an empathetic consideration of what was really best for her by attuning and inquiring. i realized that carmen would probably be safer if she was allowed to keep her “insurance” because she was in control. without the medication she would look for other ways to kill herself, and because she had already attempted strangulation several times, that was a real danger. i wrote to her psychiatrist explaining the situation and my thinking, and he agreed with me for carmen to hold on to her collection until she was ready to give it up. this immediately international journal of integrative psychotherapy, vol. 11, 2020 94 reduced her anxiety and gave us the opportunity to focus on strengthening her sense of self as potent in the world. carmen gradually learned to identify her angry response, almost as though she were learning a foreign language. through my assurances that her anger is justifiable, she has learned how to express it appropriately, which enables her to maintain a relationship with whomever she is angry at. laing (1960), in describing the schizoid person, said this: such a person is not able to experience himself “together with” others or “at home in” the world, but, on the contrary, he experiences himself in despairing aloneness and isolation; moreover, he does not experience himself as a complete person but rather as “split” in various ways, perhaps as a mind more or less tenuously linked to a body, as two or more selves, and so on. (p. 1) carmen had spent her whole life isolated from others and had no idea how to be in an intimate relationship. her husband fit her life script in that he had similar interpersonal difficulties. although we did not explore their relationship in any depth, i believe they probably had interlocking scripts. this made their divorce inevitable as carmen became more able to enjoy being in relationship with me and developed a healthy autonomy. she had few friends at school, and when she began to work, she also had found it difficult to relate to others. when she came to therapy, the only people she described as friends were friends of her parents. carmen was on sick leave from her job for a number of years and was eventually made redundant. this gave her the freedom to begin volunteering in various ways in her community. this led to part-time paid work in a primary school working with some of the more challenging children and later a more substantial role in another primary school, again supporting children who display challenging behavior. she still has a rather small friendship group, but one of the most exciting developments for me was when she began dating and found a new partner with whom she has a sound, loving, mature relationship. in summary the greatest need of a child is to obtain conclusive assurance (a) that he is genuinely loved as a person by his parents, and (b) that his parents genuinely accept his love. … frustration of his desire to be loved as a person, and frustration of his desire to have his love accepted, is the greatest trauma that a child can experience. (fairbairn, 1952, pp. 39–40) international journal of integrative psychotherapy, vol. 11, 2020 95 carmen never received assurance of being loved from her busy, professional parents. she felt in the way, not important, and that everything was her fault. she is now living fully independent of her parents and has a more robust adult-adult relationship with them within which she is able to express her needs as well as her feelings. she has no problem expressing healthy anger toward them and other people in a respectful, relational way. as our work has progressed, carmen has gradually ceased taking all medication and is now mostly as pain free as the general population. she has learned to associate an increase in physiological pain to unexpressed emotions, especially anger and disappointment. two years ago, carmen joined a group in which she is using artistic expression. she has shared some of her creative work in the group, and it has helped her to connect with some deep anger and sadness. as she spoke about the images she created, i thought i detected an unspoken question in her voice. “why did we not use these techniques earlier in my therapy?” i asked if my thinking was correct. she nodded, looked thoughtful for a while, then without me saying a word, she said, “i would have been completely overwhelmed!” i felt an element of relief because i had heard my supervisor’s voice for a moment criticizing me for years for not challenging carmen more robustly as well as the numerous reports from psychological services stipulating the need for a more solution-focused approach. i am deeply grateful for the opportunity working with carmen has given me to learn about the role that shame plays in the development of a schizoid process. i feel privileged that she trusted me enough to stay with the process through my learning how to be with her in ways that enabled the healing of the split within her. her courage to stay alive when she believed that there was no hope of anything changing has been inspirational for me. i have also learned that for some people, suicide might be the ultimate schizoid withdrawal. references bass, c. (1990). somatization: physical symptoms and psychological illness. blackwell scientific. blumer, d., & heilbronn, m. (1982). chronic pain as a variant of depressive disease: the pain-prone disorder. journal of nervous and mental disease, 170(7), 381–406. https://doi.org/10.1097/00005053-198207000-00001 international journal of integrative psychotherapy, vol. 11, 2020 96 bowlby, j. (1969). attachment. vol. 1 of attachment and loss. hogarth. engel, g. (1959). “psychogenic” pain and the pain-prone patient. american journal of medicine, 26(6), 899–918. https://doi.org/10.1016/00029343(59)90212-8 erskine, r. g. (1995). a gestalt therapy approach to shame and selfrighteousness: theory and methods. british gestalt journal, 4(2), 107–117. erskine, r g., moursund, j. p., & trautmann, r. l. (1999). beyond empathy: a therapy of contact-in-relationship. brunner/mazel. fairbairn, w. r. d. (1952). psychoanalytic studies of the personality. routledge & kegan paul. guntrip, h. (1962). the schizoid compromise and therapeutic stalemate. the british journal of medical psychology, 35(4), 273–288. https://doi.org/10.1111/j.2044-8341 johnson, s. m. (1994). characters styles. norton. laing, r d. (1960). the divided self. penguin. masterson, j. f. (1988). the search for the real self: unmasking the personality disorders of our age. free press. nathanson, d. j. (1994). shame and pride: affect, sex and the birth of the self. norton. tyrer, s. (2006). psychosomatic pain. the british journal of psychiatry, 188(1), 91–93. https://doi.org/10.1192/bjp.188.1.91 yontef, g. (2001). psychotherapy of schizoid process. transactional analysis journal, 31(1), 7–23. https://doi.org/10.1177/036215370103100103 international journal of integrative psychotherapy i preface to volume 5, no. 1. greetings ijip readers i begin this preface to volume 5, no. 1 of the ijip with a definition. in·te·grate verb \ˈin-tə-ˌgrāt\ : to combine (two or more things) to form or create something : to make (something) a part of another larger thing : to make (a person or group) part of a larger group or organization : as in in·te·grat·ed or in·te·grat·ing1 to ponder. to contemplate. to integrate. to write. to publish. this is the accomplishment of the three authors we feature in volume 5, no.1. of the ijip. as in the definitions above, each of these authors has skillfully combined two or more ideas to create an article, which is then made a part of “another larger thing” – the ijip – which is part of an even “larger group” – the iipa which then invites its membership to read, ponder, contemplate and integrate these ideas into their own lives and work. indeed, a magical and miraculous process of integration for our writers, readers, and association. ______________________ this volume presents a varied perspective of “integrative psychotherapy” through three unique formulations of ideas, personal history and clinical practice. in “into the labyrinth,” pam stocker invites us into the intimate world of her work as a novice therapist with a challenging client. she openly explores her own process of learning integrating ideas, theory, methods, feelings and personal resources, as she helps a client heal from a painful past of sexual and physical abuse. this fascinating and poignant case study is a must read for any therapist, new or old, who has ever questioned their credentials, training and overall ability to meet the challenges of a particular client. richard erskine, in “nonverbal stories: the body in psychotherapy” shares his 1http://www.merriam-webster.com/dictionary/integrate international journal of integrative psychotherapy ii formulation and integration of ideas about the role of nonverbal bodywork in psychotherapy. he includes a description of his own experiences with a nonverbal, body oriented technique, and like pam stocker, demonstrates the value of the therapist’s own self exploration in developing and integrating an understanding of the clinical needs of clients. in keeping with the nature of integrative psychotherapy, which refers to the bringing together of the affective, cognitive, behavioral, and physiological systems, this article specifically highlights the importance of the nonverbal narrative that clients bring to us through their body and physiology. finally, authors marin, senis, hastie-talledo and backenstrass, in “a pilot method for multimodal group therapy for adults with adhd,” present an integrated program for group therapy with adults with adhd, which draws on a variety of theoretical constructs and clinical modalities. although this article does not formally include integrative psychotherapy as understood within the iipa, it does challenge us to extrapolate ideas for how we may work with adults with adhd within a relational, integrative context, and understand the social and familial implications and challenges inherent in this diagnosis. i am pleased to note that all three of these articles exemplify the mission of the ijip, which is to publish: “…..papers presenting new developments in theory and practice, case studies, research articles and papers that review existing work in the area. specially valued are the articles that integrate therapists' phenomenological experience, clinical thinking, theories and research. the journal is also open to new ideas in the wider field of psychotherapy, psychology, psychiatry and other sciences that may potentially be useful for the development of integrative psychotherapy.” how will you, our readers, integrate volume 5? how will you ponder, combine and create new perspectives about your clinical work, develop research protocols, or utilize these ideas in your office? how will you be personally or professionally touched, challenged or validated by these writers? do you have a response to one of these articles? if so, please put that response into words. do you have an article brewing in your mind? i invite you to ponder, integrate and create. i invite you to explore and write, and in that exploration, become part of “another larger thing” and make yourself “part of (the) larger group and organization” that is the ijip and iipa. i look forward to hearing from you. carol merle-fishman co-editor ijip cortlandt manor, new york, usa november 2014 international journal of integrative psychotherapy, vol. 8, 2017 26 intersubjective aspects of relational group process: from exclusion to integration jose manuel martinez rodriguez abstract: through the use of relational group process (erskine, 2013) the therapist(s) and group members join together to build an intersubjective environment a co-constructed group experience. this process encourages people to respectfully listen and inquire of each other, to move out of the role of simply being observers of group dynamics, and to stop engaging in judgmental assessments of the others. the intersubjective aspects of integrative psychotherapy are essential components for achieving the goal of integration. the set of relational methods outlined in integrative psychotherapy provide a comprehensive guide for intersubjective treatment. when these methods are applied to the group setting in the format of relational group process, they allow the integration of different experiences in the group matrix. the more the group matrix holds individual experiences, the more internal and external contact of group members is fostered. a case study illustrating these concepts and dynamics is presented. key words: relational group process, integrative psychotherapy, intersubjectivity, relational psychotherapy, inquiry, attunement, involvement, group psychotherapy. --------------------------------------- introduction i have always valued the intersubjective aspects of integrative psychotherapy in clinical practice with groups. from my point of view, the set of relational methods delineated in the key hole (erskine &trautmann, 1996; erskine, 1997; erskine, moursund &trautmann, 1999; moursund & erskine, 2003) provide an intersubjective paradigm of group psychotherapy. the reflections presented in this article come partly from my group practice of integrative international journal of integrative psychotherapy, vol. 8, 2017 27 psychotherapy in public and private mental health settings, as a psychiatrist for adults, children and adolescents, and also from the relational training and supervision groups i lead at the institute of transactional analysis and integrative psychotherapy (iatpi) in valladolid, spain. . relational group process and intersubjectivity in groups relational group process (erskine, 2013) is based on the philosophical and theoretical principles of integrative psychotherapy and promotes the development of intersubjective dynamics in group psychotherapy. the practice of inquiry, attunement and involvement in a group format generates an intersubjective approach and presents new therapeutic opportunities. as the self only develops within a relationship (erskine, 1991) relational group process (erskine, 2013) offers the person a chance to express his/her unmet relational needs that may have been previously repressed, split or dissociated, in order to achieve greater levels of integration in the here and now with others (martín y martínez, 2009). an intersubjective approach differs from an “objective” analysis of the other group members, in that it underlines the difficulty and challenges of every member of the group to become truly “neutral” and “objective,” as their mutual perceptions contribute to a kind of co-construction. there is no way to separate the observer from the observed, for the role of “observer” modifies the observed field. through the use of relational group process (erskine, 2013) group members can expand beyond just the observer role of group dynamics, to the role of participant observers (stolorow & atwood, 1979). the interventions of group participants can build an intersubjective environment where they become aware that the group experience is co-constructed, and reparative on a relational level. this is very different from treating others as isolated minds, about which we may unconsciously state some value judgments coming from our script beliefs or introjections (stolorow & atwood, 1979, 1992; atwood & stolorow, 1984; de young, 2003). an intersubjective approach, which integrative psychotherapy holds in common with other schools of psychotherapeutic thought, analyzes the factors that contribute to a co-constructed relationship. this approach requires that the therapist(s) and group members take into account their own script beliefs, their mutual countertransferences, and the way they activate the transference of others. an intersubjective approach also requires the willingness of the therapist(s) and group members to be open and to resonate with the experiences of their group co members. the set of relational methods delineated in integrative psychotherapy provides a guide for intersubjective treatment a set of clear, precise relational methods that make self-restoration possible, especially through the therapist’s international journal of integrative psychotherapy, vol. 8, 2017 28 attunement and involvement, and by means of respectful inquiry applied time and again on deeper levels of experience. the social and intersubjective brain as the foundation of group interventions group therapy is designed to provide a “natural,” in vivo environment to help people improve their relationships. it strives to provide an arena for expressing and satisfying the needs for stimulus, relationship and structure. additionally, the social nature of human kind is deeply rooted in the brain. the central nervous system serves two main functions: internal regulation and relation to the environment. i consider the brain to be a result of consecutive relational solutions encountered by our species to multiple environmental, ecological and social challenges. i consider it both the result and the foundation of the universal need for relationship. some researchers consider brain development to be linked to the size of the group (dunbar, 1998). neuronal networks seem to be developed in order to predict and evaluate the behavior of the others, an advantage achieved through evolution (cozolino, 2006). we can say that the brain is a relational and social organ. siegel (2006), writing about the deep social nature of the brain, thinks that our minds are the result of the entanglement and integration of seemingly disparate aspects of reality: physical, interpersonal, social and body aspects. he believes that when two minds feel connected, there is increased possibility of integration. the firing of each participant`s brain improves the chance of increased integration and coherence. the activation of the body, of limbic circuit areas and even cortical representations of intentional states of the other enter into a kind of resonance, in which both participants match each other. in addition, several neurobiological and neuroimaging studies show that the essence of the brain is deeply intersubjective (fuchs, 2004). mirror neurons have been proposed as being the substratum of intersubjective attunement (rizzolatti et al., 1995; rizzolatti et al., 1996; rizzolatti & arbib, 1998; wolf et al, 2001; gallese, 2003; iacobini & siegel, 2004; pally, 2007). mirror neurons provide a device to “acknowledge” actions. the actions of the agent are reproduced in the premotor cortex of the observer. in group therapy, this resonance implies a change in physiological, affective and intentional states of the participant observers as determined by the perceptions of the other members of the group. trevarthen´s theories of primary and secondary intersubjectivity (1974, 1978, 1980, 2004, 2011) can help us better understand the need to participate at group and social levels. his ideas demonstrate that the primary intersubjectivity of international journal of integrative psychotherapy, vol. 8, 2017 29 babies, their need for attachment and of sharing actions and learnings with their caregivers, is the foundation of social groups and the motivation to build a cultural narrative that works as a “home” (trevarthen, 1979, 2011). trevarthen (2004, 2011) comments that human beings are born not as individuals but as social beings in search of other human beings willing to participate in reciprocal imitation and the mutual regulation of life activities. in this regard, intersubjectivity can be shown to be the basis for understanding the rhythmic motivation for comradeship at different levels of intimacy in social groups. groups can synchronize selfregulatory subjective mental states to share goals, interests and feelings (trevarthen, 2009). this helps us to understand group narratives, cultural learning and the emotional group regulation of moral attitudes within communities. trevarthen´s research (1974, 1978, 1980, 2004, 2005, 2011), suggests that people have an innate conversational mind from birth, and that mother and baby behave in a rhythmic way, generating cycles of affirmation and understanding, and of stimulation and response. throughout these cycles mother and child celebrate the fluctuations between effort and pleasure and share an affectionate comradeship. cozolino (2006) has developed the concept of “social synapse” to talk about the way we link together into larger organisms such as groups, families, tribes, societies and the human species as a whole. it is the way people, like neurons, excite, interconnect and link together to create relationships. this opens many interesting interpersonal possibilities. since the brain has been shown to change in response to experience, we influence the long-term construction of the brains of others, by impacting each other´s internal biological and emotional state. cozolino (2006) has eloquently described the complex social engagement system of the brain and its neurochemistry as a foundation of psychotherapeutic interventions. siegel (2006) thinks that being empathic with patients goes far beyond just helping the other to “feel better,” but can in fact help build a new state of neuronal activation that improves the self-regulatory capacity of the individual. external contact may provide some relief to inner tensions. therapeutic relationship may become a chance to learn and incorporate new self-regulatory patterns in order to better tolerate and integrate traumatic childhood experiences in the here and now. the access to the awareness of formerly warded off and split ego states is easier when the patient has developed, within the therapeutic relationship, new selfregulatory capacities that were previously inaccessible. what initially begins as a way of interpersonal contact with the therapist through the sharing of affective and cognitive states, evolves into a form of internal integration in the patient. these theories regarding the need for relationships, are linked to the social nature of the brain which helps us to better understand how intersubjectivity works at the group level. intersubjective communication connects our brain in cointernational journal of integrative psychotherapy, vol. 8, 2017 30 operative or competitive mental states and creates a kind of shared intelligence, which is now called the “social brain” (adolphs, 2006; dunbar, 1998). in this context, relational group process (erskine, 2013) may foster intersubjective communication at the group level. co-construction at the group level the group may be a good environment to help clients achieve increased levels of integration. groups provide stimulation, and the possibility to restructure personal script beliefs and change old attachment patterns. in order to facilitate these objectives, it is important that the group therapist be aware of the intersubjective dimension in the group setting. groups allow participants to see with increased clarity that the quality of experience within the group atmosphere, and the history of events in the group, are not dependent on anybody in particular, but are instead the result of a coconstruction. this can be observed both in small and in big groups at many social levels. berne (1963, 1966) demonstrated the similarities between small groups, psychotherapy groups, and both middle-sized and large social organizations. he also described the way they share some structural and functional principles, especially what he called internal and external group processes. these dynamics are in part the result of the temporary unconscious confluences and alliances between what berne called “individual proclivities,” that is, the unconscious wishes of the group members, and on the other hand, of the survival need of the groups. the existence of dynamics that go beyond the conscious will of particular individuals is something that can also be appreciated in professional groups. beside the existence of common interests, there are relational aspects of security, mutuality and recognition that appeal to individual members. professional groups can be a meeting point where members aspire to exchange views in a friendly way, with the comradeship of people who hold in common principles and tasks, personal learning, experiences and surprises. every participant can offer his/her knowledge for the common service and to receive the other´s feedback. the constructive dynamic of these groups is promoted by the interest in the professional experience of other colleagues and by the sharing of learning. the conflicting dynamics may come from conflicts between the individual and collective interests, or the difficulties of the group to evolve among other professional and social collectives. the practice of relational group process psychotherapy (erskine, 2013) helps to build an intersubjective environment where group members may become aware that the group experience is co-constructed. when this happens, it becomes international journal of integrative psychotherapy, vol. 8, 2017 31 clear that the wish of group members to know each other can also become an opportunity to understand themselves better through the interactions, feedback and inquiry of others. the message of a person inquiring of someone else is, “i want to get to know you with my questions. at the same time my questions may be good for you as you can get to know yourself better through your answers and reactions.” table i delineates this process. if we consider group interactions from an intersubjective point of view, we must seriously take into account the fact that the person chosen for an inquiry may have likely been for some minutes a stimulus for the other´s question. it might be that his/her silence, verbal content of statements, or non-verbal communications have strongly stimulated the other´s intrapsychic process, reactions, feelings, memories and expectations. this intrapsychic process has ended up stimulating a question from the other, which at the same time may be a question about him/her. so, in the intersubjective process the message of the person making an inquiry may be, “my questions are to you, and they are also telling you about me. you can get to know me better through them.” on the other hand, the person giving feedback to the other communicates something like, “what i am experiencing with you helps me to ask questions of myself about my present and my past.” the new questions that a group member starts to ask of himself/herself may help increase awareness of discounts in present relationships, rememberences of past warded off memories, developmental longings, discounts, or traumatic experiences. similarly, someone´s experience in the group may be a key that opens unconscious areas belonging to the warded off experiences of other table i intersubjectivity in the relational group process  “i want to get to know you with my questions. my questions may be good for you as you can get to know yourself better through your answers.”  “my questions are telling you about me. you can get to know me better through them.”  “what i am experiencing with you helps me to ask questions of myself.”  “your experience might be a key to open my unconscious.”  “me becoming conscious might be a key for you to get in touch with your unconscious.”  “together we will get to know ourselves better and celebrate our shared experience.” international journal of integrative psychotherapy, vol. 8, 2017 32 members. in this way, someone else’s working through process, and the resulting increased awareness, may facilitate the opening of unacknowledged areas for another group member, as s/he connects with forgotten, repressed, split or dissociated aspects of their own history. in addition, it is also important to take into account the expression of the perceived and expressed relationship of individual group members to the group as a whole. it is often expressed as “i feel proud of belonging to this group,” “i missed this group,” and/or “i take this group with me.” all of these comments are ways of expressing the feelings of an individual regarding the group, validating the group activities and acknowledging the impact of the group on him/her. every member may be impacted by these expressions, as the group receives good feedback that strengthens group cohesion and the group culture. conversely, we can find individual transferential relationships to the whole group, and/or to the therapist, and/or to some members, that may be only inner reactions, or overt transactions in the group (berne, 1966, erskine, 1991). all these transferential reactions and transactions build an intersubjective matrix that provides a stimulus for each individual. there is the risk of contact with some script experiences that limit the perception of the other group members’ reactions and the options of the person involved. for example, a violent member may stimulate traumatic experiences in some group members, and/or an experience of shock or reaction from defensive introjections. from exclusion to integration the group therapist holds the tasks of being sensitive to individual vulnerability and being aware of the risk of shame, humiliation or fragmentation, all of which are more difficult in the group setting (martínez, 2001). the therapist must remain attuned to both the individual and the group as a whole. within the group setting there may be inevitable ruptures in empathy. livingston & livingston (1998) have shown the factors that make it difficult to keep an empathic position in the group. for example, difficulties may occur when two people simultaneously need to express themselves, be listened to and/or validated. there are also some situations where some members might try to force another member to play a role in the service of an unconscious dynamic. case study henry is 31 years old. he has been admitted to the emergency room of our hospital and then hospitalized by order of a judge because of a public order offense. he has taken a large amount of cocaine due to his fear of abandonment by his wife and now has delusions of persecution. international journal of integrative psychotherapy, vol. 8, 2017 33 the treatment team discusses the needs of the patient and the risk of violence inside the crisis unit. he is afraid. the other patients reject him and in doing so, reinforce his script beliefs and heighten the risk of his defensive rage. during the first few hours there have been several situations between henry and other people very difficult to manage. the therapist invites him to take part in the transition entry group (aroian & prater, 1988; martínez, quiroga, pérez, san miguel et al., 1997) of which the function is to ease the patient´s adjustment to mental health hospitalization. henry accepts. the group meets for 90 minutes each day from monday to friday. the group is open and new members join at each session. in the first session henry sits next to the door. there are twelve other members and the therapist in the group. all of them have suffered humiliation, shame and violence in their lives. some of them have experienced acute traumas and/or some other cumulative traumas in their childhood. at the beginning of the session raymond expresses his rage against henry and demands that henry not be allowed to enter the group. “in this unit we are a family joined in the pain and we support each other. he has come to destroy our peace.” henry suddenly stands up and shouts loudly in an angry way, “don`t tell me what to do!” there is a risk of an angry confrontation between them. the silence of the other members in the group serves to acknowledge and support raymond´s demands. the therapist reminds the group of its rules. participants are allowed to express anger but are not allowed to act out. the group is invited to respect each other, to listen, to be empathic, to connect with inner experience and to give room for each other’s experience without exclusion. as a result of his own menacing behavior, henry is re-experiencing wellknown rejection and is at risk of reinforcing his script beliefs. he has been excluded from the important decisions in his family, and has been criticized and closely monitored by his relatives. now, he is experiencing being excluded by the other group members. additionally, his admission to the group might activate traumatic memories for the other members. there is a risk that group members will try to make him the reason for their anxiety, instead of accepting the anxiety as a signal of the reactivation of traumatic memories. during the stormy session, the therapist makes interventions to give room, to acknowledge and to validate both the anger of group members and the feelings of the new arrival. henry´s anger conspicuously decreases when the therapist asks him about his experience the day before, of being taken to hospital by the police and being admitted compulsorily by order of a judge. the group members have international journal of integrative psychotherapy, vol. 8, 2017 34 not had the opportunity to take this part of his experience into account. henry´s reduced tension in response to this inquiry, helps the other members to reduce their own fear and defensive anger and their opposition to henry’s presence in the group. at the end of the session henry apologizes. his behavior changes and he is able to work through some of his rejection fears in subsequent sessions, and connect these fears with some childhood experiences. raymond is able later on to become aware of the memories of shame and humiliation that are reactivated by henry´s anger. he is able to talk about his fear of his contemptuous, scornful father, and how he didn´t give room to his son in his family. the other members are able to talk about suspicion, mistrust and jealousy in their relationships. they talk about their script beliefs of having something wrong inside them, being crazy or feeling different. one member speaks about her reinforcing sensory experiences through “inner voices” telling her not to trust others and keep secret the abuses she experienced in her childhood. most of the participants increase their ability to accept their inner shame and memories of humiliation in different contexts. conclusion group therapy is an effective treatment for the reparation of relational difficulties. relational group process as delineated by richard erksine (erskine, 2013), provides for the universal needs of stimulus, relationship and structure required by the social and intersubjective nature of the brain. these brain “needs” are demonstrated by many studies on the origin of intersubjectivity in child development (meltzoff & moore1977, 1994, 1997); trevarthen & hubley (1978); trevarthen (2004, 2005, 2011); stern (1971, 1977, 1985); stern et al. (1985). modern neuroscientific research also supports the presence of social brain “needs” (rizzolatti et al.,1995); (rizzolatti et al.,1996); (rizzolatti & arbib,1998); (pally 2000); (wolf et al.,2001); (gallese, 2003); (iacobini &siegel, 2006); (cozolino, 2006). relational group process allows participants to see with increased clarity that the quality of interpersonal experience, group ambience, and history of group events are not dependent on anybody in particular, but are instead the result of an intersubjective co-construction. through the use of relational group process group members are encouraged to move beyond the role of simply being observers, making subjective assessments of others, mediated by their own script beliefs and introjections. in relational group process, the therapist must remain sensitive to individual vulnerability, while also being aware of the risk of group members feeling shamed, humiliated or fragmented within the group process. the therapist must remain international journal of integrative psychotherapy, vol. 8, 2017 35 attuned with each member and simultaneously with the whole group (martinez, 2001). as the relational group process gives room for acceptance and mutual respect, while also supporting inquiry, mutual attunement, acknowledgement of experience, validation and presence, the individual has the opportunity to feel held by the group. the person can then give inner voice and outer expression to his/her unmet needs that have been repressed, split or dissociated earlier in life, and achieve greater levels of integration in the here and now (martín y martínez, 2009). genuine support is shown through understanding, acceptance and acknowledgement of each of the members of the group. in addition, the validation and normalization of behavioral patterns, and the attuned presence of group members and therapist, are valuable tools in reducing the fear of approaching and processing warded off experiences. it is in the co-created therapeutic process and shared group experience through which individuals can be acknowledged, validated, restored and celebrated. author: josé manuel martínez, m.d., is a certified trainer/supervisor and certified integrative psychotherapist for the international integrative psychotherapy association (iipa) and a certified trainer/supervisor and transactional analyst for the international transactional analysis association (itaa) and european association for transactional analysis (eata). he serves as an associate professor of psychiatry in the psychiatry department at the school of medicine of the valladolid university. he works with children, adolescents and adults and is the director of the institute of transactional analysis and integrative psychotherapy (iatpi) in valladolid, spain. references aroian,k. & prater, m. (1988): transition entry groups: easing new patient´s adjustment to psychiatric hospitalization. hospital and community psychiatry, 39, 312-313 adolphs, r. (2003). investigating the cognitive neuroscience of social behavior. neuropsychologia, 41, 119–126. adolphs, r. (2006). the social brain. engineering and science,1, 13–19. atwood g.e. &stolorow r.d. (1984). structures of subjectivity: explorations in psychoanalytic phenomenology. hillsdale, n.j.: the analytic press. international journal of integrative psychotherapy, vol. 8, 2017 36 berne, e. (1963). the structure and dynamics of organisations and groups. philadelphia: lippincott. berne, e. (1966). principles of group treatment. new york: grove press. clark, b. d. (199l). empathic transactions in the deconfusion of child ego states. transactional analysis journal, 21, 92-98. cozolino, l. (2006). the neuroscience of human relationships: attachment and the developing social brain. new york: norton. dunbar, r.i.m. (1998). the social brain hypothesis. evolutionary anthropology: issues,news, and reviews, 6 (5), 178–190. erskine, r. g., y zalcman, m.j. (1979). the racket system: a model for racket analysis. transactional analysis journal, 9 (1): 51-59. erskine, r. g., &moursund, j. p. (1988). integrative psychotherapy in action. newbury park, ca: sage publications. erskine r.g. (1989). a relationship therapy: developmental perspectives. in: b.r. loria (ed.), developmental theories and the clinical process: conference proceedings of the eastern regional transactional analysis conference (pp. 123-135). madison, wi: omnipress. erskine, r. g. (1991). transference and transactions: critique from an intrapsychic and integrative perspective. transactional analysis journal, 21, 63-76. erskine, r. g. (1993). inquiry, attunement, and involvement in the psychotherapy of dissociation. transactional analysis journal, 23, 184-190. erskine, r.g. &trautmann, r.l. (1996). theories and methods of an integrative psychotherapy. transactional analysis journal, 26(4): 316-328. erskine r.g. (1997). theories and methods of an integrative transactional analysis: a volume of selected articles. san francisco: ta press. erskine r.g. (1998). the therapeutic relationship: integrating motivation and personality theories. transactional analysis journal, 28 (2), 132-141. erskine r.g., moursund j.p. &trautmann r.l. (1999). beyond empathy: a therapy of contact-in-relationship. new york: routledge. erskine, r.g. (2010). life scripts, unconscious relational patterns and psychotherapeutic involvement. in r.g. erskine (ed.), life scripts. a transactional analysis of unconcious relational patterns. london: karnac books ltd. erskine, r.g. (2013). relational group process developments in a transactional analysis model of group psychotherapy. transactional analysis journal, 43 (4), 262-275. international journal of integrative psychotherapy, vol. 8, 2017 37 erskine, r.g. (2014). nonverbal stories: the body in psychotherapy. international journal of integrative psychotherapy, 5, (1), 21-33. erskine, r.g. (2015): relational patterns, therapeutic presence. london: karnac fuchs, th. (2004). neurobiology and psychotherapy: an emerging dialogue. current opinion in psychiatry, 17, 479–485. gallese, v. (2003). the roots of empathy: the shared manifold hypothesis and the neural basis of intersubjectivity. psychopathology, 36, 171-180. iacoboni, m. & siegel, d.j. (2004). the implications of mirror neurons for psychotherapy, day-long seminar. san francisco, santa rosa: r.j. cassidy seminar recordings. little r. (2006). treatment considerations when working with pathological narcissism.transactional analysis journal, 36 (4), 303-317. little, r. (2011). impasse clarification within the transference countertransference matrix.transactional analysis journal, 41 (1), 22-38. livingston, m.s. & livingston, l.r. (1998): conflict and agression in group psychotherapy: a self psychological vantage point. international journal of group psychotherapy, 48 (3): 381-391. martín, b. y martínez, j.m. (2009). psicoterapia de grupo en una unidad de agudos revista de la asociación española de neuropsiquiatría, 29 (103): 79-96. martínez, j.m., quiroga, p. pérez, c., san miguel, r., fernández, b. (1997). grupos terapéuticos en unidades de hospitalización de corta estancia. boletín de la sociedad española de psicoterapia y técnicas de grupo, 11: 139-147 martínez, j.m. (2001). el miedo, las proyecciones paranoides y la violencia en los grupos de pacientes en crisis. boletín de la sociedad española de psicoterapia y técnicas de grupo, 19: 89-102. martínez j.m. & fernández b. (1991). análisis estructural y transferencia en los trastornos límite. rev. española de análisis transaccional, 27, 1082-1099. meltzoff, a.n. & moore, m.k. (1977). imitation of facial and manual gestures by human neonates. science, 198 (4312), 75-78. meltzoff, a.n. & moore, m.k. (1997). explaining facial imitation: a theoretical model. early development and parenting, 6, 179-192. meltzoff, a.n. & moore, m.k (1994). imitation, memory, and the representations of persons. infant behavior and development, 17, 83-99. moursund j.p. & erskine r.g. (2003).integrative psychotherapy: the art and science of relationship. pacific grove, ca: brooks/cole thomson/wadsworth. international journal of integrative psychotherapy, vol. 8, 2017 38 pally, r. (2007). the predicting brain: unconscious repetition, conscious reflection and therapeutic change. the international journal of psychoanalysis, 88 (4): 861-881. racker, h. (1972).the meanings and uses of countertransference. psychoanalytic quarterly, 41, 487-506. rizzolatti, g., camarda, r., gallese, v &fogassi, l. (1995). premotor cortex and the recognition of motor actions. cognitive brain research,3, 131-141. rizzolatti, g., matelli, m., bettinardi, v, paulesu, e., perani, d. & fazio, r. (1996). localization of grasp representations in humans by pet 1. observation vs. execution. experimental brain research,111, 246-252. rizzolatti, g. &arbib, m. (1998). language within our grasp. trends in neuroscience, 21, 188-194. siegel, d.j. (2006). an interpersonal neurobiology approach to psychotherapy: awareness, mirror neurons, and neural plasticity in the development of well-being. psychiatric annals. in press. retrieved july 2015, from http://www.researchgate.net/publication/241200655_an_interpersonal_ne urobiology_approach_to_psychotherapy_awareness_mirror_neurons_an d_neural_plasticity_in_the_development_of_well-being. stern, d. (1971). a microanalysis of mother-infant interaction. journal of the american academy of child psychiatry, 19, 501-517. stern, d. (1977). the first relationship. cambridge, ma: harvard university press. stern, d. (1985): the interpersonal world of the infant. a view from psychoanalysis and developmental psychology, pp. 145 151. new york: basic books. stern, d., hofer, l., haft, w. & dore, j. (1985): affect attunement: the sharing of feeling states between mother and infant by means of intermodal fluency. in: t field & n. fox (eds.) social perception in infants. norwood, n.j.: ablex. stolorow r.d. & atwood g.e. (1979).faces in a cloud: intersubjectivity in personality theory. new jersey: jason aronson. trevarthen, c. (1974). the psychobiology of speech development. neuroscience research program bulletin,12, 570-585. trevarthen, c.,&hubley, p. (1978). secondary intersubjectivity: confidence, confiding and acts of meaning in the first year. in a. lock (ed.), action, gesture and symbol: the emergence of language, pp. 183–229. london: academic press. http://www.researchgate.net/publication/241200655_an_interpersonal_neurobiology_approach_to_psychotherapy_awareness_mirror_neurons_and_neural_plasticity_in_the_development_of_well-being http://www.researchgate.net/publication/241200655_an_interpersonal_neurobiology_approach_to_psychotherapy_awareness_mirror_neurons_and_neural_plasticity_in_the_development_of_well-being http://www.researchgate.net/publication/241200655_an_interpersonal_neurobiology_approach_to_psychotherapy_awareness_mirror_neurons_and_neural_plasticity_in_the_development_of_well-being international journal of integrative psychotherapy, vol. 8, 2017 39 trevarthen, c. (1979). communication and cooperation in early infancy. a description of primary intersubjectivity. in m. bullowa (ed.), before speech: the beginning of human communication, pp. 321–347. london: cambridge university press. trevarthen, c. (1980): the foundations of intersubjectivity. in d. r. olson (ed.), the social foundations of language and thought, pp. 216-242. new york: norton. trevarthen, c. (2004). how infants learn how to mean. in m. tokoro& l. steels (eds.), a learning zone of one’s own (sony future of learning series), pp. 37–69). amsterdam: ios press. trevarthen, c. (2005). stepping away from the mirror: pride and shame in adventures of companionship. reflections on the nature and emotional needs of infant intersubjectivity. in c. s. carter, l. ahnert, et al. (eds.), attachment and bonding: a new synthesis. (dahlem workshop report 92), pp. 55–84. cambridge, ma: mit press. trevarthen, c. (2009). human biochronology: on the source and functions of “musicality.” in r. haas & v. brandes (eds.), music that works: contributions of biology, neurophysiology, psychology, sociology, medicine and musicology pp. 221–265. new york: springer. trevarthen, c. (2011): la psicobiología intersubjetiva del significado humano: el aprendizaje de la cultura depende del interés en el trabajo práctico cooperativo y del cariño por el gozoso arte de la buena compañía. clínica e investigación relacional, 5 (1), 17-33. wolf n.s., gales, m.e., shane, e. & shane m. (2001): the developmental trajectory from amodal perception to empathy and communication: the role of mirror neurons in this process. psychoanalytic inquiry: a topical journal for mental health professionals, 1, 94-112. http://www.tandfonline.com/toc/hpsi20/21/1 international journal of integrative psychotherapy, vol. 10, 2019 11 child development in integrative psychotherapy: erik erikson’s first three stages richard erskine abstract: child development concepts and research provide the basis for therapeutic inquiry in a developmentally based, relationally focused integrative psychotherapy. this article focuses on the developmental ideas of erik erikson and relates them to the concepts of bowlby, fraiberg, piaget, and winnicott. the various developmental concepts provide the basis for developmental attunement, forming developmental images, phenomenological inquiry, and therapeutic inference that allow implicit and procedural memory to be expressed in a therapeutic narrative. keywords: attunement, unconscious relational patterns, developmental attunement, developmental image, implicit memory, procedural memory, subsymbolic memory, child development, developmental psychotherapy, therapeutic inference, integrative psychotherapy, relational psychotherapy, erik erikson ------------------------------------- my client arrives late for our therapy session with his shoe laces untied, his hair uncombed, and his shirt stained with food. he is nervous as he shuffles into the office and plops down on the sofa. i ask him what he is feeling and he shrugs his shoulders. i have learned from past sessions that he quickly agrees with my international journal of integrative psychotherapy, vol. 10, 2019 12 feedback when i suggest what he may be feeling based on his facial expressions and body gestures. but i am concerned by his compliant answers. this is a pattern i have seen before whenever he is not talking about current difficulties such as his mother’s advancing cancer, his financial worries, or his wish for a more interesting job. he reports that he is “used by others” at work and also by his large family. he tells me that he never says “no,” certainly not to family members. he describes his boldest form of protest as silently slipping out of an uncomfortable family dinner. it seems to me as though he has no sense of will, agency, or direction in his life. i notice during our early sessions that he frequently tears pieces of tissue into small fragments and then rolls them into little balls. at first i wonder if he is distracting himself from feeling. i observe his intense facial expressions and body posture and how he plays with the tissue like a toy. in our moments of silence, he seems to be pleased with pulling the tissue into little pieces. i ask what he is experiencing and he says, “i don’t know.” he immediately puts the tissue down as though being obedient to some unspoken command. a few moments later, he takes another tissue and begins to tears it into fragments. i wonder what unconscious experience is embodied in his gestures and enacted in the behavior i am observing. at what age would i expect a typical child to retreat into such activity? to engage in repetitive play alone? and to have no words to describe what he or she is sensing? i am raising questions to myself from a developmental perspective. i think about the importance of repetitive and solitary play, the absence of self-reflective words, and the age at which saying “no” is a necessary expression of self-definition. who is my actual client? is it this 38-yearold man or a 2-year-old boy? or is it both? developmentally based psychotherapy child development theories and various research reports on the social and emotional maturation of children provide the foundations for my therapeutic interventions when i am engaging in psychotherapy with clients. the primary purpose of this article is to describe some of these foundations of a relationally focused integrative psychotherapy (erskine, 2008, 2009, 2015a) in order to provide a guide for therapists providing in-depth psychotherapy. i will articulate some of the ideas and theories that influence the work i do, particularly erik erikson’s first three stages of child development, which range from birth to about age 6. erikson delineated these first three of his eight stages as basic trust versus mistrust, autonomy versus shame and doubt, and initiative versus guilt. international journal of integrative psychotherapy, vol. 10, 2019 13 foremost in my understanding of the physical and relational needs and developmental tasks of infants and young children are the observations and hypotheses of many people who have written about child development. they include (but are not limited to) ainsworth (ainsworth, blehar, waters, & wall, 1978); beebe (2005); bowlby (1969, 1973, 1979, 1980, 1988a, 1988b); fraiberg (1959); kagan (1971); mahler (1968), mahler, pine, and bergman (1975); main (1995); piaget (1936/1952, 1954, 1960); piaget and inhelder (1969, 1973); stern (1977, 1985, 1995); and winnicott (1965, 1971). in addition, the research of several neuropsychologists have validated the way i organize my psychotherapy, including the work of cozolino (2006), damasio (1999), ledoux (1994), porges (1995, 2009), schore (2002), and siegel (1999, 2007). however, it is erikson’s (1959, 1963, 1968) concepts that have been a constant guide in forming my hypotheses about clients’ developmental conflicts, what was missing during their early formative years, and how to be in relationship with them. a developmentally based, relationally focused integrative psychotherapy, in theory and methods, emphasizes the therapeutic importance of developmental attunement. this presupposes both knowledge of children’s emotional and cognitive development and a sensitivity to each client’s unique childhood history of relationships. this includes attunement to our clients’ various affects, their rhythms and attachment patterns, how they organize experiences, and their variety of needs (erskine, moursund, & trautmann, 1999). developmental attunement necessitates the therapist’s sensitivity and responsiveness to the brief expressions of age regression and the transferential expressions of unresolved relational disruptions that emerge in the process of psychotherapy. such therapeutic sensitivity requires that we understand the personal and relational crises that young children live, the relational needs that emerge at each developmental stage, the physiological survival reactions and experiential conclusions they may come to, and what constitutes reparative therapeutic involvement. sara: lost and empty. sara came to therapy complaining that she was depressed, slept a lot, and would often find herself just staring into space. she entered the office for the first time with a toothpick in her mouth. in the next several sessions, she constantly rubbed her lips with her fingers and often looked at the wall when she talked. once we had established a comfortable working relationship, i began to make a series of inquiries, first with a variety of questions about her adolescence and middle childhood years and then specifically about her first year of life. international journal of integrative psychotherapy, vol. 10, 2019 14 she eventually told me about her mother’s breast infection, which occurred at the end of sara’s first month of life. her mother had been hospitalized for several days, sara was abruptly placed on bottle feeding, and her mother became depressed. this story helped me to understand sara’s sense of being “lost in space” and her own struggle with depression. i was forming a developmental image of a baby longing to nurse and craving her mother’s vitality. i wondered if sara’s depression was a reliving of the emotional experience of a depressed baby or if sara was bearing her mother’s depression, or both. over the next 2 years, these hypotheses shaped my interventions. i frequently talked to sara about what she may have needed as a baby, what wellcared-for babies may experience, and how she may have managed when her mother was depressed during her first year of life. early in our work, she could not tolerate my looking at her; she was afraid. we spent many sessions with her experimenting with looking at my face and then hiding her face in her hands. often she would cry with deep sobs. later, when i inquired about her crying, she said that she had “no thoughts or words.” as our emotional connection deepened, sara said that she feared i would disappear. she required reassurance that i was healthy. she suffered when we had a break in our weekly, and sometimes twice weekly, appointments. eventually, she insisted on holding my hand “just to know you are real.” she asked me to sit near her on the couch so that she could feel my presence. on several occasions, she reached out to touch the contours of my face, to rub her fingers over the shape of my nose, forehead, ears, and mouth. her touching my face was just like a baby exploring its mother’s face. she would then close her eyes and touch her own face, back and forth, touching my face and then her own. she repeated this infantile form of exploration several times before she could look into my eyes. although our sessions had long periods during which sara did not speak, when she did talk, she described the deep sense of “emptiness in my stomach,” “an emptiness that is never satisfied.” eventually, sara realized that she was longing for a mother who was alive and happy to be with her. as the therapy continued, i sought occasions for us to share moments of liveliness and exuberance together. international journal of integrative psychotherapy, vol. 10, 2019 15 developmental image in the story of sara, i describe having a developmental image that helped me to remain aware of the relational neglect she experienced as a baby and to respond sensitively to her need for authentic presence. a developmental image is based on a combination of intuition and empathic imagination of what it is like to be in a particular child’s experience and to have the quality of relationships that he or she had at a specific age (erskine, 2008). creating a developmental image allows us to constantly keep the distressed child in mind, to stay attuned to his or her relational experiences and unrequited needs, and to guide us in forming a reparative relationship. however, developmental images are formed not only on the basis of empathic imagination and intuition. to be therapeutically effective, developmental images also require a thorough understanding of children’s physical, emotional, cognitive, and social development—an understanding based on both informal and professional observations, the findings from child development research, and the theoretical concepts derived from such research. developmental images remind the therapist to focus on the client’s early life, his or her unrequited needs, and the relational crises that may have occurred at various ages. this is especially important in sessions during which the client becomes immersed in current events in his or her life. erik erikson’s developmental observations josef breuer and sigmund freud, in studies in hysteria (1893-1895/1955), were among the first to report on how early emotionally disruptive childhood experiences shape adult life. freud (1894/1962, 1915/1957) went on to describe how childhood traumas are defensively “repressed” and thus unconsciously influence an adult’s behaviors, attitudes, and emotions. in reflecting the social pressures of vienna prior to 1900, he defined five psychosexual stages of development: oral, anal, phallic, latent, and genital (freud, 1905/1953). although not dominant in my treatment planning, i periodically consider aspects of freud’s psychosexual stages as a broad guide in assessing the psychological age of my clients and in seeking age-appropriate interventions. erikson theorized that human development progresses through a life cycle composed of eight developmental stages, ranging from infancy to old age, in which each stage marks a new dimension of personal and social integration. these describe a new dimension in an individual’s phenomenological sense of himself or international journal of integrative psychotherapy, vol. 10, 2019 16 herself as well as how he or she interacts in relationship with others (erikson, 1959, 1964). this ever-evolving and integrating sense of self is the result of resolving specific personal and relational crises that an individual faces at various developmental ages. erikson (1958, 1969) referred to this process of psychological maturation as the quest for identity, a term that indicates a process that extends over several developmental stages. progression toward a healthy personality depends on the successful mastery of personal and relational tasks at each stage of development (erskine, 1971). erikson (1968) called each of these personal and relational tasks a developmental crisis, a “turning point, a crucial period of increased vulnerability and heightened potential” (p. 96) and, therefore, either a source of internal strength and growth or a source of confusion, maladjustment, and interpersonal conflict. in infancy, identity is not a mental construct. rather, it is physiological in that the baby’s nervous system may crave, tolerate, or be repulsed by the caretaker’s touch. this is reflected in bowlby’s (1969, 1973) descriptions of young children’s physical bonding and relational disruptions. the early infancy physiological sense of self, together with the presymbolic experiences of the preschool years and the experiential conclusions and explicit decisions of the school years, are all foundations on which later adolescent identity is formed. erikson (1968) said that successful passage through each stage is not an achievement secured once and for all, but rather a sense of accomplishing the developmental task of that age. this sense of accomplishment is not a cognitive or linguistic experience but rather a physically felt experience of security, agency, and/or self-esteem that is consistent with that age. in describing the eight epigenetic developmental stages, erikson purposefully prefaced each stage’s descriptive title with the phrase “a sense of.” it is this phenomenological sensation of having achieved or of having been frustrated in accomplishing the stage’s task that is important in determining successful development in succeeding stages. erikson’s (1959) theory is relational in that at each stage the child’s mastery of a specific developmental crisis depends on the quality of the parents’ presence and involvement; it is epigenetic in that each stage involves both antecedents of previous developmental experiences and the precursors of future stages. for example, trust and mistrust issues will arise repeatedly throughout every stage of development, not just in the first year of life. and, although the formation of identity is at its peak in late adolescence, an aspect of identity begins in infancy when the task of basic trust is predominant. by combining his own insights on child international journal of integrative psychotherapy, vol. 10, 2019 17 development with freud’s psychosexual stages, erikson (1946, 1959, 1963, 1968) was able to conceptualize developmental progression as an interaction of biological, psychological, and relational variables that continue throughout the life span, which differed from freud’s static concept of child development. each of erikson’s stages presents a new form of personal expression and relational engagement that lays the foundation for successive stages. at the same time, future developmental stages have a rudimentary influence on the current developmental stage (erskine, 1971). significant in a child’s development are the reciprocal relationships between parents and children (erskine, 1971). for example, as the infant struggles with issues of trust and mistrust, his or her parents are grappling with issues of generativity, that is, caring for children, negotiating marriage, managing finances, and engaging in employment. the earlier description of sara’s psychotherapy illustrates erikson’s concept of child-parent reciprocity and the effects of the parents’ affect and behavior on the child as well as freud’s concept that orality is the essential quality of infancy. erikson’s (1953, 1959, 1963, 1968, 1971) writings also provide an understanding of the long-term negative effects of childhood relational disruptions and serve as a guide in forming psychotherapy inquiry and shaping a reparative therapeutic relationship. for instance, when an adult client has difficulty with creativity or finishing projects, i often think about the 4or 5-year-old child’s relational need for an adult companion who shares in the child’s industrious activity. i may make several historical and phenomenological inquiries about the nature of the child’s play time, the creative projects in which he or she engaged, who shared his or her interests, and whether the significant adults were supportive and enthusiastic about the child’s play activities or if the child was criticized for or prohibited in exuberant play. such information allows me to be instrumental in helping the client express appreciation for the need-fulfilling relationships that he or she may have had as a kindergarten-age child—or, alternatively, to therapeutically grieve and/or express anger at the lack of relationship with significant others. a developmentally attuned understanding may then lead me to demonstrate an active interest in the client’s projects, hopes, and plans and thereby to create a reparative therapeutic relationship (erskine & moursund, 1988/2011; moursund & erskine, 2003). international journal of integrative psychotherapy, vol. 10, 2019 18 trust versus mistrust erikson (1963) placed the foundation for all later development on the first year of life and the corresponding crisis of basic trust versus mistrust. he wrote that even prior to the infant’s birth, the mother’s attitudes toward her child throughout pregnancy and delivery have an effect on the newborn’s responses. once the child is born, symbiosis with the mother’s body is replaced by a mutual activation between mother and infant. fairbairn (1952), winnicott (1965, 1971), and stern (1985) described how an infant is capable of experiencing relationship from the very beginning of life and that the quality of the infant’s experiences depends on interpersonal contact with significant others. the interpersonal contact and reciprocity of giving and receiving permits the mother to respond to the needs and demands of the baby’s body and mind. when the infant’s needs for nurturing touch, comfort, and security are largely satisfied under this reciprocal relationship, the child learns to trust the mother, himself or herself, and the world. erikson (1963) emphasized this point by saying that the parents “must be able to represent to the child a deep, almost somatic conviction that there is a meaning to what they are doing” (p. 249). the parents’ consistency, reliability, and dependability communicate to the child that he or she is safe and that his or her basic and vital needs will be met, at least most of the time. this intermix of trust and mistrust is echoed by winnicott’s (1965) often quoted idea of the “good-enough mother” (p. 117). because the infant still lacks body image and object permanence, his or her sense of trust or distrust is nonspecific. it applies to all persons, including the self that is still undifferentiated from the maternal world. a mother who is consistently stabilizing and who regulates the infant’s affect and physical needs is experienced as a sense of trust in both self and the external world. an emerging sense of trust leads to the establishment of hope. a mother who is inconsistent or neglectful is experienced by the child with a sense of distrust in himself or herself and in relationships. distrust of an unreliable mother becomes self-distrust because the infant does not sense his or her mother as separate from himself or herself. developmental psychologist jean piaget said that during this early “sensory-motor” stage the infant is not aware of cause and effect; self-focused sensations are all that exist (maier, 1969). therefore, “the failure of the parent to provide the basis of trust is the infant’s failure since he is not ‘cognitively’ able to perceive his existence as separate from his parents” (erskine, 1971, p. 39). in my experience, the absence of a secure and trusting relational foundation may result international journal of integrative psychotherapy, vol. 10, 2019 19 in clients having a physiologically based, indescribable sense of hopelessness. when adult clients talk about a sense of hopelessness—an internal sense of despair that exists even when their life is going well—i am inclined to focus on their first year of life. i begin by inquiring how they receive another person’s touch and physical closeness, and i am interested to know if they have a sense of comfort and emotional stabilization through physical closeness or if they feel agitated by such intimacy. i may then inquire about the quality of the infant-mother relationship in significant aspects of baby care: feeding, diaper changing, bathing, play, and sleep time. if a young child’s sense of attachment is infused with a greater degree of mistrust than trust, later in life he or she may react disagreeably to even minor inconsistencies in someone else’s behavior and use those inconsistencies as evidence that the person should not be trusted (erskine, 2015b). if, on the other hand, the child has gained a sense of trust and it has been reinforced over several developmental ages, then in adult life he or she may see such inconsistencies as insignificant and a normal part of life. i am particularly interested when clients perceive inconsistencies in my behavior or affect that lead them to mistrust me. i want to know how their perception stimulated and influenced this sense of mistrust and devote time to exploring how my behavior may have been an impetus for their lack of trust in our relationship. it is important for me to take responsibility for my inconsistencies and/or therapeutic errors before we investigate any possible early childhood sense of mistrust. it is essential that we work within our current person-to-person relationship to establish (as much as possible) a secure interpersonal connection before investigating the qualities of their early mother-infant relationship. during the same era that erikson was working, bowlby (1969, 1973, 1980) also wrote about early child development. he described the biological imperative of prolonged physical and affective bonding in the creation of a visceral core from which all experiences of self and others emerge. both bowlby’s and erikson’s writings delineate the unconscious relational patterns that are generalized from experiences in infancy and early childhood (erskine, 2009). bowlby proposed that healthy development emerges from the mutuality of a child’s and a caretaker’s reciprocal enjoyment in their physical connection and affective relationship. mothers who are attuned to their baby’s affect and rhythm, who are sensitive to misattunements and quick to correct their errors of attunement, establish for their infant a secure base (bowlby, 1988b). it is these qualities of interpersonal contact, communication of affect, and reparation that are of utmost importance in forming international journal of integrative psychotherapy, vol. 10, 2019 20 secure relationships, a sense of mastery, and resilience in later life (ainsworth et al., 1978). bowlby’s comments provide an outline of what a relationally focused integrative psychotherapist actually does with clients, that is, we create a secure base. just as with involved, responsive parents, we attune to our clients’ affects and rhythms, are sensitive to and take responsibility for our misattunements, correct our errors, strive to establish and maintain emotional and physical stability, create relational safety, and enjoy who they are (tronick, 1989). bowlby (1973) articulated how the quality of a young child’s relationship with his or her parents provides “a sense of how acceptable or unacceptable he himself is in the eyes of attachment figures” (p. 203). these repeated experiences establish internal working models that unconsciously determine anticipation, emotional and behavioral responses to others, the nature of fantasy, and the quality of interpersonal transactions. stern (1995) referred to these same phenomena with the term schemes of ways of being-with-another. both bowlby and stern were describing subsymbolic procedural forms of memory—memory that is not available to conscious thought although it is expressed in physiological sensations, affect, and relationships. bowlby went on to describe insecure attachments as the psychological result of disruptions in bonding within dependent relationships. repeated experiences of security or lack of security in the first few months of life are what erikson (1963) was referring to when he described this period of development as a time of trust versus mistrust. although eric berne provided no indication that he was aware of bowlby’s early research findings and theoretical ideas, he was well aware of erikson’s emphasis on the formation of trust or mistrust in the first 2 years of life. berne (1961) described the relational disruptions in infancy as the “primal dramas of childhood” (p. 116), which resulted in an “extensive unconscious life plan” (p. 123). berne used the terms protocol and palimpsests to describe the infant and early childhood interactions between a child and his or her caretakers that are imprinted as presymbolic, subsymbolic, and procedural forms of memory that form “unconscious relational patterns” (erskine, 2015a) that later in life interfere with health maintenance, problem solving, and relationships with people—the early basis of a life script. international journal of integrative psychotherapy, vol. 10, 2019 21 winnicott referred to this early period in a child’s life as a time when body memories are formed even though the infant is nonconscious and does not have a fully formed sense of “me.” the infant is only aware of sensation, but body sensations are the neurological substructure of the child’s emerging sense of trust and mistrust (porges, 2009). winnicott (1965) wrote that the baby is always struggling with the contrast between spontaneously expressing needs and having them fulfilled versus reacting to the demands from outside that interrupt the baby’s “continuity of being. … [w]hen reacting, an infant is not ‘being’ ” (p. 185). incidents of relational disruption will undoubtedly occur between children and caretakers. such reactions denote moments of disruption in the baby’s sense of relying on the caretaker. the impediments to trust happen through recurring relational disruptions, wherein the child has an ongoing sense of a lack of security. such a lack of security, mistrust, and the sense of needs not satisfied is not thought about or cognitive. such body senses are subsymbolic, procedural forms of memory that are established when the child is preverbal. but these physiological sensations may last a lifetime and are influential in shaping relationships later in life. fraiberg’s (1982/1983) research showed that behavioral signs of infant and parent relational disruptions are evident in the first few months of life. to paraphrase fraiberg, these self-stabilizing survival reactions include infants freezing their body movements, flailing in agitation with their arms and legs, turning away from face-to-face contact, and transforming their affect. we may see subtle versions of these same self-stabilizing dynamics in adult clients when they tighten their bodies, agitate, avoid eye contact, or deflect from their feelings. such behaviors may signal unresolved relational disruptions in early childhood. applying developmental concepts in practice in the first couple of months of psychotherapy, sheila sat in my office biting her fingernails and constantly shaking her foot. not only was she physically agitated, she also had great difficulty talking about her internal experience. she could freely tell me about her social interactions with other people during the previous week but usually without any eye contact. if i made more than one or two phenomenological inquiries, she would tighten the muscles in her face, shoulders, and chest and become silent. often in the first few months, i thought about sheila’s repetitive body gestures, her tense muscles, and how these behaviors might be an adult’s international journal of integrative psychotherapy, vol. 10, 2019 22 manifestation of an infant’s gestures of agitated flailing, physical freezing, and turning away from contact—desperate attempts at self-stabilization when a significant caretaker fails to provide the physical and emotional stabilization necessary for the infant to develop a basic sense of trust (fraiberg,1982/1983). pacing my developmental investigation with only a few historical questions in each session, we began to slowly construct, over the next 9 months, the story of her first 2 years of life with a mother whom she described (with information provided by her two aunts) as “often high-strung, upset, and distressed.” gradually, sheila was able to tolerate my inquiries about her body sensations, variety of affects, fantasies, and how she coped, even as a toddler, with what she described as an “uptight mother” who had constant fights with her alcoholic father. she described family stories about how her mother would leave her in a playpen all day until her father came home to change her diaper and eventually feed her. she had a recurring image of being strapped into a high chair, crying to be let out, and “then just giving up.” sheila said that she did not remember the fights between her parents when she was 2, but she had a number of explicit memories of the verbal fights between them in her preschool and school years. she said, “i know in my body that i lived with constant tension” and “i could not trust anyone.” “even now it seems impossible for me to rely on anyone.” with some clients, i ask what they know about their conception, how their mother felt during pregnancy, and the quality of their parents’ relationship with each other both during pregnancy and in the first few months after the birth. the client’s rudimentary knowledge is usually based on family stories and fragments of information that he or she has put together over the years. also, i may ask the client to “imagine” being fed by his or her mother during the first few months of life. i inquire about the client’s “internal sense” of mother’s touch, the rhythm of the feeding, the mother’s sensitivity to the infant’s need to be nurtured, and the presence or absence of eye contact. did mother sing or talk when feeding or was it done in silence? i am curious to know if mother was relaxed or stressed and how my client physically responded to mother’s body. based on what the person knows of his or her mother’s personality, i ask the client to imagine those affectively charged and relationally significant interpersonal interactions (stern, 1998; tronick, 1989). although most clients say that they do not have explicit memories of this period in their life, i am interested in their impressions because those are configured from physiological and international journal of integrative psychotherapy, vol. 10, 2019 23 emotional experiences that are recorded as subsymbolic memory. although not based on explicit memory, such prelinguistic, procedural memories are the foundation for unconscious relational patterns that may influence the client’s affect, behavior, and relationships later in life (bowlby, 1969, 1973, 1980; erskine, 2009). these forms of memory are not conscious in that they are not transposed into thought, concept, language, or narrative, but they are phenomenologically communicated through physiological tensions, undifferentiated affects, longings and repulsions, tone of voice, and interpersonal interactions (bucci, 2001; kihlstrom, 1984; lyons-ruth, 2000; schacter & buckner, 1998). in helping our clients construct a comprehensive narrative of their life, we are working with therapeutic inference, which is made from assembling bits and pieces of information, emotional and body reactions, internal images, family stories, and fantasies (erskine, 2008, p. 136). these inferences are constructed through intersubjective dialogue between client and psychotherapist about the client’s early life and may not be based on verifiable information. they are composed of internal sensations, impressions, physical reactions, and emotions that determine the client’s internal processes and perceptions and may shape their behaviors in adult life. metaphorically, i think that in a developmentally focused psychotherapy we are constructing the client’s narrative in a way that is similar to doing number-tonumber drawings where a picture is formed by connecting various dots. for example, just as a child drawing a line between the dots numbered one, two, … nine, and ten reveals the image of a cat or horse, we help clients construct a narrative that gives meaning to their experience through: • affective, rhythmic, and developmental attunement • consistent phenomenological and historical inquiry • fragments of information • developmental images • family stories • judicious use of child development theory, observation, and research autonomy versus shame and doubt erikson’s (1963, 1968) theory states that the second developmental conflict—autonomy versus shame and doubt—occurs between 18 months and 3 years of age. this period corresponds with freud’s anal stage and is built on the foundations of trust or mistrust established during the oral stage. as the child nears international journal of integrative psychotherapy, vol. 10, 2019 24 his or her second birthday, a qualitatively new kind of intellectual functioning occurs that piaget (1951; piaget & inhelder, 1969) termed preoperational. the child has become more physically developed (walks and climbs), better coordinated (selffeeds), perceptually aware (observes family interactions), and determined to express his or her own wants (the need for self-definition and to make an impact on another person). this struggle for autonomy starts at age 2 and lasts until about 3-and-a-half years of age, although piaget describes it as lasting until about age 7. if the child does not have a basic sense of trust when entering the second stage, erikson (1959, 1963) theorized that “the child will turn against himself all the urges to discriminate and to manipulate” (p. 70) and will over manipulate himself or herself, develop a precocious conscience, become obsessive, and, in adult life, subscribe to more authoritarian attitudes. the dominant behavior of this second stage is manifested in the child’s ability to both tightly hold on to items and to willfully throw them away. at the same time, the child is developing physically with “the arrival of a better formed stool and the general coordination of the muscle system which permits the development of voluntary release as well as of physical retention” (erikson, 1968, p. 107). in writing about this stage, erikson expanded freud’s concept of the anal period and framed it in terms of the relationship between child and caretakers—a struggle for the child to exercise choice and a growing sense of autonomy. at this age, children are actively exploring, doing what they want, doing things their own way and at their own pace. with ongoing support and a protective environment, they form a sense of autonomy. if a child at this age is repeatedly criticized, if caretakers are demanding, controlling, or impatient, the child may be left with a sense of selfdoubt. erikson’s (1959) discussion of autonomy largely focused on toilet training. but he emphasized that the quality of the relationship between the child and his or her parents at this time is a primary factor in whether or not the child will leave this stage with a sense of self-worth and competency or will feel powerless, ashamed, and inhibited. erikson (1963) emphasized that it is important that the child not feel that his or her will is being broken. the quality of autonomy that children develop depends on their parents’ ability to grant autonomy with dignity and a sense of personal independence. in addition to the rapid gains in muscular maturation, during this stage, the child learns to coordinate a number of highly conflicting action patterns and international journal of integrative psychotherapy, vol. 10, 2019 25 vocalizations that delineate the world as “i” and “you,” “me” and “mine, “no” and “i want.” the development of language is a tremendous tool in helping children to expand their world beyond the primary mother-child relationship. although language at this point is poorly formed and more expressive than communicative, it allows distance between mother and child. mother can now direct the child verbally without physically having to touch him or her. the child can refuse to obey by saying “no” or ignoring her, thus declaring his or her will, an expression of the emerging sense of autonomy. erikson wrote that a child’s “sense of self-control, without loss of selfesteem,” is the basis for a “lasting sense of autonomy and pride”; it is the ontogenetic source of a sense of free will.” he went on to say that “from … a loss of self-control, and of parental over control, comes a lasting sense of doubt and shame” (erikson, 1959, p. 109). a sense of doubt and shame results from the parents’ belittling, teasing, and overcontrol, which robs the child of the sense that he or she is capable of self-control and is able to direct his or her own life successfully. david: no will. david came to psychotherapy to resolve his career difficulties as a jazz musician and to address the lack of a permanent partner in his life. in the many months that i worked with him, it was increasingly clear that he became distant each time i was empathetic, such as when i validated his feelings or when we were saying good-bye. david’s distancing was subtle, but i could feel the emotional space between us, a vague disquieting sense within me, a desire to emotionally reach out to him and, at the same time, a contradictory sense of respecting the physical space between us. most likely i was responding to david’s recurring patterns of managing emotional closeness and/or to what he may have needed as a boy. i thought about erikson’s descriptions of how a young child grapples with trust and mistrust. although david attended his sessions weekly, i wondered if, at some primal level, he did not trust me. in several sessions i asked how he perceived our relationship. he hesitantly talked about how he imagined that i would eventually control him: “i know you won’t control me. i’ve watched you all these times, but i keep waiting for you to manipulate or criticize me.” those transferential transactions prompted me to ask david several questions, first about our current relationship and then about his life as a little boy. although he did not have specific memories of his early life, he described his mother as being “strict” and “always in control.” i asked him to imagine being 2 international journal of integrative psychotherapy, vol. 10, 2019 26 or 3 years old and wanting to climb on the furniture. he tightened his shoulder and back muscles and immediately said, “she would hit me if i did that. she would curse at me. she would destroy me.” although david did not have an explicit memory of being hit, he said “i know it to be true.” he then went into detail about how he, both as a boy and as a man, feared his mother. david described several times in his early life when his mother reprimanded, criticized, or hit him for being “willful.” he did not want to be physically close to her and never told her what he was feeling or thinking. he realized that with me he was not only enacting an early pattern of mistrust but also that he was afraid of expressing his opinions and aspirations in his intimate relationships and his professional life as a musician. david’s sense of will had been stymied. my therapeutic task included creating an emotionally and physically secure interpersonal space, supporting his aspirations, validating his self-definitions, and allowing myself to be impacted by him. initiative versus guilt erikson’s (1963) third stage is initiative versus guilt, which begins to develop at approximately 3-and-a-half years and continues until about age 6. however, the time frame may vary for some children. for piaget, children in this same age range organize cognitive experiences preoperationally, with intuitive thought. they engage in symbolic play and manipulate symbols and toys, but they do not yet use concrete logic or transform, combine, or separate ideas (piaget, 1951, 1952). this is the beginning of what fraiberg (1959) called the “magic years,” a time of fantasy, egocentrism, and parallel play. what children of this age do not understand in reality they create in fantasy. this stage encompasses the genital and oedipal stages in freud’s theory. in the previous period of autonomy versus shame and doubt, the driving force behind the child’s behaviors was the establishment of self-will and making an impact. the third stage is characterized by the child’s capacity to plan and execute playful projects for the pleasure of being active, to self-define, and to satisfy the imagination. it is a time of purpose, direction, and repetitive manipulation of toys. although children in this stage are full of play, exaggeration, and fantasy, they yearn for companionship, someone to play alongside them, someone who will be used as a toy and will respond to their initiative. successful building of children’s’ sense of initiative is based on their increased awareness of their own autonomy, which leads to more self-direction in their behaviors. in the preschool years, children develop a clear notion of goals international journal of integrative psychotherapy, vol. 10, 2019 27 and how they want to achieve them. if they cannot succeed in reaching their goals, they are able to either modify them or change the method by which they intend to reach those goals. erikson (1953) wrote that the dominating behavior of the initiative stage is a variety of repetitive activities and fantasies into which the child intrudes, including into people’s ears and minds with loud noises, space by vigorous actions, other people’s bodies by jumping and climbing on them, and the unknown with consuming curiosity (erikson, 1968, p. 116). at this age, children have developed greater freedom of movement that allows them to move vigorously and to have a wider radius of goals. language development has progressed so that they can ask about and understand many concrete events, although they may not comprehend diverse human relationships. their understandings are concrete and egocentric (maier, 1969). at the same time, children are expanding their imagination by playing out the roles they imagine are available in life. they model their play on those adults they see as strong and beautiful. it is this imagination of the young child that provides the groundwork for the development of initiative. the selection of goals and the perseverance in accomplishing them have their origin in the child’s fantasies about being almost as good as grown-ups. because children in this stage may not distinguish clearly between actuality and fantasy, overzealous parents can easily squelch their developing sense of initiative. if many of the child’s vigorous and intrusive activities, play projects, or fantasies are forbidden, he or she begins to think of his or her ideas as wrong or bad. a sense of guilt may overshadow the child’s playful imagination and resourcefulness (erikson, 1968, p. 122). the developmental task at this stage is a sense of conviction, without guilt, that “i can be what i imagine myself to be.” in my therapeutic experience with adult clients who were repeatedly hindered in their childhood play, expressions of fantasy and a self-defining sense of purpose tend to be inhibited, and they retreat to a passive internal world. erikson (1963) agreed with piaget (1951) that in this stage, between 3-anda-half and 6 years, play is necessary for a child’s development. play facilitates children’s natural progression toward new mastery and new developmental stages; it is their way of reasoning about their world. erikson (1963) wrote, “the child’s play is the infantile form of the human ability to deal with experience by creating model situations and to master reality by experiment and planning” (p. 22). he went international journal of integrative psychotherapy, vol. 10, 2019 28 on to say that he agreed with freud that play provides the fantasy needed to rectify anxiety experienced by the young child. it allows the child to free himself or herself of the boundaries of time, space, and reality and provides an acceptable avenue for self-expression. however, a reality orientation is maintained because he or she and others know that it is “just play.” timothy: longing for companionship. after timothy had been in therapy for 2 years, he embarrassingly described how he frequently masturbated, often more than once a day, from the time he was in kindergarten until today. he said that it was the most pleasurable thing in his life. this stimulated me to think of five developmental dynamics: • freud’s descriptions of the phallic stage that occurs about 5 years of age • erikson’s descriptions of the child’s budding sense of initiative and play • the importance of play in piaget’s theory of child development • fraiberg’s description of how fantasy is a dominant form of mental activity for a kindergarten-age child • my own observations regarding the 5-year-old child’s increased need for a shared experience (erskine et al., 1999) these five concepts guided me to inquire about timothy’s family relationships when he was in kindergarten. he described how his mother was always busy, “too busy to be with me.” his father was traveling for work. timothy always played alone because he was not allowed to play outside the house or to invite friends over. his most vivid memory was of being reprimanded for making too much noise. he was prohibited from playing with his toys except in his bedroom. in his telling me this history, i could sense his loneliness and longing for a shared experience, and, at the same time, he was ashamed to tell me about what he was feeling and doing. as i wove a series of historical and phenomenological inquiries into our sessions over the next several weeks, timothy became aware of a great sense of emptiness and sadness, a longing for companionship. he recalled at age 5 hiding under the stairs, playing with his penis in order to not feel his loneliness. it dawned on him that as an adult he was still comforting himself with masturbation rather than engaging with people. he remembered how he felt restricted and could not reach out to either parent for comfort. he said, “by age five i was already a loner.” this led me to inquire about the earlier years of his life. a year later he joined a men’s group that met weekly. after the men’s group spent several sessions talking about various aspects of shame in their lives, timothy told the group about the international journal of integrative psychotherapy, vol. 10, 2019 29 harsh, cold family in which he had lived and his constant sense of loneliness. he wept in response to compassion and understanding voiced by the other men in the group. conclusion the writings of erikson and other developmental psychologists mentioned earlier serve as a beacon to guide my phenomenological inquiry and understanding about the relational dynamics of my clients’ early lives. of course, our clients will not have explicit memories of early relational interactions. the symbolic, cognitive, and linguistic areas of the brain are not sufficiently formed during the first few years to allow for explicit memory, but memory consists of so much more. early childhood memory may be embodied in physiological sensations, entrenched in affect, or unconsciously enacted in relationships (erskine, 2008). these memories are not available to conscious thought because they are prelinguistic, presymbolic, procedural, and implicit. however, these neurological imprints give rise to “unconscious relational patterns,” what bowlby called internal working models of self-in-relationship (erskine, 2009, 2015a). when i am with a client, i frequently imagine myself as a curious detective searching for nonobvious clues as to what happened in that person’s early life. these clues are encoded in the person’s stories, fantasies, hopes, and dreams. hence, a major psychotherapeutic task includes decoding the clues that may reveal the early childhood ruptures in relationship and thereby help provide a therapeutic relationship that repairs those relational ruptures. although sensitively attending to the current crisis and central events in a client’s life is essential in a relationally focused psychotherapy, prolonged attention to current events may lessen the time devoted to a developmentally based, indepth psychotherapy. however, as we know, the client’s past relational disruptions are often being relived through current crises. to minimize the amount of time spent on current events in therapy, i make use of consistent phenomenological inquiry. my questions focus on bodily experience and related affect to bring the client’s attention to what is occurring internally. i ask about early family dynamics, even though the usual answer early in therapy is, “i have no memories before elementary school.” nevertheless, i often ask clients to imagine being a specific age, such as a nursing baby, a toddler learning to self-feed, a preschooler having a bath, or a kindergarten-age child playing with toys. i explore with them their feelings and associations when i inquire about bedtime at various ages, what they felt when international journal of integrative psychotherapy, vol. 10, 2019 30 they observed interactions between their parents, and other emotionally charged happenings in their life. i ask about who was present or absent, what interpersonal involvement happened between the child and grown-ups, and what relational needs were satisfied or ignored (erskine et al., 1999). i encourage them to interview family members who were either adults or older children when they were between infancy and kindergarten age to gather information that may confirm or disconfirm their own stories. in much of this work, my clients and i are using therapeutic inference, that is, constructing a story based on clients’ internal sensations, impressions, and fragments of information. we are working with early childhood implicit and procedural forms of knowing rather than only with explicit memories. such phenomenological and historical inquiry stimulates implicit and procedural memory and provides an opportunity to put that memory into thought and language, often for the first time. these are the foundations of a developmentally based, relationally focused integrative psychotherapy. author: richard g. erskine, institute for integrative psychotherapy, vancouver, canada, & deusto university, bilbao, spain references ainsworth, m. d. s., blehar, m. c., waters, e., & wall, s. (1978). patterns of attachment: a psychological study of the strange situation. oxford: erlbaum. beebe, b. (2005). mother-infant research informs mother-infant treatment. psychoanalytic study of the child, 60, 7–46. doi:10.1080/00797308.2005.11800745 berne, e. (1961). transactional analysis in psychotherapy: a systematic individual and social psychiatry. new york, ny: grove press. bowlby, j. (1969). attachment. volume i of attachment and loss. new york, ny: basic books. bowlby, j. (1973). separation: anxiety and anger. volume ii of attachment and loss. new york, ny: basic books. bowlby, j. (1979). the making and breaking of affectional bonds. london: tavistock. international journal of integrative psychotherapy, vol. 10, 2019 31 bowlby, j. (1980). loss: sadness and depression. volume iii of attachment and loss. new york, ny: basic books. bowlby, j. (1988a). developmental psychology comes of age. american journal of psychiatry, 145, 1–10. doi:10.1176/ajp.145.1.1 bowlby, j. (1988b). a secure base. new york, ny: basic books. breuer, j., & freud, s. (1955). studies on hysteria. in j. strachey (ed. & trans.), the standard edition of the complete psychological works of sigmund freud (vol. 2, 1–321). london: hogarth press. (original work published 18931895) bucci, w. (2001). pathways to emotional communication. psychoanalytic inquiry, 21, 40–70. doi:10.1080/07351692109348923 cozolino, l. (2006). the neuroscience of human relationships: attachment and the developing social brain. new york, ny: norton. damasio, a. (1999). the feeling of what happens: body and emotion in the making of consciousness. new york, ny: harcourt brace. erikson, e. h. (1946). ego development and historical change. psychoanalytic study of the child, 2, 359–396. doi:10.1080/00797308.1946.11823553 erikson, e. h. (1953). growth and crisis of the “healthy personality.” in c. klockhohn & h. murray (eds.), personality in nature, society and culture (pp. 185–225). new york, ny: knopf. erikson, e. h. (1958). young man luther: a study in psychoanalysis and history. new york, ny: norton. erikson, e. h. (1959). identity and the life cycle. psychological issues,1, 18–171. erikson, e. h. (1963). childhood and society. new york, ny: norton. erikson, e. h. (1964). insight and responsibility. new york, ny: norton. erikson, e. h. (1968). identity: youth and crisis. new york, ny: norton. erikson, e. h. (1969). gandhi’s truth: on the origins of militant nonviolence. new york, ny: norton. erikson, e. h. (1971). a healthy personality for every child. in r. h. anderson & h. s. shane (eds.), as the tree is bent: readings in early childhood education (pp. 120–137). boston, ma: houghton mifflin. erskine, r. g. (1971). the effects of parent-child interaction on the development of a concept of self: an eriksonian view [unpublished research report]. purdue university, lafayette, indiana. erskine, r. g. (2008). psychotherapy of unconscious experience. transactional analysis journal, 38, 128–138. doi:10.1177/036215370803800206 erskine, r. g. (2009). life scripts and attachment patterns: theoretical integration and therapeutic involvement. transactional analysis journal, 39, 207–218. doi:10.1177/036215370903900304 international journal of integrative psychotherapy, vol. 10, 2019 32 erskine, r. g. (2015a). relational patterns, therapeutic presence: concepts and practice of integrative psychotherapy. london: karnac books. erskine, r. g. (2015b). the script system: an unconscious organization of experience. in r. g. erskine (ed.), relational patterns, therapeutic presence: concepts and practice of integrative psychotherapy (pp. 73–89). london: karnac books. erskine, r. g., & moursund, j. p. (2011). integrative psychotherapy in action. london: karnac books. (original work published 1988) erskine, r. g., moursund, j. p. & trautmann r. l. (1999). beyond empathy: a therapy of contact-in-relationship. new york, ny: brunner/mazel. fairbairn, w. r. d. (1952). an object-relations theory of the personality. new york, ny: basic books. fraiberg, s. (1959). the magic years: understanding and handling the problems of early childhood. new york, ny: scribner’s. fraiberg, s. (1983). pathological defenses in infancy. psychoanalytic quarterly, 51, 612–635. (original work published 1982) doi:10.1080/21674086.1982.11927012 freud, s. (1953). three essays on the theory of sexuality. in j. strachey (ed. & trans.), the standard edition of the complete psychological works of sigmund freud (vol. 7, pp. 123–246). london: hogarth press. (original work published 1905) freud, s. (1957). the unconscious. in j. strachey (ed. & trans.), the standard edition of the complete psychological works of sigmund freud (vol. 14, pp. 159–215). london: hogarth press. (original work published 1915) freud, s. (1962) the neuro-psychoses of defence. in j. strachey (ed. & trans.), the standard edition of the complete psychological works of sigmund freud (volume 3, pp. 41–61). hogarth press. (original work published 1894) kagan, j. (1971). understanding children: behavior, motives, and thought. new york, ny: harcourt brace jovanovich. kihlstrom, j. f. (1984). conscious, subconscious, unconscious: a cognitive perspective. in k. s. bowers & d. meichenbaum (eds.), the unconscious reconsidered (pp. 149–210). new york, ny: wiley. ledoux, j. e. (1994). emotion, memory and the brain. scientific american, 270, 50–57. doi:10.1038/scientificamerican0694-50 lyons-ruth, k. (2000). “i sense that you sense that i sense …”: sander’s recognition process and the specificity of relational moves in the psychotherapeutic setting. infant mental health journal, 21, 85–98. doi:10.1002/(sici)1097-0355(200001/04)21:1/2<85::aidimhj10>3.0.co;2-f international journal of integrative psychotherapy, vol. 10, 2019 33 mahler, m. s. (1968). on human symbiosis and the vicissitudes of individuation. new york, ny: international universities press. mahler, m., pine, f., & bergman, a. (1975). the psychological birth of the human infant: symbiosis and individuation. new york, ny: basic books. maier, h. w. (1969). three theories of child development. new york, ny: harper & row. main, m. (1995). recent studies in attachment: overview with selected implications for clinical work. in s. goldberg, r. muir, & j. kerr (eds.), attachment theory: social, developmental and clinical perspectives (pp. 407–474). hillsdale, nj: the analytic press. moursund, j. p., & erskine, r. g. (2003). integrative psychotherapy: the art and science of relationship. pacific grove, ca: brooks/cole-thomson learning. piaget, j. (1951). play, dreams and imitation in childhood. london: qeinemann. piaget, j. (1952). the origins of intelligence in children. (m. cook, trans.). new york, ny: international universities press. (original french edition published 1936) piaget, j. (1954). the construction of reality in the child. new york, ny: basic books. piaget, j. (1960). the general problems of the psychobiological development of the child. in u. m. tanner & b. inhelder (eds.), discussions on child development: proceedings of the world health organization study group on the psychobiological development of the child, 4, 3–27. piaget, j., & inhedler, b. (1969). the psychology of the child. new york, ny: basic books. piaget, j., & inhelder, b. (1973). memory and intelligence. london: routledge and kegan paul. porges, s. w. (1995). orienting in a defensive world: mammalian modifications of our evolutionary heritage. psychophysiology, 32, 301--318. doi:10.1111/j.1469-8986.1995.tb01213.x porges, s. w. (2009, april). the polyvagal theory: new insights into adaptive reactions of the autonomic nervous system. cleveland clinic journal of medicine, 76(suppl. 2), s86–s90. doi:10.3949/ccjm.76.s2.17 schacter, d. l., & buckner, r. l. (1998). priming and the brain. neuron, 20, 185–195. schore, a. n. (2002). advances in neuropsychoanalysis, attachment theory, and trauma research: implications for self-psychology. psychoanalytic inquiry, 22, 433–484. doi:10.1080/07351692209348996 siegel, d. (1999). the developing mind: toward a neurobiology of interpersonal experience. new york, ny: guilford. international journal of integrative psychotherapy, vol. 10, 2019 34 siegel, d. j. (2007). the mindful brain: reflection and attunement in the cultivation of well-being. new york, ny: norton. stern, d. n. (1977). the first relationship: infant and mother. cambridge, ma: harvard university press. stern, d. n. (1985). the interpersonal world of the infant: a view from psychoanalysis and developmental psychology. new york, ny: basic books. stern, d. n. (1995). the motherhood constellation: a unified view of parent-infant psychotherapy. new york, ny: basic books. stern, d. n. (1998). the process of therapeutic change involving implicit knowledge: some implications of developmental observations for adult psychotherapy. infant mental health journal, 19(3), 300–308. doi:10.1002/(sici)1097-0355(199823)19:3<300::aid-imhj5>3.0.co;2-p tronick, e. z. (1989). emotions and emotional communication in infants. american psychologist, 44, 112–119. doi:10.1037/0003-066x.44.2.112 winnicott, d. w. (1965). the maturational processes and the facilitating environment: studies in the theory of emotional development. new york, ny: international universities press. winnicott, d. w. (1971). therapeutic consultations in child psychiatry. new york, ny: basic books. international journal of integrative psychotherapy, vol. 6, 2015 1 helpful aspects of the therapeutic relationship in integrative psychotherapy karmen urška modic & gregor žvelc abstract: this article describes a qualitative study of helpful aspects of the therapeutic relationship in integrative psychotherapy. participants of the study were sixteen clients who were in the process of integrative psychotherapy for at least a year. participants were interviewed with the adapted version of the change interview (elliott, 1999), which involves a semi-structured empathic exploration of the client's experience in therapy. the analysis of the clients’ experience of integrative psychotherapy revealed six categories of helpful aspects of therapeutic relationship: the therapist’s empathic attunement, the therapist’s acceptance, the match between the client and the therapist, feelings of trust and safety, feeling of connection, and experience of a new relational experience. based on results of the research, we developed a model of the healing relationship in integrative psychotherapy. this model describes the interrelatedness of these six helpful aspects of the therapeutic relationship. the categories of empathic attunement and acceptance proved to be the most important categories relating to the therapist’s contribution to the healing therapeutic relationship. clients described that the therapist’s empathic attunement and acceptance influenced the development of safety and trust, feelings of connection and promotion of new relational experiences. the results of this study are discussed in relation to the theories of integrative psychotherapy and research regarding the therapeutic relationship in psychotherapy. key words: integrative psychotherapy, therapeutic relationship, helpful aspects of psychotherapy, significant events in psychotherapy, qualitative research in psychotherapy ______________________ introduction psychotherapy integration has become a significant paradigm in psychotherapy and is increasingly used among mental health practitioners international journal of integrative psychotherapy, vol. 6, 2015 2 across the world. there are many different forms of psychotherapy integration. in this article we will focus on a particular approach – the theory and methodology of integrative psychotherapy developed by richard g. erskine and his colleagues (erskine & trautmann, 1997; erskine, moursund & trautmann, 1999; erskine & moursund, 2011; erskine, 2015). this approach integrates theories and methods from psychoanalytic, humanistic and behavioural traditions in psychotherapy, forming a coherent theoretical background that serves as the basis of psychotherapeutic interventions (erskine & moursund, 2011). the term "integrative" also relates to the process of integration of the personality or rather, integration of the split and unconscious parts of self into a cohesive unit. the therapist's role is to help the clients towards the integration of cognitive, behavioural, emotional and physiological dimensions of their personality by considering social and transpersonal aspects. integrative psychotherapy is based on three related theories: theory of personality, theory of motivation and theory of methods (erskine, 1997). the relationship between the therapist and the client is of central importance in integrative psychotherapy. it is not just the basis for therapeutic interventions but a healing factor on its own. the main aim of integrative psychotherapy is establishing a therapeutic relationship that enables the clients to establish contact with themselves and others. integrative psychotherapy describes three main methods of work within the therapeutic relationship: inquiry, attunement, and involvement (erskine et al., 1999). through inquiry (erskine et al., 1999), the therapist helps the clients on their path of self-discovery and healing. inquiry involves a respectful exploration of the client's phenomenological experience. it is based on the assumption that the therapist does not know anything about the client’s subjective experience and behaviour. the aim is to help the clients see previous and current ways they interrupt both internal (intrapersonal) and external (interpersonal) contact. by recognising and changing such patterns, clients can strive to develop genuine contact with themselves and others, and access more spontaneity, flexibility and satisfaction. the emphasis is on the process whereby the therapist invites the client to look for answers, think differently and explore new levels of awareness. with inquiry, the main aim is not necessarily the answers per se, but rather the process of the inquiry. the inquiry is healing on its own if it takes place in an authentic relationship between the therapist and the client, whereby the clients can safely explore themselves in a new light and gain new ways of functioning in contact with another human being. attunement (erskine et al., 1999) is the kinesthetic and emotional sensing of the other, knowing his or her rhythm, affect and experience accompanied by a resonating response and/or reciprocal emotion. the therapist's ability to resonate with the client's experience makes it possible for the client to bring back to international journal of integrative psychotherapy, vol. 6, 2015 3 awareness the experiences and components of the self that have been split off and suppressed, thus validating the past and present needs and emotions. erskine et al. (1999) describe the following aspects of attunement: cognitive, affective, rhythmic, developmental as well as attunement to relational needs. in the case of cognitive attunement, the therapist attunes to the client's cognitive processes and their way of thinking. affective attunement involves responding to both the clients’ internal affects and emotional expressions with a reciprocal emotional response from the therapist. rhythmic attunement is the pacing of therapeutic inquiry and involvement at the natural and preferred tempo of the client, whereby s/he is able to best process external and internal information. with developmental attunement, the therapist attunes to the client's developmental level of psychological functioning, which may fluctuate during treatment and even within a session, and not necessarily correlate to the client’s chronological age. an important part of attunement is the recognition of the relational needs of the client and an adequate reciprocal response from the therapist to the need for security, respect and validation, affirmation, confirmation of personal experience, self-definition, the need to have an impact on the other person, the need to have the other initiate and the need to express love. attunement directs therapeutic inquiry and shapes the nature of therapeutic involvement (erskine et al., 1999). involvement (erskine et al., 1999) means that the therapist is willing to be affected by what happens in the relationship with the client. integrative psychotherapy authors describe four main aspects of involvement: acknowledgement, validation, normalisation and presence. with acknowledgment, the therapist demonstrates that he or she is aware of what the client is saying and experiencing. validation is the acknowledgment of the significance of the client’s experience. normalisation de-pathologises the clients’ definition of their internal experiences or their coping mechanisms. in this manner, therapists communicate to clients that their experiences are normal, and not a pathological or defensive reaction. presence means that the therapist ‘is there’ for and with the client and that the therapist is committed to the client's welfare. inquiry, attunement and involvement, the central methods of relational psychotherapy, enable clients to gain a new relational experience that invites them out of their old repetitive patterns. the three methods described here are strongly intertwined and represent the main elements of a healing therapeutic relationship in integrative psychotherapy. methods and theories of integrative psychotherapy are congruent with the research of common factors in psychotherapy and the knowledge that the therapeutic relationship is one of the main factors of successful therapy (lambert and barley, 2001; norcross and lambert, 2011; norcross and wampold, 2011; international journal of integrative psychotherapy, vol. 6, 2015 4 orlinsky, ronnestad and willutzki, 2004). however, the main characteristics of the therapeutic relationship in integrative psychotherapy, as developed by erskine and colleagues, have not yet been studied systematically. therefore, these authors decided to conduct a study that would examine the clients' experience of the therapeutic relationship. the aim of the study was to examine the clients' experience of helpful aspects of the therapeutic relationship in the process of integrative psychotherapy. we thus formulated the research question: “how do clients experience helpful aspects of the therapeutic relationship in the process of integrative psychotherapy?” “significant events” research (elliott, 1985) is a unique approach to studying specific events in psychotherapy the events that the client experiences as significant. this kind of research usually analyses transcripts of sessions as well as the client's and the therapist's reflections on specific events (elliot, 1989). elliott and shapiro (1992) define “significant event” as the part in the therapeutic session experienced by the client as most helpful or important. the comprehensive process analysis method (elliot, 1989; elliott and shapiro, 1992) focuses on understanding the context in which a significant event occurs, significant aspects of the event itself and the impacts of the event. our study examines the client's retrospective recall of significant events in therapy from a perspective with some time distance (rhodes, hill, thompson & elliott, 1994). significant events research has been used in qualitative research for more than twenty-five years and this paradigm was used to study various therapeutic modalities and client problems (cahill, paley & hardy, 2013; elliott & shapiro, 1992; glass & arnkoff, 2000; levitt, butler & hill, 2006; lietaer, 1992; manthei, 2007; mcvea, gow & lowe, 2011; moertl & wietersheim, 2008; oliveira, sousa & pires, 2012; rennie, 1992; svanborg, baarnhielm, wistedt & lutzen, 2008; timulak, 2007, 2010). our study is based on the assumption that moments which clients identify as helpful may be the most fruitful instances of the psychotherapeutic process (timulak, 2007). studying such events can shed some additional light on understanding elements of psychotherapy that facilitate change, how they facilitate it (bergin & lambert, 1978) and how therapists can contribute to the healing effect of therapy. we resorted to qualitative methodology due to the descriptive nature of our research question. our study is a part of a broader research project dealing with the efficiency of integrative psychotherapy, currently being conducted as part of the doctoral study of applied psychology within the faculty of arts at the university of ljubljana, slovenia, department of psychology. this study was approved by the ethical commission of the faculty of arts, university of ljubljana. international journal of integrative psychotherapy, vol. 6, 2015 5 method participants we invited clients who had either concluded or were still in the process of integrative psychotherapy with psychotherapists who were educated at the institute for integrative psychotherapy and counselling, ljubljana, slovenia, and were members of the slovenian association of integrative psychotherapy and transactional analysis. the size of the sample was not decided upon beforehand, but instead via the method of data saturation (glaser & strauss, 1967), participants were no longer added when gathering new data failed to produce new categories. the sample was comprised of 16 participants, 11 female and 5 male, who had been in therapy with 11 different therapists. the age range of the participants was 25-52 years; m=33.4 years. thirteen participants were employed, two were unemployed, and one was a student. the participants presented a variety of educational backgrounds; 9 completed secondary education, 5 completed a university degree, and 2 completed a postgraduate degree. presenting psychotherapy issues included anxiety, stress, cognitive/learning disorders, personality disorders, eating disorders, physical symptoms, trauma/abuse, grieving/loss, poor selfesteem, interpersonal/relational problems and work/study problems. all of the participants had been included in the process of integrative psychotherapy for at least a year (14 clients had completed 1-3 years of therapy, 2 clients had completed more than 3 years of therapy). instruments for the purpose of this study, we created a demographic questionnaire for participants. our demographic questionnaire was used to obtain data regarding: (1) the style of therapy; (2) length of time in the process of therapy; (3) gender; (4) age; (5) level of education; (6) status of employment; (7) their problems/problem areas; (8) history of seeking help; (9) psychiatric diagnosis; (10) whether they were prescribed any medication relating to mental health issues. we adapted the change interview (elliot, 1999; elliott, slatick & urman, 2001) for the purpose of this study. this “interview” is comprised of a semi-structured empathic exploration of the client's experience in therapy. the researchers posed open questions that helped the clients elaborate on their experience and asked the clients to provide as much detailed information about the events in therapy as they could. while interviewing the clients, they explored key research areas and adjusted questions in line with individual characteristics of participants, following their narration. in accordance with the main assumptions of the interview method international journal of integrative psychotherapy, vol. 6, 2015 6 (fassinger, 2005), the interview protocol allowed the participants' narration to develop freely and the participants to explain their experience in their own way. examples of questions are: what change did you notice since starting therapy? what was the cause of change? what helped you in the process of change? the study analysis focused exclusively on the description of helpful aspects of the therapeutic relationship. procedure the study was conducted by a phd student of applied psychological sciences (researcher a) and a clinical psychologist with fifteen years experience as a psychotherapist (researcher b). the invitation to participate was sent through email to members of the slovenian association for integrative psychotherapy and transactional analysis. therapists asked their clients whether they wanted to participate and we were then contacted by the clients. we informed the participants about the purpose of our study and they signed a statement stating that their participation was voluntary. individual interviews were recorded in a safe environment that allowed privacy and then transcribed word-by-word. we further employed the method of theoretical sampling (glaser and strauss, 1967), or rather triangulation of data (flick, 2014), to include different participants and different problem areas. we began the analysis after completing the first four interviews. interviews were analysed according to corbin and strauss (1998, 2008) using the strategies of asking questions and constant comparisons. the interview process and the analysis were run simultaneously. we used a software programme for qualitative analysis atlas.ti to do this (friese, 2014). in the first phase of open coding (corbin and strauss, 1998), we thoughtfully read line by line, studied the transcription, analysed it and identified concepts or units of meaning. we then compared concepts and formed broader categories with those that described similar phenomena. after we completed the open coding, we continued with axial coding to establish relations within specific categories as well as the relation between a category and subcategories. we then selected those concepts and categories that were relevant with regards to the problem and purpose of our study. we formed definitions to capture the essence of concepts and categories. selective coding (strauss and corbin, 1998) was used to unify data around a core category. following the completion and analysis of the last three interviews, we found that some topics repeated themselves. saturation of data occurs when newly acquired data no longer contribute to the existing characteristics of the already established categories (glaser and strauss, 1967). after we concluded the sixteenth interview, we found that categories were saturated and we concluded the study. international journal of integrative psychotherapy, vol. 6, 2015 7 while obtaining and analysing data, we met weekly to compare codes and categories that we formed separately in each phase of the analysis. triangulation of researchers (flick, 2014) was used to reduce the bias likely to be present due to subjectivity of researchers. based on our theoretical starting points, bias would likely be linked to the perspective represented by integrative psychotherapy. within the context of the described study, our view of the underlying events in the process of psychotherapy served as the “sensitising concept” (charmaz, 2006), meaning that we were aware of our theoretical background and at the same time maintained an open conceptual framework and let the material speak for itself. our study entailed a process that could be described as iterative (mesec, 1998), since every step was followed by reviewing and analysing previous findings. the main strategies used to maximise the validity and reliability of our qualitative study were: writing memos to complete the categories and relations between the categories, finding missing data, discussing results with a colleague, comprehensive selection of participants, as well as multiple and continuous verification of data and conclusions. results the analysis of 16 interviews (approximately 113 transcribed pages in a4 format) revealed 130 coded citations (cc) relating to the main question of our research. table 1 shows the taxonomy of helpful factors in the process of integrative psychotherapy and the total number of coded citations. a significant event was defined as an event or experience that helped the client change or alleviate a problem situation (elliott and shapiro, 1992). every time a client referred to something as helpful or the statement made it obvious an event was helpful, we marked the text with a code that was appropriate to the content. statements were grouped into categories based on their meaning and we finally arrived at six main categories. table 1 contains descriptions of the categories in question as well as the number of coded transcripts (ct), i.e. the number of participants that mentioned a specific category. when interpreting the cited numbers, one should bear in mind that the interviews conducted were semi-structured. we thus did not ask the participants about specific areas; rather, the participants described parts of their experience within the process of therapy that they found especially memorable. the cited number is thus an estimate of the number of participants that mentioned a specific experience constituting a significant part of their therapy. international journal of integrative psychotherapy, vol. 6, 2015 8 table 1 taxonomy of helpful aspects of the therapeutic relationship in integrative psychotherapy helpful aspects of the therapeutic relationship cc ᵃ ct ᵇ 1. empathic attunement 44 14 1.1. the therapist's emotional attunement 1.2. understanding the client's experience 1.3. attuning to the client's process 1.4. experience of contact 2. acceptance 24 9 3. safety and trust 19 10 4. connection 19 8 5. a new relational experience 12 8 6. match 12 4 note. ᵃ number of coded citations. ᵇ number of coded transcripts. helpful aspects of the therapeutic relationship were cited by every one of the participants of our study; we collected 130 coded citations relating to the therapists’ empathic attunement, unconditional acceptance, safety and trust, connection, a new relational experience and the therapist being a good match for the client. the following descriptions provide concise definitions of categories and their essence, followed by a broader description and examples of citations. statements are accompanied by their id, i.e. the code assigned to the interview and code of the citation (e.g. 5:39 – 39th citation of the 5th interview). the section on results is comprised of two parts. the first one relates to categories and statements associated to the problem of our research and the second one is the sum of results represented as a model. 1. empathic attunement empathic attunement consists of several subcategories linked to the therapist’s empathic attunement: a) emotional attunement, b) understanding the client’s international journal of integrative psychotherapy, vol. 6, 2015 9 experience, c) attunement to the client’s process and d) the client’s experience of contact. 1.1. therapist’s emotional attunement the citations suggest that the clients found it very important for the therapist to be emotionally attuned to them, have empathy and feel their distress. the clients stressed the sensitivity and emotional responsiveness of the therapist transmitted by the therapist’s body language. the citations below, taken from our client sample, illustrate this. “and empathy as well, it meant a lot to me, i did not expect someone to cry with me, especially because it was not even a friend, but a psychotherapist. i did notice that, when things were really hard for me, she could feel my distress. i could tell by her mimics, her face, as if she were suffering, it was a very empathic relationship. that helped me a lot.” 5:39 “yesterday as well, just before we finished, we touched on a difficult issue. i could tell, i saw that she was a bit concerned and she told me to look after myself the next day because it might be a bit hard. it means a lot to me that i mean something to her.” 10:59 another aspect that seems to be very important to clients is the therapist’s genuine interest in their feelings and physical responses. “after anything like that, before we say goodbye, she always asks me how i feel and takes the time and i also see that when i start to breathe faster… like, she does.” 10:82 moreover, statements relating to the significance of therapist’s genuine emotional response to the clients’ feelings are also very interesting. the clients find it important for the therapist to be genuinely emotionally engaged in the relationship. “and also that she, the therapist, is happy every time you succeed.” 13:36 1.2. understanding the client’s experience clients further stressed as truly significant the therapist attempts to understand their inner world and investing some time and effort into it. international journal of integrative psychotherapy, vol. 6, 2015 10 “yes, precisely for those things that i thought he could not understand, he actually made an effort to understand. we talked about delicate issues and i somehow needed a lot of effort and will to even go into it it meant a lot to me that he also invested some effort into understanding it.” 11:12 “herself, just the way she is, the way she talks, the things she says and her actions, i feel like she gets it. she does not make me feel like i’m a junkie, a number, but that i am her equal.” 10:57 1.3. attuning to the client’s process clients find the therapist’s attunement to their process important, which can be seen from the citations relating to the therapists being sensitive to the clients’ experience and valuing their opinion. the therapist follows the client’s willingness to work on specific topics and reacts from one moment to another. “but it is true that there are so many other topics. i come there and need to talk about something and then the next time i might have to talk about something else. she makes sure that we talk about the things that bother me the most.” 10:67 additionally, some clients find it important for the therapist to adapt to their own tempo and inner experience. “i liked the fact that i could be the one setting the tempo. i could always choose the topic. it was not like me getting there and her saying, right, let’s talk about whatever was left from previous session.” 8:48 “i think she sets the tempo just right, because if it was too much, i would probably say that i cannot go forward and would go to therapy even more nervous, thinking about what is going to happen at the session. so i feel like she does something like that only when it is appropriate – i guess she must assess when it is okay.” 12:58 clients find it very important for the therapist not to pressure them into something they do not want, put words in their mouths or suggest what they should do. “she never forced me to do anything, put words in my mouth or forced her own opinion. she somehow always let me reach my own conclusion. sometimes i could have something in front of my nose for the whole month and i could not see it. it’s good that i could see it on my own, that she did not just say it, because it’s just different if you figure it out by yourself.” 8:39 international journal of integrative psychotherapy, vol. 6, 2015 11 “thirdly, not imposing her opinion. i very much dislike that, someone telling you what’s right and what’s wrong. because it was me who built my own personality, it was not her, she just helped a little. because then i would again believe that she was the one who built it. it would not have been me. that’s why it was so important that she did not do that.” 16:46 the clients further find it important for the therapist to ask about the way therapeutic interventions and reactions affected them and how the client felt about the relationship. “if she does something, like when we communicated through e-mails and she asked how i felt about her reaction. just that, the fact that nothing goes unnoticed, it’s always important. if i find something important, she finds it important. the feeling that she is taking you seriously.” 12:53 “what she is really doing well, which gives you the feeling that this relationship is important, is that she asks for feedback. that as a therapist she asks if she is doing well and you can say yes or no. and she can use that in the future.” 12:73 1.4. the experience of contact the experience of contact is described by some clients as a qualitative change in the relationship that occurred based on the therapist’s warmth and emotional participation. the experience is described as an experience of deep contact with the therapist and some clients find it to be a key moment in therapy. “and that unconditional acceptance, the warmth that can be felt. i remember when that happened, it was after a few sessions that we got to this positive warm contact that changed the quality of what was going on in therapy before and after. i am not sure i can describe it in words. it was just this subconscious, nonverbal click, yeah, a click. i was really surprised by it, it happened in about one or two sessions. it was about a year ago, after two or three years. it was not like that before, it was different, on a more conscious level.” 6:38 2. acceptance the category of acceptance includes factors of the therapist’s complete, unconditional, absolutely positive acceptance of the client devoid of judgement. the clients reported that therapist’s acceptance and lack of judgement enabled them to talk about things they would otherwise find unpleasant to talk about. international journal of integrative psychotherapy, vol. 6, 2015 12 “without judgement, i felt safe and was not afraid to talk about things. i was not afraid to say anything. when we established the relationship, i was sure that no matter what state i might be in, she would be able to get me out of it.” 5:40 in relation to the above, the clients further reported a beneficial effect of the therapist’s acceptance of feelings they struggled to accept themselves, such as shame and sadness. the therapist’s acceptance helped them accept their feelings and get some relief. a positive accepting relationship with the therapist was further associated with normalisation. the clients felt that their experience was normal and human. “whenever i talked about anything that triggered shame, when i shared that and she was very accepting of me and made it easier for me to accept myself. i felt like it was something that would be good to discuss, but it was not easy.” 6:19 “but in the background i did and i learnt about grief for the first time. that it’s allowed, that it’s just a process, that it is quite normal. it went much faster, it hurt at first, but it was a lot easier because i worked through it on my own before.” 8:47 some of the participants highlighted that the therapist’s absolute positive acceptance helped normalise their inner experience, helped them become aware of their own value and develop self-respect. “for me, it was important that somebody said: it is normal, it is normal that you feel that way and what you are saying is perfectly normal. the fact that somebody accepted me without judgement, no matter what i did and her understanding.” 16:39 “a specific event is mainly her understanding, that she listens and lets you know that nothing is wrong with you.” 15:37 some clients found it important for the therapist to accept them even if he/she did not agree with the client or if they had a conflict. “the therapist’s all-encompassing acceptance. that he gives me the space to process things, but still accepts me. that he is able to stay in the relationship despite the occasional conflict.” 6:31 in the following paragraphs, we list some interesting quotes with clients recalling how they felt free to experience anything and it would be accepted; they felt that the therapist provided them with unconditional acceptance, even with things that international journal of integrative psychotherapy, vol. 6, 2015 13 seemed irrelevant or silly on the surface. “because with him, it didn’t matter what came out, it was always okay. i did not feel like it was crazy. that freedom in the sense of letting something seemingly irrelevant come and then seeing that it is not even really irrelevant, because it might trigger a feeling and then you see there is something more to it.” 7:82 “i really like it that we get along so well, that you can say a lot of things, you can make a joke and she is not really formal, that she is a warm person. you can say something funny sometimes when you are struggling to lift the spirit a bit and she understands.” 9:38 3. safety and trust this category consists of aspects of safety and trust established by the therapist in the key moments of the therapeutic process, sometimes purposely and other times intuitively. the feeling of safety minimises the client’s distance and offers a safe space serving as the basis of therapeutic work. some clients reported that trust was built slowly and gradually; “just like you read, when the fox in the little prince tells the prince ‘come at the same hour every day and we will sit closer every time’. that is how trust is built, slowly, slowly, bit by bit.” 4:37 “and a trusting relationship. if that wasn’t there, i surely would not be able to work. absolutely a relation of trust. our relationship was built like that as well. i remember some key moments, this was very early on, when our relationship was established. so, definitely, the relationship.” 7:80 with other clients, the trust was established intuitively. “the feeling of trust – you either have it or you don’t. i went to her because it felt like i could trust her. i trusted her from the very beginning.” 15:50 in relation to trust, participants talked about the feeling of safety they experienced with therapist. it seemed important for them to feel that the therapist was able to help, that they are safe and can open up. “he did not tell me that we would reach the end at a certain point. but just the fact that he was there the way he was, so that i could open up to him and knew that it was my space and it was safe. that he was there, that he knows that no international journal of integrative psychotherapy, vol. 6, 2015 14 matter what happens, he is there and he would know how to react. i am only beginning to realise that i had that feeling of safety the whole time. it is very important, if i thought that he did not know what he was doing, i would not have entered it in the same way.” 7:95 furthermore, other quotes indicated that clients’ feelings of safety are often connected to the structure and order that therapy provides and in terms of a regular time scheduled for therapy. “a relationship built on trust, support, understanding, a certain order. order is important as well as meeting at a specific hour and keeping the timing. it is important, so you know what to expect. it brings about certain safety.” 14:28 4. connection this category includes factors of connection with a therapist who is perceived as a stable, constant and reliable person. half of the clients thought it to be important to feel a sense of connection with their therapists, and know that the therapist thinks of them outside of their sessions. they appreciated the feeling that they were in someone else’s thoughts; a person who was willing to be there for them. “yes, we have a connection. when i am in distress, i think of her sometimes and the things we talked about. but i don’t really have the wish to call her or let her know.” 2:27 “and also, when she went on vacation, she gave me her co-worker’s number and was available through e-mail. she let me know that she is there for me whenever i need her.” 10:31 a number of clients found it to be important to know that they had someone who could be reached, was reliable, constant and who they could go back to after concluding the process of therapy. “and knowing that you have someone who is just there.” 5:41 “i was a bit like, it did not feel like it was final, even on our last session. i still don’t feel like it is final. i feel like i have a backup, that even if anything happened to me and i felt like i could not cope, i would have a backup.” 8:63 international journal of integrative psychotherapy, vol. 6, 2015 15 5. a new relational experience this category includes aspects of a new relational experience that occurred in the process of therapy and contributed to the desired change. eight of the clients found it important to be able to experience a new, different quality in the relation with the therapist. quotes also relate to the feelings of mutual affection that the clients can then look for outside of therapy, thus seeing mutual affection is possible. “the feeling that you care for someone and they care for you. i don’t know if that would happen without therapy, or maybe it would. sometimes some intense experience gives us a sense of possibility. feeling that it is possible and then you look for something like that.” 4:7 some participants reported feeling for the first time they were equal and taken into account in the relationship. similarly, they had the experience for the first time that somebody was aware of important events in their lives. “my therapist helps me and encourages me to go on. she is happy with my way of thinking and functioning and supports me. if she disagrees with me, she tells me and then i think about it. she helps me maintain it and it means a lot that someone knows what i am doing. my mom doesn’t know it, no one knows it.” 10:70 despite the fact that clients mention new relational experiences as a significant beneficial aspect, the new experience can at first be unpleasant and hard. “perhaps it helped in a way that the sharing was not mutual and i was more exposed. it made me feel uncomfortable at first, but probably helped because it pushed me. it was out of my comfort zone, it crossed that boundary. it was stressful for me to come there and talk and confide in her. because she was always focusing on me and my feelings.” 1:6 a similar description can be found in the words of a client who mentioned that the feeling of connection had been very intense for her and described it as ‘collapse of the system’. “the first time she talked to my child, i felt like i was going... it was like a total collapse of the system. i can’t even describe how i felt. i don’t know if anyone else ever went that deep. it is such a primary experience.” 13:43 international journal of integrative psychotherapy, vol. 6, 2015 16 6. match this category includes aspects of the match between the personalities of the therapist and the client, as well as agreement on the tasks or contract of the therapy work. four of the clients mentioned the importance of a good personality match with the therapist and feeling of compatibility with the therapist’s way of working with them. “i liked her as a person as well. if i didn’t like her as a person, we couldn’t do much and her way of working would not matter. but we had a very nice relationship from the very beginning, so i didn’t fear coming there, i was rather open, i was looking forward to it.” 8:42 “in time, we became a really good match. and that is really important to me.” 6:55 the model of a healing therapeutic relationship results reveal a mutual relationship between all of the factors of the therapeutic relationship. the model below serves to illustrate this type of a healing therapeutic relationship (figure 1). international journal of integrative psychotherapy, vol. 6, 2015 17 figure 1. the model of a healing therapeutic relationship in integrative psychotherapy. in this model we identified the core category “healing therapeutic relationship.” based on the client’s description of categories, it was evident that helpful aspects of the therapeutic relationship represent aspects of healing in psychotherapy. the six categories describe different aspects of the healing therapeutic relationship, which are strongly interrelated, as illustrated by the circle in the model. the upper triangle describes the core aspects contributing to the development of a healing relationship. empathic attunement and acceptance represent aspects of the therapist’s contribution to the healing relationship, while the category of match relates both to the therapist and the client. the lower triangle, however, relates to the client’s experience of the healing relationship, characterised by the connection, safety and a new relational experience. arrows in the diagram illustrate the fact that the aspects are strongly interrelated and influence one-another. the categories of empathic attunement and acceptance proved to be the most important categories and relate to the therapist’s contribution to the healing match empathic attunement acceptance connection safety and trust new relational experience healing relationship international journal of integrative psychotherapy, vol. 6, 2015 18 therapeutic relationship. clients related that the therapist’s empathic attunement and acceptance influence the development of safety and trust, feeling of connection and new relational experiences. some of the citations describing the above-mentioned influence are included below. the therapist’s empathic attunement helped create a new relational experience and connection. “and then there was a real sense of connection. i was surprised when it happened. it happened very fast. as if someone turned on a switch. after that, therapy became a real pillar, a strong source of support that was internalised as well.” 6:39 it was unconditional acceptance that was at the core of the new relational experience. “a brand new experience, on a purely relational level. that i can talk about things and get a different reaction from a new person, a more accepting one. love heals on all levels.” 6:49 unconditional acceptance, safety and trust are interrelated. “that i didn’t feel any judgement. whatever i told her i always had a feeling of safety. she always made me feel safe, unusually safe. the same thing i am looking for in relation with my best friends, my partner, a certain feeling of safety. i had to establish that with her, she gave me this feeling of safety, of complete acceptance, that she does not judge me.” the interrelation of categories is associated to feelings of connection, safety and trust. “that i mean something to her, that means a lot to me. that she is there for me. and i trust her even more because of that.” 10:76 discussion the qualitative analysis of the clients’ experience of integrative psychotherapy revealed six aspects of a healing therapeutic relationship the clients found to be crucial: empathic attunement of the therapist, the therapist’s acceptance, the match between the client and the therapist, feelings of trust and safety, feeling of connection and a new relational experiences. the clients’ answers showed that it was the empathically attuned and accepting therapist and the match between the international journal of integrative psychotherapy, vol. 6, 2015 19 therapist and the client that lead to the clients’ feeling of trust and safety, as well as the connection with the therapist and a new relational experience. at the same time, the six aspects of the therapeutic relationship are strongly related and bear a strong influence on one-another. obtained aspects of the healing therapeutic relationship are comparable to the model of “the keyhole” in integrative psychotherapy, which illustrates the methods of inquiry, attunement and involvement (erskine et al., 1999). the category of empathic attunement is linked to the concept of attunement in integrative psychotherapy and includes the therapist’s affective attunement and responsiveness, sensitivity to the client’s experience from one moment to another, and ability to adjust to the clients’ tempo (erskine et al., 1999; erskine, 2015). erskine et al. (1999) talks about the affective, cognitive, rhythmic and developmental attunement of the therapist and the attunement to the client’s relational needs. these aspects of attunement are demonstrated in the comments made by participants in our study, and their mention of their experience of contact in the therapeutic relationship. our category of acceptance contains factors of the therapist’s complete, unconditional and all-encompassing acceptance, devoid of any judgement. the clients felt that the therapist’s understanding and absolute positive acceptance provided them with a sense that what they were feeling is normal, as well as providing a feeling of one’s worth and self-respect. in integrative psychotherapy, factors of acceptance can be related to the concept of involvement which includes acknowledgement, validation, normalisation and the presence of the therapist (erskine et al., 1999; erskine, 2015). in relation to acceptance, clients reported that the therapist’s acceptance of their feelings of shame and sadness, which they struggled to accept themselves, was also helpful and enabled them to start to accept and value themselves. closely related to acceptance is the category of new relational experience. some participants described that they experienced something new in the relationship with the therapist that they had not experienced before in their life. for some, this was an experience of affection and genuine concern as well as being taken into account, and seen as an equal. some participants said the new relational experience at first made them feel uncomfortable and ill at ease, while at the same time helped them on their path to change. erskine et al. (1999) has named this a juxtaposition response that occurs as a reaction to the discrepancy between the involved and responsive therapeutic relationship and the emotional memories of previous miss-attunements. the new relational experience can be painful since it triggers an awareness of what the clients yearned for but did not receive in the past relationships. our category connection relates to factors of connection and the deep bond with the therapist who is experienced as a stable, constant and reliable person. the international journal of integrative psychotherapy, vol. 6, 2015 20 category encompasses the emotional and psychological sense of connection that provides the client with a feeling of safety and acceptance. the factors of safety and trust minimise the client’s distance and form the basis of therapeutic work. in integrative psychotherapy erskine et al. (1999) stress the importance of responding to basic relational needs in the therapeutic relationship, including the need for safety, and the need to be accepted by a stable, reliable and protective person. our obtained descriptions of helpful factors in therapeutic relationship are comparable to the findings of other authors who explored significant events, factors of effective psychotherapy and the healing therapeutic relationship (cahill et al., 2013; elliott & shapiro, 1992; glass & arnkoff, 2000; levitt et al., 2006; lietaer, 1992; manthei, 2007; mcvea et al., 2011; moertl & wietersheim, 2008; oliveira et al. (2012); rennie, 1992; svanborg et al., 2008; timulak, 2007, 2010). the above-mentioned studies utilized qualitative and/or quantitative methodology and focused on helpful aspects of various modes of psychotherapy and different problem areas approached by clients. in our study, we decided to analyse the clients’ retrospective view of at least one year of therapy, while the studies cited above analysed the process of psychotherapy and its outcome on different levels, which means the timeframe of observation could be anything ranging from a fraction of a second to an entire concluded process of therapy (orlinsky et al., 2004). norcross and lambert (2011) found that the therapeutic relationship significantly contributed to the results of psychotherapy regardless of the therapeutic modality and the client’s problems. they explain the similar effect of different therapeutic modalities with factors that are common to all therapeutic approaches (norcross and lambert, 2011). based on a meta-analysis of research in psychotherapy, norcross and lambert (2011) talk about aspects of the therapeutic relationship that were proven to be effective, such as therapeutic alliance, empathy and getting feedback from the clients. results of our qualitative study similarly show that empathic attunement is of high importance in integrative psychotherapy and is comprised of the therapist’s empathic response and inquiring about the feedback from the client. categories of connection, safety, trust and match between the client and the therapist, on the other hand, relate to the concept of therapeutic alliance. norcross and wampold (2011) mention goal congruence, collaborative relationship and positive acceptance as the aspects of therapeutic relationship most likely to be effective. this is reflected also in our research, in which participants stressed the importance of the therapist’s unconditional acceptance. rogers (1967) already reached similar conclusions, emphasizing the importance of the therapist’s congruence, empathic understanding and unconditional international journal of integrative psychotherapy, vol. 6, 2015 21 acceptance; elements which our participants also cited as beneficial. conclusion our study is the first qualitative study examining helpful factors of the relationship in integrative psychotherapy, as developed by erskine and colleagues (erskine et al., 1999; erskine, 2015). when interpreting the results of our study, it needs to be taken into account that our participants were most likely those who had a positive experience in therapy and were willing to discuss it. we cannot be sure about the number of clients who had a negative experience and therefore ended the process of psychotherapy. a further limitation of our study lies in the limited source of data, since we only analysed transcribed interviews. an alternative to our approach would be using questionnaires in order to obtain data. additionally, gathering and analysing results could include more independent researchers from other modalities as well, minimising researcher bias and adding to the credibility of our study. an advantage of using the chosen method of research is that we gathered data that is rich in content and would be otherwise difficult to obtain by using classic questionnaires. in addition to this, our conclusions are based on participants’ own descriptions and illustrate a variety of client experiences. our study contributes to a deeper understanding of the client’s experience in psychotherapy and thoroughly examines the client’s experience of the therapeutic relationship. this research is part of a larger study aimed to develop a comprehensive theory relating to important factors and change in the long-term process of integrative psychotherapy. we expect to gain insight into the complexity of the therapeutic encounter, as created by various contributing factors from the client and the therapist, and the relationship, techniques used in therapy and therapeutic processes which interact and lead to the client’s change. authors: karmen urška modic is a psychologist and phd candidate for applicative psychological studies (department of psychology, faculty of arts, university of ljubljana, slovenia). karmen is employed as research assistant at the sociomedical institute of the research centre of the slovenian academy of sciences and arts (zrc sazu). she passed the professional exam for working in the public healthcare sector (ministry of health of the republic of slovenia) during her apprentice at university psychiatric hospital. she is also student of integrative psychotherapy for the european certificate of psychotherapy. her special interest is in effectiveness and changes in the process of integrative international journal of integrative psychotherapy, vol. 6, 2015 22 psychotherapy. address: sociomedical institute, research centre of the slovenian academy of sciences and arts, novi trg 2, 1001 ljubljana, slovenia e-mail: modickarmen@yahoo.com, karmen.modic@zrc-sazu.si assist. prof. gregor žvelc, phd is clinical psychologist and assistant professor at department for psychology, ljubljana (university of ljubljana, faculty of arts) and department for psychology, koper (university of primorska, up famnit). he is international integrative psychotherapy trainer & supervisor (iipa) and director of the institute for integrative psychotherapy and counseling in ljubljana. he is co-editor of international journal of integrative psychotherapy and author of the book 'relational theories in psychotherapy: integrative model of interpersonal relationship'. address: 1) university of ljubljana, faculty of arts, department for psychology, aškerčeva 2, 1000 ljubljana, slovenia. 2) university of primorska, faculty of mathematics, natural sciences and information technologies, glagoljaška 8, 6000 koper, slovenia e-mail: gregor.zvelc@guest.arnes.si references bergin, a. e., & lambert, m. j. (1978). the evaluation of therapeutic outcomes. in s.l. garfield & a. e. bergin (eds.), handbook of psychotherapy and behavior change: an empirical analysis (pp. 139-190). new york: wiley. cahill, j., paley, g., & hardy, g. (2013). what do patients find helpful in psychotherapy? implications for the therapeutic relationship in mental health nursing. journal of psychiatric and mental health nursing, 20, 782791. charmaz, k. (2006). constructing grounded theory: a practical guide through qualitative analysis. london: sage publications. corbin, j., & strauss, a. (2008). basics of qualitative research: techniques and procedures for developing grounded theory (3rd ed). thousand oaks: sage publications. elliott, r. (1985). helpful and nonhelpful events in brief counseling interviews: an empirical taxonomy. journal of counseling psychology, 32(3), 307322. elliott, r. (1989). comprehensive process analysis: understanding the change process in significant therapy events. in m. j. packer & r. b. addison (eds.), entering the circle. hermeneutic investigation in psychology. albany: state university of new york press. elliott, r. (1999). the client change interview protocol. network for research on experiential psychotherapies. retrieved from mailto:modickarmen@yahoo.com mailto:karmen.modic@zrc-sazu.si mailto:gregor.zvelc@guest.arnes.si international journal of integrative psychotherapy, vol. 6, 2015 23 http://www.experiential-researchers.org/instruments/elliott/changei.html 1.5.2015. elliott, r., slatick, e., & urman, m. (2001). qualitative change process research on psychotherapy: alternative strategies. in j. frommer & d. l. rennie (eds.), qualitative psychotherapy research: methods and methodology (pp. 69-111). lengerich, germany: pabst science. elliott, r., & shapiro, d. a. (1992). client and therapist as analysts of significant events. in s. g. toukmanian & d. l. rennie (eds.), psychotherapy process research: paradigmatic and narrative approaches (pp. 163187). london: sage publications. erskine, r. g. (1997). the therapeutic relationship: integrating motivation and personality theories. in r. g. erskine (ed.), theories and methods of an integrative transactional analysis (pp. 7-19). san francisco: ta press. erskine, r. g. & moursund, j. p. (2011). integrative psychotherapy in action. london: karnac. erskine, r. g. (2015). relational patterns, therapeutic presence. concepts and practice of integrative psychotherapy. london: karnac books. erskine, r. g., moursund, j. p., & trautmann, r. l. (1999). beyond empathy. a therapy of contact-in-relationship. philadelphia: brunner/mazel. erskine, r.g. & trautmann, r. l. (1997). methods of an integrative psychotherapy. in r. g. erskine (ed.), theories and methods of an integrative transactional analysis (pp. 20-36). san francisco: ta press. erskine, r.g. & trautmann, r. l. (1997). the process of integrative psychotherapy. in r. g. erskine (ed.), theories and methods of an integrative transactional analysis (pp. 79-95). san francisco: ta press. fassinger, r. e. (2005). paradigms, praxis, problems, and promise: grounded theory in counseling psychology research. journal of counseling psychology, 52(2),156-166. flick, u. (2014). an introduction to qualitative research (5th ed). london: sage. friese, s. (2014). qualitative data analysis with atlas.ti. los angeles: sage. glass, c. r., & arnkoff, d. b. (2000). consumers´ perspectives on helpful and hindering factors in mental health treatment. psychotherapy in practice, 56(11), 1467-1480. glaser, b. g., & strauss, a. l. (1967). the discovery of grounded theory. strategies for qualitative research. new jersey: aldine-transaction. lambert, m. j, & barley, d. e. (2001). research summary on the therapeutic relationship and psychotherapy outcome. psychotherapy: theory, research, practice and training, 38(4), 357-361. levitt, h., butler, m., & hill, t. (2006). what clients find helpful in psychotherapy: developing principles for facilitating moment-to-moment change. journal of counselling psychology, 53(3), 314-324. lietaer, g. (1992). helping and hindering processes in client centered/experiential psychotherapy: a content analysis of client and http://www.experiential-researchers.org/instruments/elliott/changei.html international journal of integrative psychotherapy, vol. 6, 2015 24 therapist postsession perceptions. in s. g. toukmanian & d. l. rennie (eds.), psychotherapy process research. paradigmatic and narrative approaches (pp. 134-162). london: sage publications. manthei, r. j. (2007). clients talk about their experience of the process of counselling. counselling psychology quarterly, 20(1), 1-26. mcvea, c. s., gow, k., & lowe, r. (2011). corrective interpersonal experience in psychodrama group therapy: a comprehensive process analysis of significant therapeutic events. psychotherapy research, 21(4), 416-429. mesec, b. (1998). uvod v kvalitativno raziskovanje v socialnem delu. [introduction to qualitative research in social work]. ljubljana: visoka šola za socialno delo [faculty for social work, university of ljubljana]. moertl, k. & wietersheim, j. (2008). client experience of helpful factors in a day treatment program: a qualitative approach. psychotherapy research, 18(3), 281-293. norcross, j. c. & lambert, m. j. (2011). evidence-based therapy relationships. in j. c. norcross (ed.), psychotherapy relationships that work: evidence-based responsiveness (pp. 3-24). new york: oxford university press. norcross, j. c. & wampold, b. e. (2011). evidence-based therapy relationships: research conclusions and clinical practices. psychotherapy, 48(1), 98-102. oliveira, a., sousa, d., & pires, a. p. (2012). significant events in existential psychotherapy: the client's perspective. existential analysis, 23(2), 288 -304. orlinsky, d. e., ronnestad, m. h., & willutzki, u. (2004). fifty years of psychotherapy process-outcome research: continuity and change. in m. j. lambert (ed.), bergin and garfield's handbook of psychotherapy and behavior change (pp. 307-389). new york: wiley. rennie, d. l. (1992). qualitative analysis of the client's experience of psychotherapy: the unfolding of reflexivity. in s. g. toukmanian & d. l. rennie (eds.), psychotherapy process research. paradigmatic and narrative approaches (pp.134-162). london: sage publications. rhodes, r. h., hill, c. e., thompson, b. j., & elliott, r. (1994). client retrospective recall of resolved and unresolved misunderstanding events. journal of counseling psychology, 41(4), 473-483. rogers, c. r. (1976). the interpersonal relationship: the core of guidance. in c. r. rogers & b. stevens (eds.), person to person. the problem of being human (pp. 89-105). london: souvenir press. strauss, a., & corbin, j. (1998). basics of qualitative research techniques and procedures for developing grounded theory (2nd ed). london: sage publications. svanborg, c., baarnhielm s., wistedt, a. a., & lutzen, k. (2008). helpful and hindering factors for remission in dysthymia and panic disorder at 9-year international journal of integrative psychotherapy, vol. 6, 2015 25 follow-up: a mixed methods study. bmc psychiatry, 1-9. timulak, l. (2007). identifying core categories of client-identified impact of helpful events in psychotherapy: a qualitative meta-analysis. psychotherapy research,17(3), 310-320. timulak, l. (2010). significant events in psychotherapy: an update of research findings. psychology and psychotherapy: theory, research and practice, 83, 421-447. date of publication: 10.12.2015 alcoholism is such a common condition that therapists must be exposed to clients who suffer from it, whether the therapist is organizing self-experiences marye o’reilly-knapp abstract: psychotherapy can provide an organization of experiences so that a person attains a sense of self in relation to self and others. the first part of the paper addresses the developing self, the withdrawn self, and an introduction to the yearning self. the second part of the paper considers the domain of relatedness with a focus on the development of self via the concepts of coherence, agency, affectivity, and continuity in time. key words: isolated attachment, integrative psychotherapy, domain of relatedness, coherence, agency ________________________ “there is this secret part of me”, says linda, as she begins her session. “i do not let anyone know about this piece of me; when i am afraid i hide here.” as she spoke i thought about a little girl who has no one to help her when she is afraid. she figured out a way to protect herself from the shouts and raging behavior of her stepfather and a mother who withdrew. linda describes to me this hidden place where big rocks surround her in darkness. she cannot be seen nor can she be found. her rocks remind me of tustin’s (1986) description of “an imaginary hard shell” which protects a little child from the hostile world (p. 57). in linda’s situation her mother was unresponsive to her child and failed to provide the protection needed for linda to feel safe. in an earlier paper on the nature of the schizoid process, the existence of an individual in such a world was described along with the therapeutic interventions needed to establish and maintain a therapeutic relationship (o’reilly-knapp, 2001). using the theory and methods of integrative psychotherapy as developed by erskine (1997) and guntrip’s (1995) work on the schizoid phenomenon, a framework was identified to work with the state of self that is split off and encapsulated. using inquiry, attunement, and involvement in working with the splits described by guntrip, international journal of integrative psychotherapy, vol. 3, no. 1, 2012 1 interventions were documented which invited the self into relationship. within the theory of integrative psychotherapy an emphasis is placed on the therapeutic relationship as healing. the process encourages a person in the therapeutic relationship to bring to awareness what has been denied or disavowed and to be immersed in a relationship where the client can express and learn to connect with the therapist, one’s self and, ultimately with others. an empathic, clientcentered inquiry, attunement to the client’s rhythms, developmental levels, relational needs, cognition and affect, and involvement in acknowledging, validating and normalizing experiences provides the course of action for working with a person’s splits. fairbairn (1952) and guntrip (1968/1995) proposed that the ego splits into four parts. the first split is between the central ego which is in contact with the outer world and the withdrawn ego which pulls into the inner world. the withdrawal into an inner state is an attempt to move away from perceived danger. as the central ego attempts to deal with the outer world, the wants and needs of the child are obstructed by the persecutory ego. thus the second split occurs. guntrip (1995) describes the struggle with the second split of the ego as a part dealing with unsatisfied desires and needs while another part persecutes desires and needs. this active persecution “keeps the basic self weak” and makes ‘cure’ a slow and difficult process” (p. 142). he went on to describe the ultimate split of the ego into the oral ego and regressed ego. fueled by fear and flight from the outer world and an internal conflict dealing with helplessness and aggression, this last split holds the “dread of collapse in a depersonalized state”. (hazell,1994, p. 199). this paper expands on the previous paper on the encapsulated self by focusing on specific interventions for working with the hidden and lost self. the self-invariants of coherence, agency, affectivity, and continuity in time as identified by stern (1985) are incorporated in this paper as: 1.) a way to further understand the formation of a core self and 2.) a therapeutic direction to facilitate the organization and emergence of self. consideration is given to the person’s use of withdrawal and at the same time, the longing to be a part of life. i propose that in the therapeutic relationship, the therapist must address the discord of persecution that is occurring and the struggle between the withdrawn self and the ‘yearning self’, aching to push out toward life and the world. since the emerging self has withdrawn into an inner world, the core of self appears to be missing. there is no sense of continuity, inner feelings are denied or disavowed, needs are out of conscious awareness, and a sense of power over one’s actions is absent. treatment of this self-state involves a connection with the therapist and use of rhythmic attunement to mutually create the holding space for emergence. the therapist provides the relationship where a safe environment allows for the self to be in contact and grow. the involvement of the therapist in the use of one’s own self is fundamental in the therapeutic process and will be demonstrated in a case study. the methods of integrative psychotherapy are the foundation of the therapeutic international journal of integrative psychotherapy, vol. 3, no. 1, 2012 2 interventions; stern’s (1985) four crucial invariants used in the early development and emergence of the self are employed in this paper as a way to assist in the organization of a person’s self. the developing self human beings have an innate propensity to seek out learning opportunities (stern, 1985) through social relatedness. in the ‘coming-into-being’ state, emerging organization operates out of awareness as an experiential pattern from which cognitive and affective functioning eventually arise. this time of “awakening”, as identified by mahler, pine, and bergman (1975), is a time of emergent relatedness where the sense of being is designed to eventually engage in human interactions. in the next stage, a sense of self with other, there are many ways that the sense of a core self is experienced. from self/other fusion to being-with experiences which result in integration of a “distinct self with a distinct other”, the self emerges as a separate, organized, physical unit, with a sense of coherence (consistency), agency, affectivity, and continuity in time (stern, 1983, p.11). when fusion is disrupted, when a self-regulating caretaker is absent, where regulation of security is lacking, a sense of a core self and the domain of core relatedness is threatened. the quality of relatedness plays a key role in developmental vulnerability. as a matter of fact, the quality of relatedness is critical throughout the life span. stern (1985) states: “all senses of the self, once formed, remain active, growing, subjective processes throughout life, [and] any one of them is vulnerable to deformations occurring at any life point” (p. 260). the formative phase for the sense of an emergent self and the subsequent phases of a sense of core self, a sense of a subjective self, and a sense of a verbal self become the foundation for the subjective experience of social development. the ‘i’ becomes through the interactions with a ‘you’. through the relationship, the self needs an other to support integration of life experiences and to sustain self identity. “self-organization emerges out of selfother interactions.” (siegel, 1999, p. 8). when cumulative interactive patterns reinforce an infant’s withdrawal, the loss of contact with others reinforces an autistic-like state where isolation becomes the norm. however, there remains dormant and out of awareness the desire to be engaged. this fundamental, essential self-part has never been reached or was threatened and remains split off, feeling lonely and empty. as a result, there is no integration nor whole of the self and without this sense of self, connection with others becomes difficult if not impossible. a social facade masks the pain and loneliness of an isolated existence. international journal of integrative psychotherapy, vol. 3, no. 1, 2012 3 linda’s early years the thomas family had two boys when twin girls were born. the father worked as a bus driver and the mother was a stay-at-home mom. the mother’s mother was present for the first year and did a lot to help her daughter. when she died the mother reported that she became depressed. when her husband suddenly died three years later the mother collapsed into a major depression. linda remembers her mother sitting at the kitchen table and eating bags of candy. she remembers the candy because she was never allowed to have a piece. when she entered a group where i was co-therapist she came to deal with her sadness and her alcohol problem. there were very few memories of linda’s early childhood. she was close to an older brother who left the family to go into the seminary. linda was four at the time. her brother’s departure took place only six months before her father died. linda was very close to her father. he would take her and her twin sister on the bus with him and was extremely proud of his daughters. he would put them to bed and played with them when he was home. when her father died linda soon realized she had no one to rely on since her mother was severely depressed and was both physically and emotionally absent for her children. linda numbed herself to protect against her loneliness and fear. alcohol numbed her later in life when she began to struggle with the surfacing memories of her childhood. school was a place that linda liked because she enjoyed learning. the taunts of the children at school were minimized by linda’s numbness. after her father died her mother remarried and the family moved to another house. although the children did not tease her at her new home, she was alone. after another move to another state linda said she felt like she had a new beginning; she “forgot all the things that happened before”. she was starting high school, and even though her mother remained distant and her step-father angry and controlling, she became more involved with classmates and joined the gymnast club at school. she won prizes for her athletic ability. after graduation she worked in the insurance business. she learned on the job and now has a very good position in her company. her second marriage and the birth of two children helped her to connect to her family in ways that she never experienced in childhood and early adulthood. these connections as a mother and wife also began to stir up feelings of pain which linda could not understand. as a member of aa she no longer used alcohol; her sponsor recommended she go to therapy. in the remaining parts of the paper you will hear about the pieces that linda filled in as she retrieved the memories and feelings of her narrative. the withdrawn self when linda was age four she spent as much time as she could out doors. she describes with delight her running around the streets until it was dark and all international journal of integrative psychotherapy, vol. 3, no. 1, 2012 4 the other children went inside. asked to describe what happened when she went home she could only remember that she came into the house. later in her therapy she remembered no one ever greeting her or asking her what was going on. with her twin she describes her “as there, but we never talked or played together”. when asked what she was feeling as she talked about her family she replied “i don’t have any feelings” or would say “i am numb”. over the course of therapy she began to piece together the memories of her early childhood. in one session linda mentioned the song by simon “i am a rock”. parts of this song are: “i’ve built walls… a fortress…that none can penetrate … i am shielded in my armour, hiding in my room … i touch no one and no one touches me.” i brought the song to the next session and played it. after a few minutes of quiet (i remained silent waiting for her response), she said softly “that’s me”. we then spent the rest of the session, and following sessions with linda describing her stronghold and the numbness she had created to keep her from feeling and knowing. when her father died of a massive heart attack she reported that she “gave up”. he had been a very loving man and his energy most likely held the family together. when he died everything seemed to stop in the home. linda had to get breakfast for herself and her sister, pull clothes to wear out of a pile of dirty laundry, and go to bed with sheets that were rarely changed. she was able to sense some sadness as we talked. expressing her sad feelings and my acknowledging the depth of her feelings facilitated her coming out of hiding and talking about what had happened to her in her early childhood. i would tell her that “my heart is aching for your little girl”. in the beginning she would look at me and could not take hold of my caring about and for that small child. this experience was foreign to her and she was confused by the idea that she could be cared about. little by little she allowed herself to grasp the meaning of my message and allow herself to sense herself in relationship with me. in later sessions she began to feel and remember more the part of her she had sequestered as a child. when she was dealing with her cognitions, i would follow with asking her about her feelings, and when she was feeling i would guide her in connecting the feelings to experiences in order for her to integrate her narrative. the bringing together of the cognitive components of memory also invited the retrieval of affect and body sensations. linda had used alcohol to facilitate the numbness she felt when she was not in her fortress. as she worked in therapy she twice went back to alcohol as an attempt to deal with feelings. both times she came in and told me she had been drinking and we then looked at her past patterns to cope and what she needed to do today. her strong urges to drink continued to surface as linda recognized the reasons for her numbness and her drinking. she had started to drink when she was twelve and continued for six years until she joined aa. when she began to drink again she shared in the meeting that she had used alcohol after twenty years of sobriety. the group was very supportive. in the withdrawal formed in the schizoid state, the person lives an isolated and insulated existence with the outer world cut off and the inner world compartmentalized. this invisible fortress, as described by bettleheim (1976), international journal of integrative psychotherapy, vol. 3, no. 1, 2012 5 severely restricts the person’s contact with others. this state can also have a component of an autistic barrier. tustin’s (1986) basic thesis is: the autistic state is a reaction to a traumatic awareness of separateness from the ‘sensation-giving mother’ (p. 27). she concludes that an awareness of separateness occurred in what stern called the emergent self and was at a time when there was not yet formed a secure sense of ‘going-on-being’. as a result feelings of terror occurred in a state which was “preverbal, pre-image and preconceptual” (p. 23). autistic encapsulation protects the hidden part from fear of threats and death when there is no safeguard experienced. these autistic barriers bring about difficulties in cognitive and affective functioning. “encapsulating reactions mean that in an isolated area of the personality, attention has been deflected away from the objective world which presents such threats, in favor of a subjective, sensationdominated world which is under direct control.” (tustin, p. 25). as linda’s protective shell softened and she allowed me to be with her, she began to have panic attacks. with my presence she felt the terror of her loneliness. at the same time she was dealing with the intensity of her fear i encouraged her to both describe and appreciate the inner space she had built to protect her. i invited her to go into her hiding place and then come out as she willed. this began to give her the power she needed to own the control she had. at home she reported feeling closer to her husband and children and was able to look at the impact her withdrawal behaviors were having on her family. her desire to drink slowly decreased and eventually ceased. the yearning self a basic thesis of this paper is: an encapsulated, withdrawn state is a reaction to traumatic or cumulative events where human connection is missing when needed in the emergence of self and development of the core self. as significant as a protected, encapsulated self there is a yearning for human connectedness which remains an active part of the hidden self. this energy force or push-pull toward life needs to be addressed as well as the methods for connecting with the withdrawn, fearful self. the push appears to be an innate sense to move forward. security is essential for an individual to feel safe and come out into the world to explore. in a secure attachment the child can go away from the primary care-giver, knowing that he or she can return if needed for reinforcements (bowlby, 1988). internalization of a caring, nurturing relationship allows for self-soothing and self-protecting with a sense of organization and agency. if not present, as is the case of a person with an isolated attachment (o’reilly-knapp, 2001), retreat occurs and opportunity for growth is restricted. the risks necessary for growth are not taken because of fear enveloped in hopelessness and helplessness. in her creative way, linda found a way to survive for twelve years in her stepfather’s house. school was somewhat of a refuge for her. she liked learning and active in sports the last four years of school. when she was at home she international journal of integrative psychotherapy, vol. 3, no. 1, 2012 6 went to her room or was outside as much as possible. she told herself that as soon as she was eighteen she would leave home. this message that she would get out kept her hope alive. two days after her eighteenth birthday she left her parents home and found a place with a group of friends. the pull or push to move forward seems to be a part of hope that things will be different “out there” in the world. when in her sessions, i often held the hope for linda as she became aware and expressed her feelings, as she owned her body sensations, as she retrieved the forgotten and painful memories, and as her yearnings were re-awakened. at times i imagined a scale (like the scale of justice) in front of me where her past, painful memories weighed her down, while on the other side of the scale, not to be forgotten, were linda’s hopes, wishes, and sense of power. my focusing her on both sides allowed her to slowly form a regulating self. consistency, dependability, and reliability on my part were important variables in engaging linda in the therapeutic process and helping her stay engaged in therapy. she was able to move through the terror of falling apart and the internal dialogue of wanting to die through my supportive and calm presence both in and outside the sessions. there were times when she would call me, usually in the evenings, and we would talk for 5 minutes or less. she needed reassurance that i was there and would be there for her. she was not alone. i held the self-in-relationship model (erskine, 1997, p. 81) in my mind. this helped me to think about the areas of integration required. linda needed to know (cognitive), feel (affective), and sense (physiological) she was not alone. the domain of relatedness: engaging in human interaction in the psychotherapeutic process, working with a person who has withdrawn and is isolated and hidden, the social self needs to be validated. with a foundation built on reliance and dependability, the focus is then placed on the vulnerable part which provides access to subsequent work with the hidden self. entrance into relationship requires some amount of trust and a shared belief that each one, client and therapist, are important in the process. the invariants of self-coherence, continuity, self-affectivity, and agency as identified in stern’s (1985) development of the core self are employed in this paper in working with the self that is isolated and hidden. how i use these concepts in working with linda to move from her protected space and begin to experience a safe environment is addressed in the next part of this paper. coherence is discussed in rhythmic attunement (moursund & erskine , 2004); the concept of continuity follows in the part that speaks to reclaiming the past in order to form the autobiographical narrative; affect modulation is addressed in the section on modulation of affect; and agency is included in the section on interpersonal process as empowering. international journal of integrative psychotherapy, vol. 3, no. 1, 2012 7 rhythmic attunement in developing coherence attunement involves an awareness of another’s “sensations, needs, or feelings, and the communication of that sensitivity to the other person” (erskine & trautmann, 1997, p. 24). attunement to the rhythms and relational needs of the client can help fill the gaps of early relationships and provide boundaries and organization. respect for a person’s rhythmic struggle is paramount in connecting with the hidden, encapsulated self. to begin to feel safe in order to give up the empty, disembodied state tustin (1986) explains that “these patients have to be enfolded with firm, confident, understanding care” (p. 301). a rhythmic attunement which involves empathy and the communication of sensitivity to the person (erskine & trautmann, 1997) provides a framework through the therapeutic relationship for healing the wounds of separation and isolation and for building a coherent identity. in his seminal work on attachment, bowly (1969; 1988) identified attachment behavior that engages an other in order to maintain a desired proximity. there is an innate propensity to be in contact with a specific caring figure when frightened, tired, or ill. with a secure base formed, the child then can then go out into the world. secure attachment histories “reflect the capacity of the individual to integrate a coherent sense of self” (siegel, 1999, p. 9). without the needed attachment that facilitates a sense of safety, there are repeated retreats into the inner world in an attempt to stabilize one’s self. isolation reinforces the danger outside and the need to take control. there is no one but one’s self to depend on and deal with life situations. unfortunately, there is little if any response from others and information remains restricted. relationship with others as well is constrained as a person withdraws into an encapsulated state. at the core of therapy and ultimate healing for such an individual is the therapist’s relationship with the client’s hidden self. rhythmic attunement involves a heightened sensitivity to the struggles a person goes through in maintaining a hidden self. being responsive to “the client’s affect, rhythm, developmental level of functioning, and relational needs” forms the attunement needed in a contactoriented, relationship-focused method” (erskine, 1997, p. 15). as the self experiences an affirmative environment in the therapeutic relationship and a significant other in the bond formed with the therapist, organization of a once-hidden self can now begin to form an identity. the ability to integrate is effected by the experiences found in the therapeutic relationship. rhythmic attunement, as communion with the client and therapist (erskine & trautmann, 1996), forms the therapeutic space for co-creation and growth for both the client and therapist. in this process, connecting with the hidden self in the relationship invites an emergence of an energy-source that promotes personal growth. in working with the earliest form of communication, empathic communion (tustin, 1986), i became aware of the presence of an energy that seemed counter to the power exerted by the hidden self to stay in a withdrawn state. this energy appeared after the withdrawn self started to connect and come out tentatively into the world. i now recognize this energy as an important part of international journal of integrative psychotherapy, vol. 3, no. 1, 2012 8 the self that was sequestered. i believe this energy is at the earliest developmental level, at the self/other fusion. for the therapeutic interventions, a quiet, supportive holding environment is needed to reinforce the fusion necessary to move into a state of separation and the sense of a core self. in this emerging state, no words, no sight is needed. it is as if there is no sense of separateness, only a beginning sense of being somewhere, not knowing where, and everything is good. the self-other fusion state is the earliest contact of the client with the therapist. often while sitting with linda i sensed a strong connection to her in my body. i would also have a picture of her as a child which kept my contact with her intact. the use of attunement facilitates contact with long-forgotten parts of the self and may repair failures of previous relationships. with linda, there were long silences. some of the times she was in her hidden retreat. at other times she described being with me “where everything is good”. when in both these places i imaged linda as a little girl and i was with her. i often experienced a smile on my face which was a reflection of the love i experienced as i sat with her. my imaging of her helped me to stay engaged in the process and to stay in contact with her. reclaiming the past for continuity by organizing the self “across past, present, and future, the integrating mind creates a sense of coherence and continuity.” (siegel, 2012, p.9). for linda, consistency and continuity had been absent. she had few memories of her first thirteen years. after she started to drink she had difficulty remembering her years in high school. she did remember doing well in her studies from first grade to high school graduation. the pieces began to come together so that she could have an understanding of her lost years and the memories that went with those years. in both individual and group sessions, linda has worked through a great deal of the neglect in her family of origin. i listened to her memories of going with her father to his work. the more she talked about her father the more memories she retrieved of him. when her father died suddenly her mother abandoned her role as care-taker. the children were left to take care of themselves. linda spent a lot of time playing on the streets of her neighborhood. she describes eating dinner quickly so that she could go back out and play. often in her work, especially when she would start to remember or a feeling would start to surface, she used the old way of coping by switching to another topic. my internal experience was often of her running. when i realized this i was able to tune into linda’s creative way to manage a family situation where her relational needs were not responded to and she was terrorized. we talked about her ‘running’ running from her past, from herself, and from me. many times linda was left with little internal resources and certainly very few external supports. sometimes she was invited to her friend’s home for international journal of integrative psychotherapy, vol. 3, no. 1, 2012 9 dinner. they were very nice to her and the food was very good. this was both a good and unfortunate experience in that the contrast to what she needed and did not get in her own home was evident when she went to her friend’s house. when she went to school she tells about how she lied a lot. when the teacher asked her where her hat or gloves were, she told her she forgot them. she was afraid she might get her mother in trouble so she said she left her hat at home. she did not have any gloves or hat to wear. her hands were always cold in the winter. the other children teased her because her clothes were wrinkled or dirty. she had to wear dirty clothes a lot of times, since her mother rarely did the wash. when i first met linda she did not want to be touched. she reported that she could not stand the feeling she had deep inside herself. the only way she could explain it was to say that it felt dangerous. in her early work in therapy she dealt with her stepfather and her first husband, both emotionally abusive. linda at six years of age was told her mother was going to get married. she was happy because she had hope that they would have a happy life again. she realized soon after the wedding that her wishes to have a better life would not take place. her stepfather was very controlling. some examples of his power were that they could only eat a certain portion of food as defined by him, were not allowed to go into the refrigerator at any time, and could only take a three minute shower once a week. linda kept the promise she had made to herself to leave home, never to return. she had started to use alcohol and marijuana in high school and when she finished school her drinking increased. her first marriage was to an alcoholic who was controlling and angry most of the time. after two years she left him. in this phase of her therapy she addressed her anger. there was a great deal of scare connected with her anger and she needed support to be angry and express it. part of linda’s work in therapy was to grieve the loss of a father who left her way too soon and a mother who was not there for her. in this phase she asked to be seen for individual sessions. she continued in group, and saw me weekly in individual sessions. in addressing her father’s death, she was able to identify her role as the caretaker for her mother. she began to recognize her efforts to protect her and watch over her younger sister. as she realized that she had spent her entire life taking care of her mother, this helped her become conscious of the deprivation in her childhood. she was doing for her mother what her mother needed to do for her daughter and her other children. up until this time in her therapy, it was difficult for linda to show or feel any kind of sadness. i sometimes would say to her that i was feeling sad for that little girl with no hat or mittens, for the occasions when she was teased and called names, and the times she went to bed hungry. as she moved through the pain of one heartache after another, she touched her hopelessness and despair. at this time in the work there were disruptions of cognitive and affective functioning. she became severely depressed and had difficulty concentrating at work. she was able to take care of her two children and did have some support from her husband. she was remembering what she could dare not let herself know or feel with the death of her father, the absence of her mother both physically and emotionally, and the international journal of integrative psychotherapy, vol. 3, no. 1, 2012 10 pressures of a controlling and rageful stepfather. i became the presence for what was missing by being there to listen to her, acknowledge and validate her experiences. i supported her tears and listened intensely to her rages. i held the hope as she dealt with intense feelings. affectivity: dealing with modulation of intense affect it takes the relationship with a caretaker to regulate affects experienced by the infant. throughout life it takes a caring other to help modulate intense affect. siegel (2012 ) states: “interpersonal experience plays a special organizing role in determining the development of brain structure early in life and the ongoing emergence of brain function throughout the lifespan” (p. 33). a person who has been living an isolated existence with little or no connection to another human being has learned to repress feelings and compartmentalize them in order to survive. in therapy the sequestered affects will emerge and often erupt in sessions. dealing with the intense affect necessitates a therapist who can bear the intensity of the feelings and help the client adjust to the feelings. i helped linda to understand her feelings and give meaning to affect experiences and i remained calm in the presence of her strong emotions, providing her with a model for self-regulation. linda’s despair, panic, and rage had an impact on me. she was ‘felt’ by me. these experiences helped me to realize and appreciate the pain that she was experiencing and help her deal with the memories. rather than be distressed by the feelings, as linda was, i was able to hold the feelings in order for us both to talk about and give meaning to them. this was a part of the healing that needed to take place. early in her individual sessions, linda brought a “magic wand” to me. she wanted me to wave the wand and make “all the bad feelings” go away so she could feel better. her feelings of despair and rage emerged into her consciousness. she went back to the times at night where she went to bed and was so frightened. she wet her bed almost every night. she was able to see the same sheets still on her bed the following night. she did not say anything to her mother and apparently her mother did not make any attempt to change the sheets or talk with her daughter. realizing that her mother did nothing to help her linda became outraged. she was able to identify the feelings and then connect the reasons for her feelings. in the beginning she did not know that she was even feeling. she began to connect her feelings of loneliness and panic as she talked about and understood her fear, her anger, the feelings of emptiness, and her wishes to give up. resonating with linda’s affect and sensing her pain, i told her i wish i could take all the pain away instantly, that indeed i wish i did have a magic wand to wave over her. i added that i did know that the pain would diminish as she continued the work. i also reassured her that i was there with her and that we could work this out together. at about this time she began to reach out to give me a hug. when she hugged me she barely touched me and her body reactions international journal of integrative psychotherapy, vol. 3, no. 1, 2012 11 were rigid and very brief. i inquired about her stiffness and eventually she was aware of how frightened and sad she was. she later connected her brief hugs as a way not to get close to any one. when her father died she told herself she would not get close “ever again” because she was fearful that person would die or go away just like her father did. eventually, my giving her a hug was accepted and her body stiffness began to soften. when we talked about this she said she realized that i would not hurt her and it felt good. however, she continued to fear that something would happen to me and i would go away. we talked often about this in the sessions. i reassured her by saying that i had no intentions of going away and i hoped that i would have a long life. the interpersonal process as empowering linda had created a special place to protect herself. i was sensitive to the space she had created to give herself a sense of safety. i was also aware that the therapeutic space that both linda and i had created together gave her a place where the process provided safety and stability that could enable her to remember more of her early experiences. as she described her hiding place i listened intensely. this means that my focus was deeply centered on linda’s words, her posture, her facial expressions, her breathing, her body movements. as erskine (1997) states: [one] listens with a “third ear and watches with a “third eye” (p. 27). there are no expectations, no thought-out ideas. there is this moment to focus on linda’s process. at the same time, i am aware of what i need to do and say to respond to linda’s words and behaviors. this has been noted as “the therapist’s capacity to anticipate and observe the effects of his or her behavior on the client” (erskine, 1997, p. 24). attuning to her relational needs meant linda experienced my sensitivity and could hear my words as responding to her relational needs. while linda talked about her space i listened. i had asked her to close her eyes and go to her space to describe it to me. i allowed for silence and i was aware that she needed some reinforcement from me, so i would tell her “i am here, i am listening”. linda, with my guidance, led the therapeutic process. this enabled her to feel her power while at the same time having a witness. witnessing and acknowledging her were essential for her development and growth. in her present work, linda is working on how she has numbed her body. she is discovering how her truths are no longer dismissed or experienced as crazy. she is creating her narrative and in doing so she is realizing how much power she has today. her growing sense of self and her contact with others has given her a center of agency. stern (1985) writes that a core self is critical for agency because “without a sense of self and other …. agency would have no place of residence” (p.82). with a sense of self, through a developing autobiographical narrative, modulating of affect within the therapeutic relationship, linda has been able to come out of her place of hiding. she is learning with her international journal of integrative psychotherapy, vol. 3, no. 1, 2012 12 words and behavior to take action with new meanings given to her thoughts and feelings. she now has a space outside herself to explore. conclusion in closing, the therapeutic relationship can provide the relationship for a person to attain a sense of identity. critical in the emergence of the self is the therapist who maintains a position of inquiry, involvement, and attunement. the theories of integrative psychotherapy as developed by erskine provide the framework in working with the withdrawn, secluded self through a “contactoriented, relationship based psychotherapy in honoring the integrity of the client” (erskine, 1997, p. 2). from its inception integrative psychotherapy has been a relationship therapy. a major goal of its theory and methods is to create full contact in the present (erskine, 1989). kept as a constant, coherence, continuity, affectivity, and agency guided the work to be accomplished in linda’s therapy. throughout the work my focus was on the relationship and her contact with me and with herself as well as my contact with her. this process i saw as a “stepping stone”, described by erskine (1989) toward “healthier relationships with other people and a satisfying sense of self” (p. 77). author: marye o’reilly-knapp, rn, phd is a psychotherapist in private practice in nj. in june 2010 she retired from widener university school of nursing and was awarded emerita status. she continues to write and teach. marye is a teaching and supervisor faculty of the international integrative psychotherapy association. special thanks to richard g. erskine, phd for his continuous support of my writings and to my former colleagues of the professional development seminar of kent, ct. for their critique of this paper. references: bettelheim, b. (1967). the empty fortress: infantile autism and the birth of self. new york: the free press. bollas, c. (1987). the shadow of the object: psychoanalysis of the unthought known. new york: columbia university press. bowlby, j. (1969). attachment and loss, vol. i. new york: basic books. bowlby, j. (1988). a secure base: parent-child attachment and healthy human development. new york: basic books. erskine, r. g. (1989). a relationship therapy: developmental perspectives. in b.b.loria (ed.), developmental theories and the clinical process: conference international journal of integrative psychotherapy, vol. 3, no. 1, 2012 13 international journal of integrative psychotherapy, vol. 3, no. 1, 2012 14 proceedings of the eastern regional transactional analysis conference. madison, wi: omnipress. erskine, r.g. (1997). theories and methods of an integrative transactional analysis: a volume of selected articles. san francisco: ta press. erskine, r.g., moursund, j.p. & trautmann, r. l. (1999). beyond empathy: a therapy of contact-in-relationship. philadelphia, pa: brunner/mazel. erskine, r.g. & trautmann, r.l. (1996). theories and methods of an integrative transactional analysis. transactional analysis journal, 26, 316-328. guntrip, h. (1995). schizoid phenomena, object relations and the self. madison, ct: international universities press. hazell, j. (ed. (1994). personal relations therapy: the collected papers of h.j. guntrip. northvale, new jersey: jason aronson. mahler, m.s., pine, f. & bergman,a. (1975). the psychological birth of the human infant: symbiosis and individuation. new york: basic books. moursund, j.p. & erskine, r.g. (2004). integrative psychotherapy: the art and science of relationship. pacific grove, ca: brooks/cole-thomson. o’reilly-knapp, m. (2001). between two worlds: the encapsulated self. transactional analysis journal, 31, 44-54. siegel, d. j. (1999). the developing mind: how relationships and the brain interact to shape who we are. new york: the guilford press. siegel, d.j. (2nd ed). (2012) the developing mind: how relationships and the brain interact to shape who we are. new york: the guilford press. stern d. n. (1985). the interpersonal world of the infant: a view from psychoanalysis and developmental psychology. new york: basic books. tustin, f. (1986). autistic barriers in neurotic patients. london: karnac books. date of publication: 18.6.2012 a dialectical perspective of trauma processing brurit laub and nomi weiner abstract: this article presents a dialectical perspective, which attempts to elucidate the integrative components of trauma processing in therapy. it is proposed that the inherent movement toward greater integration is an expanding dialectical movement. it is conceived as a spiral resulting from the synergy of two dialectical movements. the horizontal line moves between the opposite aspects of the individual (thesis vs. antithesis) toward a synthesis. the vertical line moves upward via whole/part shifts toward greater integration, or downward toward disintegration and fragmentation. it is proposed that the complementary processes of differentiation and linking are the building blocks of the integrative/dialectical movement. differentiation relates to the separation of parts and linking relates to their connection. the role of differentiation and linking in three basic interacting systems of trauma work is discussed. it is proposed that the dialectical principles are applicable to various therapeutic approaches and clinical vignettes are included to illustrate. key words: dialectical therapy, integrative therapy, mindfulness, dual awareness, trauma processing. emdr, voice dialogue. ______________________ in this article a dialectical perspective is suggested which elucidates the integrative components of trauma processing in therapy. trauma is regarded as any event that has a lasting negative effect on the self or psyche (shapiro 2001). it includes not only “big t traumas” such as the shattering experiences of earthquakes or war, but also any of the ubiquitous experiences of childhood that can qualify as “small t traumas” like humiliation or abandonment. cvetek adds to “small t traumas” life difficulties such as divorce or unemployment if “…recalling them from memory still causes a certain degree of anxiety and brings forth negative images, feelings, and cognitions that were present at the time of event” (2008, p.2). the dialectical principles of three major systems of trauma work will be discussed; the therapeutic relationship, mindful dual awareness (mda) and integrative trauma processing. the dialectical perspective can be helpful for therapists of various approaches in understanding and using dialectical principles in their clinical work. international journal of integrative psychotherapy, vol. 4, no. 2, 2013 24 the dialectical perspective bopp and weeks (1984) present a thorough description of dialectical principles in systems. its essentials are that motion inherently proceeds in an unfolding process of thesis, antithesis and synthesis. the synthesis is not a simple sum of both but entails a transformation. motion is a developmental process having an end-state toward which change proceeds. this process is not linear but a function of reciprocal interactions. the universe is seen as a vastly differentiated organism in which interacting systems are organized hierarchically with phenomena being parts of larger wholes. the dialectical movement between opposites the dialectical tension between opposites is a universal phenomena which is expressed in nature (darkness vs. light) as well as in various levels of the individual such as the sensorimotor (inhaling vs. exhaling), the emotional (happiness vs. sadness) and the cognitive (worthiness vs. unworthiness). the dialectical perspective, rooted in eastern (watts, 1963) and western (rychlack, 1968) philosophy, plays a significant role in different therapeutic approaches both ancient (harner, 1990) and modern. both jung (1963) and perls (1959) discuss various polarities in the psyche. psychosynthesis (assiagoli, 1965) and voice dialogue (stone & winkelman, 1985) deal with opposing sub-personalities. somatic experiencing (levine, 1997) relies on the natural movement between the "trauma vortex" and the "healing vortex.” dialectical thinking is predominant in linehan's (2006) dialectical behavior model for borderline clients. systemic family therapy is based on dialectical principles (bopp and weeks, 1984) and many family therapists have specifically elaborated these concepts (pepp, 1994; hoffmann, gafni & laub, 1994; hoffman & laub, 2006); almagor, 2011). laub & weiner (2007) in their pyramid model proposed that the integrative movement in therapy is dialectical and moves in a spiral (fig.1). this article further elaborates these dialectical concepts. a dialectical perspective of integrative trauma processing integrative trauma processing is based on the tenet that there is an inherent tendency of the individual to move toward self-actualization (maslow, 1970; rogers, 1951) and greater integration (piaget, 1970; klein, 1976; koestler, 1978; wilber, 1996, siegel, 2012). siegel (2012) suggests that there is a selforganizing tendency of systems to move toward maximizing complexity and harmony. it is proposed that this integrative movement toward well being and wholeness is dialectical and proceeds via the tension between the opposite aspects of the individual toward a new synthesis. levine (1997) relates to this as the universal law of polarity "… which is available to us as a tool to help us transform our traumas” (p.119). international journal of integrative psychotherapy, vol. 4, no. 2, 2013 25 trauma processing is conceived as a developmental process based on the synergy of two inherent dialectical movements, horizontal and vertical (laub & weiner, 2007). the horizontal moves between opposite aspects of the individual such as a sense of threat vs. safety, or dependence vs. independence. this movement enables the client to relate more flexibly to her opposites and see them within a new whole. the vertical movement consists of expanding levels of integration, which enable the client to shift from a partial perspective of her experiences to a more complex and whole perspective. it is proposed in this article that this expansion moves via whole/part shifts, in which a whole becomes a part of a greater whole, which then transcends the former one (koestler, 1978; wilber, 1996). for example an intrusive sensation becomes part of a wider emotional experience that expands further to include cognitive understanding. during processing, the parts of traumatic experiences are gradually integrated into a whole; a coherent autobiographical story. according to our perspective disintegration and fragmentation resulting from trauma (janet, 1925) reflect a disruption of the dialectical movement while trauma processing attempts to restore it. siegel defines integration as “linking differentiated parts into a functional whole” (siegel, 2012, p. 9). it is proposed that from a dialectical perspective differentiation and linking are complementary processes that are at the core of the integrative/dialectical movement. differentiation relates to the movement to be apart from, to separate, to distance, to put a boundary. linking relates to the movement to be a part of, to connect, to get close, to identify with. they are also referred to as separation and connection (klein, 1976; pipp, 1990; laub & weiner, 2007), autonomy and intimacy (bowlby, 1973) individuation and fusion (bowen, 1978), self-definition and interpersonal relatedness (blatt, 1995), agency and communion (wilber, 1996). as clients focus on their inner experience, associative connections begin to be activated. these differentiate the condensed traumatic experience into different parts promoting new links. the way this process unfolds depends on the client’s trauma history, her resources and the nature of the therapeutic relationship. differentiation and linking are illustrated in the following example. itamar came to emdr (eye movement desensitization reprocessing) therapy (shapiro, 2001) after a recent car accident. in emdr therapy the client begins by focusing on a traumatic event while receiving bilateral stimulation (bls) and then relates his associations to the therapist. at first itamar focused on being hit suddenly in his chest. he recalled the strong pain and feeling choked. he also felt sadness for himself at having to go through such suffering. he then noticed that the intensity of his distress was somewhat reduced. a little later he recalled the compassionate man who took him out of the car. as processing proceeded, the suffocating sensations were associated with early memories of his fear of diving and suffocating from asthma. in this example the condensed sensation of being hit began to differentiate into many parts; the pain, the choking, the fear and the sadness. it also began to link to some relief and to new positive elements international journal of integrative psychotherapy, vol. 4, no. 2, 2013 26 of the traumatic event such as the compassionate man who helped him. further associative connections expanded to memories of his childhood with a domineering mother with whom he felt “choked.” he differentiated various aspects of his loneliness, suffering and constriction as a child. as he connected to his earlier traumatic experiences, new links to positive memories also came up. he linked to his inherent joy in companionship and selfexpression. the synergy of the horizontal and vertical dialectical movements, consisting of differentiating and linking associative connections, is depicted as a spiral (fig.1). the spiral of integration narrows as the gap between opposite aspects of the individual gets smaller and they begin to be perceived as parts of one whole. fig. 1 the spiral of integration results from the synergy of horizontal and vertical dialectical movements horizontal dialectical movement between opposite aspects of the individual. as the opposites get closer the spiral narrows. vertical dialectical movement of hierarchical whole/part shifts rising upward towards greater integration and downward toward disintegration and fragmentation. a dialectical perspective of trauma processing international journal of integrative psychotherapy, vol. 4, no. 2, 2013 27 a session with another client illustrates the spiral movement. sharon came to therapy and complained of feeling trapped in her marriage, especially on weekends when there was a lot of tension. the therapist used the voice dialogue method (stone & winkelman, 1998) in which it is assumed that the client has a multitude of parts that are not harmoniously connected. the therapist helps the client become aware of these parts and makes them accessible by interviewing each part. the client, in the role of the part, sits in a different place and links to the energy, feelings, thoughts and memories of this part. as the client links to these they become more differentiated. when the client returns to her seat the therapist invites her to identify the opposite part. she chooses another seat and this part is interviewed. in this process some parts with which the client is overidentified become more differentiated from her, and others to which she is less connected, begin to be more linked. in this meeting the therapist helped sharon access the part of her that wanted to run away from situations in which there was stress and conflict. she felt it strongly in her stomach and was asked to focus on that. it became clear that she identified strongly with this part, which had been very important in her childhood. this part helped her leave the house when her parents where fighting at home. as sharon focused inward she recalled many situations in which the part had suggested avenues of escape. she also became aware of the link of this part to her sense of aliveness stating, "i gave sharon the option to breathe.” when sharon returned to her seat the therapist asked her to focus inward and access the less acknowledged opposite part. she called it the coping part, which told her to stick around and see things more in proportion. after sharon moved to another seat the therapist talked to the coping part. she told the therapist she believed she helped sharon stay in work situations when there was a lot of tension. the therapist asked the coping part where it had learned this and it answered immediately, “i am like her dad. her dad never ran away when mom was nervous or depressed." with more work in therapy sharon began to move more flexibly between these opposing parts, accepting them both as important aspects of her. as she externalized the running away part and linked to it, she differentiated her condensed sense of being trapped in various experiences and linked these to her past. she also made a new link to her sense of aliveness when she could escape. similarly, as she linked to her coping part she also differentiated it, noticing when it functioned well, and where and from whom she had learned to use it. as the horizontal dialectical movement between her running away part and her coping part became more flexible, an upward vertical shift took place in which she was able to contain both. in this wider, more whole perspective she could envision staying in her present family during stress and still feel alive and well. it is proposed that the vertical whole/part shifts relate to sensorimotor, emotional, cognitive and spiritual levels of information (wilber, 1996). each higher level includes the previous one and transcends it. ogden, minton & pain international journal of integrative psychotherapy, vol. 4, no. 2, 2013 28 (2006) adopted the first three levels in their conceptualization of sensorimotor therapy. another whole/part sequence proposed in the memory consolidation process after recent trauma (shapiro & laub 2008; laub & weiner, 2010) moves from a fragment, to an event, to an episode which includes many events, to a theme which organizes many events, to an identity with many themes. both expanding sequences interact closely. this is illustrated in a session with ron who asked for therapy two months after a fire ruined his house. in the adapted emdr protocol for recent trauma (shapiro & laub, 2008) ron first focused on his sensations of discomfort (sensorimotor fragment) while staying at the shabby apartment of his neighbor who hosted him. on the first set of bls, his associations were mostly sensory differentiating his discomfort into his difficulty with taking a shower in the neighbor’s dirty bathroom and eating in the messy kitchen. after additional bls sets he seemed calmer and said, "now it occurs to me that she (the neighbor) was very distressed by the fire and didn't change the table cloth.” this new adaptive link reflected the expansion of the horizontal movement from the sensorimotor opposites of discomfort and relief to the more complex emotional opposites of criticism and acceptance in the episode. this facilitated a vertical shift in which he could integrate the opposites of cleanliness and dirt, and see the neighbor from a wider perspective. "the other rooms were in order and only the bathroom and kitchen were shabby but not dirty." later his processing shifted to the cognitive level expressed in his ambivalence between authentic gratitude and rigid obligation. he wanted to put boundaries on his need to compensate his neighbor so as to be authentically grateful. this was another vertical shift in which he began to balance gratitude and duty in a more integrated way (a new theme organization). the expanding nature of the whole/part sequences can be more easily seen in recent trauma processing, than in nonrecent trauma work where the levels of integration may overlap more. differentiation and linking processes in the therapeutic relationship the dialectical/integrative movement in therapy develops within an attuned therapeutic relationship. it is possible to identify within this relationship the complementary interaction of the basic integrative processes of differentiation and linking. the therapist links to the client’s inner world empathically, while at the same time staying apart and differentiating herself. this process is similar to what takes place in the secure attachment relationship. the mother is empathic to the child's experience, providing mirroring and attunement (linking), and at the same time respecting the infant’s autonomy (differentiation) (winnicott, 1965). fonagy, gergely, jurist & target (2004) claim that there is a dialectical process, in which the secure caregiver soothes the child by combining mirroring with a display that is incompatible with the child’s affect, implying that it is possible to cope with the current situation. bion (1962) also emphasized the idea that the mother contains the affect state that feels intolerable to the baby, acknowledging his mental state while also modulating unmanageable feelings. when the caregiver is in an attuned, predictable relationship with the child, respecting her international journal of integrative psychotherapy, vol. 4, no. 2, 2013 29 individuality as well as identifying with her, the child can develop a sense of autonomy, integrity and self-regulation (siegel and hartzell, 2003; schore, 1994). if the caregiver identifies too closely with the child, feeling overwhelmed and anxious herself, the child will have trouble organizing his affective world coherently. if the caregiver is too remote and not attuned, the child will have difficulty identifying his own feelings and intentions. in both cases the parent does not create for the child a coherent image of the child’s internal mental life and her intentionality, thus hampering her affect regulation, self agency and integration (fonagy et al, 2004). the lack of a secure attachment relationship “is carried forward as internal processes in the child that directly influence how the child interacts with others in the future” (siegel and hartzell, 2003, p.104). the child may develop an avoidant/dismissive stance, an ambivalent/preoccupied stance, or in more severe cases a disorganized stance (ainsworth, belhar, waters, & wall, 1978; main, 1995). all these can lead to impairments in the integrative capacities of the individual, to inflexible ways of adaption and to a diminished sense of well-being (siegel, 2012). likewise, in the secure therapeutic relationship integration and healing are enhanced if the therapist is closely attuned to the client and at the same time encourages her on her own path. in linehan's (2006) work with borderline clients, she stresses both the importance of validating the client (linking) and challenging her to take responsibility for change (differentiating). in dialectical cotherapy (hoffman et al, 1994, hoffman & laub, 2006), one therapist is close and empathic to the client (linking) and the other is more distant and challenging (differentiating). in addition, the therapist needs to be aware of the attachment history of her clients and its effects on their need for closeness and/or distance in the therapeutic relationship. clients with insecure attachment styles tend to be more wary about the availability of the attachment figure (liotti, 2004) and may stay distant and/or come close too quickly. the therapist should move between closeness and distance in an attuned, predictable way so the client can begin to experience elements of a secure attachment. integration can take place as the client begins to feel safe in the therapeutic relationship, allowing herself to trust the therapist and bring her authentic self to the process. with an empathic, sensitive therapist the client can begin to form a bond, and reexperience highly stressful, dysregulating affects in a safe environment so that the overwhelming traumatic feelings can be regulated and integrated (schore, 1994). an example of the dialectical interplay of differentiation and linking in the therapeutic relationship is illustrated with tom. in therapy he focused on his traumatic relationship with his father, in which he felt pushed aside and neglected. as he recalled these childhood memories a great deal of anger came up. at this stage in the therapy tom became very angry with the therapist, especially if she had to cancel a session. when the therapist was sick for a week tom sent many demanding messages and raged at her when she came back. the therapist empathized with his feelings (linking) and tried to help him see where they were coming from (differentiating). as new memories of neglect came international journal of integrative psychotherapy, vol. 4, no. 2, 2013 30 up and tom exposed more of his vulnerability, any change in the setting made tom agitated and he accused the therapist of being continually neglectful. the therapist became aware of feelings of guilt and anger at tom and recalled her own memories of her relationship with her father. she felt bad about having been sick or making changes, but also irritated and attacked unreasonably just as she had been as a child. differentiating herself from tom's reaction and linking to her own pain with her father enabled the therapist to contain her anger and resume a more balanced attitude of getting closer to tom while putting appropriate limits on his outbursts outside the clinical setting. differentiation and linking processes in mindful dual awareness (mda) the dual awareness setting in certain therapeutic approaches (ogden et al, 2006; gendlin, 1981; shapiro, 2001; levine, 1997; rossi, 1996; zvelc, 2012) emphasizes both the client's focus on her internal processing (sensory, somatic, emotional and cognitive), usually of a distressing experience, and an awareness of the present safety of the therapeutic situation. these approaches use brief intervals of moment to moment tracking of the internal experience and sharing it with an attuned therapist. shapiro (2012) emphasizes that in traumatic experiences there is a sense of terrible aloneness and that the therapist's felt presence is very important during processing. dual awareness also plays an important role in other experiential therapies such as gestalt (perls, 1959), psychodrama (moreno, 1987), voice dialogue (stone & winkelman,1985), and internal family systems therapy (schwartz,1995), in which the therapist may be more directive. according to porges's hierarchical polyvagal theory (2003) the experience of threat sends the sympathetic nervous system into the flight-or fight arousal pattern. higher levels of threat and more helplessness send the dorsal vagal branch of the parasympathetic nervous systems into immobilization, freeze and collapse. the sense of safety, connected to the "social engagement system" which operates through the ventral vagal branch of the parasympathetic nervous system, ensures a calm state. it may be that dual awareness in trauma processing facilitates the dialectical/integrative movement between these two systems of threat (the distressing inner experience) and safety (the therapeutic situation). this movement promotes a differentiation between them thus enabling new links to occur. most of the therapies which emphasize dual awareness in trauma work (shapiro, 2001; ogden et al, 2006; gendlin, 1981; levine, 1997; rossi, 1996, zvelc, 2012) use mindful instructions (kabat-zinn, 1990; siegel, 2007), which ask the client to notice and track her experience without judging it. mindful instructions promote the client's ability to observe and process her traumatic experience within a "window of tolerance" where the client is not in hyper or hypo aroused zones (ogden et al, 2006; siegel, 2012). ogden and her colleagues international journal of integrative psychotherapy, vol. 4, no. 2, 2013 31 suggest that with mindful awareness "retraumatization is minimized because the prefrontal cortex remains 'online' to observe inner experience, thus inhibiting escalation of subcortical activation" (2006, p.195). in emdr bi-lateral stimulation (bls) is added to mindful instructions, promoting a relaxation response via distracting eye movements (maxfield, melnyk & hayman, 2008; gunter & budner, 2009). present feelings and 'felt senses' are also used to facilitate the client’s mindful inner exploration (gendlin, 1981; levine, 1997; teasdale and bernard (1993). in this article mindful dual awareness (mda) is referred to as the client’s ability to be in touch (linking) with her experiences while keeping an appropriate distance (differentiation) in a mindful, non-judgmental way. shapiro emphasizes both processes and writes, "it may be that the effectiveness of emdr arises from its ability to evoke exactly the right balance between re-experiencing emotional disturbances and attaining a non-evaluative 'observer' stance” (2001, p. 323). the therapist, modeling mindfulness, may suggest to a detached client that she notice her body sensations, feelings and images, so as to help her to get closer (linking) to the traumatic experience. when the client is overwhelmed the therapist may suggest a distancing metaphor such as viewing the threatening traumatic experience on a tv screen (differentiation). the ability to develop mda is rooted in the secure attachment relationship. through attuned interactions with caregivers the child develops her reflective abilities; what fonagy (2004) and colleagues have named mentalization. the child finds in the mind of the sensitive caregiver an image of herself as motivated by beliefs, feelings and intentions. she also learns to have conceptions about other’s beliefs, feelings and attitudes, which make their behavior meaningful and predictable for her. she begins to see her ideas as merely ideas and not facts, to play with different points of view and to test ideas against reality so as to moderate their impact. ogden and her colleagues suggest that "…one of the skills that enables mentalizing is the mother’s ability to perceive her child’s world, identify with it and align with it while simultaneously realizing that the child is a separate person” (ogden, et. al., 2006, p.44). it seems that the complementary working of the integrative functions of aligning with the inner world of the child (linking) and acknowledging her autonomy (differentiation) are at the core of the development of the child's reflective capacity. this capacity is impaired by early insecure and disorganized attachment relationships (siegel, 2012; liotti, 2004). therefore with clients with early traumatic experiences the therapist needs to be especially aware of first strengthening their resources and sense of safety in the therapeutic relationship. she can then help them develop dual awareness by a slow and gradual exposure to traumatic material while keeping the link to the safety of the therapeutic situation (ogden et al, 2006; knipe, 2008). siegel (2007) suggests that mindfulness can be looked at as the empathic capacity of the observing self toward the experiencing self. how does the observing stance in trauma processing acquire an empathic hue? it is proposed international journal of integrative psychotherapy, vol. 4, no. 2, 2013 32 that mda goes through various levels toward greater integration during trauma processing. incorporating siegel's (2007) four components of mindfulness, which are curiosity, openness, acceptance and love (coal), we suggest that in trauma processing these components develop in a whole/part sequence in which each new one includes the previous one. in order for the client to allow herself to open mindfully to her distressing inner experience, she needs to feel safe enough to allow some experience of threat. the client's mda can widen to curiosity about the various hues of her unfolding inner experience, as her trust in the relationship with the therapist and the processing grows. mda expands further, becoming an open, curious and accepting stance towards conflicting sensations, emotions and thoughts as the client, with the help of the therapist, moves toward a wider and more whole perspective. when integration continues to higher levels, mda expands even further to experiences of love toward oneself, others and the universe. zvelc (2012) suggests that the therapist, during mindful processing, should accept his own experience, while also inviting the client to explore and accept hers. “therapeutic involvement includes acknowledgment, validation, normalization and presence” (zvelc, 2012, p. 44). the following example illustrates the development of the client’s mda in a couple’s session. udi and his spouse had been in therapy for several months. at first udi was very closed to the idea that his problems with his wife had anything to do with his childhood. he insisted that she was demanding and bossy without taking his opinions into account. as the therapist asked him to recollect a time in his childhood when his opinions had been ignored, he said there was no connection and that the therapist was not making sense. at this stage there was very little openness. the therapist remained open to her own feelings of being pushed away, allowing herself to be affected by them and linking them to udi’s constant feeling of being pushed around. as the therapist gave him space to express the feelings of being dominated by his wife, udi began to observe more openly that these feelings kept repeating themselves. the therapist, linking to udi’s vulnerability, said in a slow, gentle accepting voice that she wondered if, in his family of very hardworking holocaust survivors, he had ever been asked about his feelings and needs. for the first time he showed a glint of curiosity and began to wonder about how he had lived in a home where no one asked him anything. he recalled that his father was always working and his mother was concerned with basics such as food and clothing. he went into himself again, looking rather sad, and said he had also hardly ever been hugged or kissed. the therapist was touched and conveyed empathy for the child who had been so neglected. udi met the therapist’s eyes and said he could connect to his loneliness then. there seemed to be a beginning of some empathy and acceptance toward his denied feelings of neediness. at the end of the session he realized for the first time that it was hard for his wife that he stayed distant when she was needy. international journal of integrative psychotherapy, vol. 4, no. 2, 2013 33 the interaction between the therapeutic relationship, mindful dual awareness (mda), and integrative trauma processing from a dialectical perspective three basic integrative systems in trauma work inter-relate and resonate with each other; the therapeutic relationship, mindful dual awareness (mda), and integrative trauma processing. all three aim toward greater integration by moving dialectically between opposites. figure 1 illustrates the spiral of integrative trauma processing as enveloped both by the therapeutic relationship and mda. the safe and attuned therapeutic relationship provides a container for integrative trauma processing just as the secure attachment relationship offers the appropriate container for the integrative development of the child. mda is depicted as a further container providing the client with a non-judgmental observing stance. this is similar to the way that mentalization is crucial for the child's growing self-regulation and reflective capacities. the mutual interaction of these systems can be illustrated in an emdr session with tali who came to therapy after a traumatic divorce. in one session she focused on a humiliating scene in which she heard her ex-husband’s father speak to her ex-husband about how to manipulate her financially in the divorce process. connecting to her pain and hurt she began to cry and asked to stop the processing. the therapist validated her helplessness gently but encouraged her to stay with her distress a little longer, challenging her to continue the processing. the therapist’s trust in tali’s abilities to stay with her pain while being supported enabled her to dare to go on in the session, opening further to mda. soon after she felt some relief saying, "i can breathe… i feel relieved… i can see myself from the outside." this indicated an initial horizontal movement between the sensorimotor opposites of distress and relief and more of a balance in her mda from being absorbed in her distress to being able to distance from it. on the next set of bls she said: "…it was not me who was humiliated." this indicated that she could begin to differentiate herself from her humiliated part. she shifted to the emotional level, moving horizontally between humiliation and self-worth. as her integrative processing expanded, so did her mda, exploring (curiosity of mda) her father's role in the situation. she realized that her highly respectful father had been willing to be humiliated by her ex-father-in-law in order to help get her a divorce. now she could see her father's humiliation as a noble act of love in which his humiliation and worthiness were integrated. this was a vertical shift to a cognitive level in which her mda expanded to empathy and acceptance. in the next session strong feelings of anger toward her ex-father-inlaw came up. the therapist acknowledged these feelings and encouraged her to discharge her anger toward her ex-father-in-law in her imagination. the therapist’s message that strong anger could be contained and expressed allowed tali to accept it. this led to tali’s insightful recognition that her ex-father-in-law’s behavior was connected to his insecurities and desire to help his son. the horizontal movement between anger and acceptance enabled a vertical shift in international journal of integrative psychotherapy, vol. 4, no. 2, 2013 34 which her mda expanded to some compassion for her previous enemy (love of mda). the therapist was very moved and inspired by the transformation in tali’s attitude toward herself and others, and shared this with her. a dialectical perspective to information processing models can a dialectical perspective contribute to information processing based models? as the science of neurobiology progresses, many therapeutic approaches and models of trauma work base their theoretical formulations on information processing of memory networks. examples are the adaptive information processing (aip) model of emdr (shapiro, 2001, solomon & shapiro, 2008), sensorimotor therapy (ogden, et al, 2006), emotional processing theory (foa & rothbaum, 1998), the cognitive model of ptsd (ehlers & clark, 2000), dual-representation theory (berwin, dalgesleich, & joseph, 1996), emotion focused therapy (eft) (greenberg, 2010), and coherence therapy (ecker & toomey, 2008). from an information processing lens the dialectical perspective may account for three phenomena. the first is the way the inherent integrative movement proceeds via complementary cycles of associative connections, which differentiate the condensed traumatic memory into parts, enabling new associative links to occur. the second is the spontaneous associative connection between the traumatic memory networks and adaptive ones, moving between opposites toward a new synthesis. the third is the transformation reflected in a new self-affirmation or 'post traumatic growth' due to the expanding nature of the integrative/dialectical movement. all three phenomena lead to the integration of the traumatic memory network, via associative connections of differentiation and linking, into a coherent semantic memory network. recent studies (schiller, monfils, raio, johnson, ledoux & phelps, 2010) of the malleability of memory and the adaptive role of reconsolidation as a window of opportunity suggest a possible neuro-biological mechanism behind the transformation of memories. the dialectical perspective suggested in this article may shed some light on the way this transformation occurs. conclusion this article addresses the basic principles and characteristics of the integrative process during trauma processing. it is proposed that a dialectical perspective can contribute to an understanding of the way integrative trauma processing takes place. discussions regarding trauma processing must take into account the interaction of three basic systems; the therapeutic relationship, mindful dual awareness and integrative trauma processing. an appreciation of the dialectical principles in all three may help therapists of various approaches enhance their skills in facilitating the inherent integrative/dialectical movement, international journal of integrative psychotherapy, vol. 4, no. 2, 2013 35 thus promoting the healing process. hopefully the dialectical perspective may also encourage research in the field of therapeutic change. authors: brurit laub is a senior clinical psychologist and family therapist supervisor working in a private practice. she worked for 24 years in a community mental health center. she taught and supervised at the integrative psychotherapy program, magid institute, hebrew university for 9 years. she uses voice dialogue and internal family systems therapy in her work with sub personalities. she is an emdr europe accredited consultant and developed the recent traumatic episode protocol for early emdr intervention with elan shapiro and presented it at numerous conferences around the world. nomi weiner is a senior clinical psychologist and family therapist supervisor working in a private practice. she worked for 17 years at the kibbutz guidance clinic with individuals, couples and families.. she taught and supervised at leslie college for two years and then at the integrative psychotherapy program, magid institute, hebrew university for 10 years. she teaches and supervises at shiluvim institute for individual, couple and family therapy. she is a certified imago and emdr therapist and works with subpersonalities using voice dialogue and internal family systems therapy. references ainsworth, m., belhar, m., waters, e., &wall, s. (1978). patterns of attachment: a psychological study of the strange situation. hillsdale, n.j: erlbaum. assagioli, r. (1965). psychosynthesis. a collection of basic writings. london: hobbs dorman. almagor, m. (2011). the functional dialectic system approach to therapy for individuals, couples and families. minnesota: university of minnesota press. bion, w. r. (1962). second thoughts. london: william heinemann. blatt, s.j. (1995). the destructiveness of perfectionism: implications for the treatment of depression. american psychologist. vol. 50, pp. 1003-1020. bopp, m. j., week, g. r. (1984). dialectical meta-theory in family therapy. family. process. 23, 49-61. bowen, m. (1978). family therapy in clinical practice. northvale, nj: jason aronson. bowlby, j. (1973). attachment and loss: v, 2, separation: anxiety and anger. middlesex, uk: penguin. brewin, c. r., dalgleish, t., joseph, s. (1996). a dual representation theory of post-traumatic stress disorder. psychological review, 103, 670-686 international journal of integrative psychotherapy, vol. 4, no. 2, 2013 36 bromberg, p. m. (2006). awakening the dreamer: clinical journeys, mahwah, nj: the analytic press. cvetek, r. (2008). emdr treatment of distressful experiences that fail to meet the criteria for ptsd. journal of emdr practice and research, 2 (1), 2– 14. ecker, b., & toomey, b. (2008). depotentiation of symptom-producing implicit memory in coherence therapy. journal of constructivist psychology, 21, 87-150. doi: 10.1080/10720530701853685. ehlers, a., & clark, d. m. (2000). a cognitive model of post-traumatic stress disorder. behaviour research and therapy, 38, 319-345. foa, e. b., & rothbaum, b. o. (1998). treating the trauma of rape: cognitive behavioural therapy for ptsd. new york: guilford press. fonagy, p., gergely, g., jurist. e. l., target, m. (2004). affect regulation, mentalization, and the development of the self. new york: other press gendlin, e. t. (1981). focusing. new york: bantam books. greenberg, l. s. (2010) emotion-focused therapy: a clinical synthesis, focus, 8, 32-42 gunter, r.w., bodner, e. (2009). emdr works...but how? recent progress in the search for treatment mechanisms. journal of emdr practice and research, 3, (3), 161-168. harner, m. (1990). the way of the shaman. new york: harper & row. hoffman, s., gafni, s., & laub, b. (1994). (eds.), cotherapy with individuals, families and groups. northvale, nj: jason aronson. hoffman, s., & laub, b. (2006) innovative intervention in psychotherapy. boca raton, florida: universal publishers. janet, p. (1925). principles of psychotherapy. london: allen & unwin. (originally published in paris, 1919). jung, c. g. (1963). memories, dreams, reflections. london: random house. kabat-zinn, j. (1990). full catastrophe living: using the wisdom of your body and mind to face stress, pain and illness. new york: dell. klein, g. (1976). psychoanalytic theory. new york: international universities press. knipe, j. (2008). loving eyes. procedures to therapeutically reverse dissociative processes while preserving emotional safety. in c. forgash & m. copeley (eds.). healing the heart of trauma and dissociations with emdr and ego state therapy. new york: springer. koestler, a., (1978). janus: a summing up. new york: random house. laub, b., & weiner, n. (2007). the pyramid model – dialectical polarity in therapy. journal of transpersonal psychology, 39 (2) 199-221. laub, b., & weiner, n. (2011). a developmental/integrative perspective of the recent traumatic episode protocol (r-tep). journal of emdr practice and research 1, (1). 57-72 levine, p. a. with frederick. a. (1997). waking the tiger: healing trauma. berkely, c.a.: north atlantic books. international journal of integrative psychotherapy, vol. 4, no. 2, 2013 37 linehan, m. m. (2006). mechanisms of change in dialectical behavior therapy: theoretical and empirical observations. journal of clinical psychlogy.v.62 (4) 459-480. liotti, g. (2004). trauma, dissociation, and disorganized attachment: three strands of a single brand. psychotherapy: theory, research, practice, v. 41, (4), 472–486. main, m. attachment: overview, with implications for clinical work. in s. goldberg, r. muir, & j. kerr (eds.) attachment theory: social, developmental, and clinical perspectives (pp.407-474). hillsdale, nj: analytic press. maslow, a. h. (1970). motivation and personality. new york: harper & row. maxfield, l., melnyk, w. t., & hayman, c. a. g. (2008). a working memory explanation for the effects of eye movements in emdr. journal of emdr practice and research, 2(4), 247–261. moreno, j. l. (1987). in j. fox (ed.), the essential moreno: writings on psychodrama, group method, and spontaneity. new york: springer. ogden, p., minton, k., & pain, c. (2006). trauma and the body: a sensorimotor approach to psychotherapy. new york: norton. pepp, p. (1994). the process of change. new york: guilford. perls, f.s. (1959). gestalt therapy verbatim. new york: real people. piaget, j. (1970). piaget’s theory. in p. h. mussen (ed.), carmichael’s manual of child psychology (vol. 2, pp. 703–732). new york: wiley. pipp, s. (1990). sensorimotor representational internal working models of self, other, and relationship: mechanisms of connection and separation. in d. cicchetti & m. beeghly (eds.), the self in transition. infancy to childhood, (pp.243264). chicago: the university of chicago press. porges, s. w. (2003). the polyvagal theory: phylogenetic contributions to social behavior, physiology and behavior, 79, 503-513. rogers, c. r. (1951). client-centered therapy. boston: houghton-mifflin. rychlak, j. f. (1968). a philosophy of science for personality theory. boston: houghton-mifflin. rossi, e. l. (1996). the symptom path to enlightenment: the new dynamics of self-organization in hypnotherapy: an advanced manual for beginners. pacific palisades, ca: palisades gateway. schiller, d., monfils, m. h., raio, c. m., johnson, d. c., ledoux, j. e., & phelps, e. a. (2010). preventing the return of fear in humans using reconsolidation update mechanisms. nature, 463, 49-53. schore, a. n. (1994). affect regulation and the origin of the self: the neurobiology of emotional development. hillsdale, nj: lawrence erlbaum associates. schwartz, r. c. internal family system therapy. new york: guilford. shapiro, f. (2001). eye movement desensitization and reprocessing: basic principles, protocols and procedures. (2nd ed.). new york, guilford. shapiro, e., laub, b. (2008). early emdr intervention (eei): a summary, a theoretical model, and the recent traumatic episode protocol (r-tep). journal of emdr practice and research 2, (2), 79-96. international journal of integrative psychotherapy, vol. 4, no. 2, 2013 38 international journal of integrative psychotherapy, vol. 4, no. 2, 2013 39 shapiro, s, (2012). therapeutic change from the perspective of integrative trauma treatment. psychoanalytic perspectives, 9, (1), 51-65 siegel, d. j., & hartzel, m. (2003). parenting from the inside out. new york: penguin putnam. siegel, d.j. (2007). the mindful brain. reflection and attunement in the cultivation of well-being. new york: norton. siegel, d. j. (2012). the developing mind. how relationships and the brain interact to shape who we are. second edition, new york: guilford press. solomon, r. m., & shapiro, f. (2008). emdr and the adaptive information processing model. journal of emdr practice and research, 2, 315-325. stone, h., & winkelman, s. (1985). embracing ourselves. voice dialogue. marina del rey, ca: devorss & company, publisher. teasdale, j.d., & barnard, p.j. (2003). affect, cognition and change: remodeling depressive thought. hove, uk: erlbaum. watts, a.w. (1963). the two hands of god. the myth of polarity. new york: collier books. wilber, k. (1996). a brief history of everything. boston & london: shambhala winnicott, d. w. (1965). the maturational processes and the facilitating environment. london: hogarth. zvelc, g. (2012). mindful processing in psychotherapy – facilitating natural healing process within attuned therapeutic relationship. international journal of integrative psychotherapy, 3(1), 42-58. date of publication: 23.3.2014 international journal of integrative psychotherapy, vol. 9, 2018 56 integrating feminist narrative therapy, person-centered therapy, and rational emotive behavioral therapy: a short-term case study loni crumb abstract: there is increased literature in the mental health field regarding the merits of integrating techniques and procedures from multiple therapeutic frameworks to facilitate a positive change process. this article presents an integrative approach using feminist narrative therapy, person-centered therapy, and rational emotive behavior therapy to address behavioral, emotional, and psychological concerns. the author provides an overview of each therapeutic approach followed by a justification of the theoretical and therapeutic viability. a case illustration is provided to demonstrate the integration of the three noted therapeutic approaches. finally, limitations and implications for practice are discussed. keywords: integrative, mental health, feminist narrative therapy, person-centered therapy, rational emotive behavior therapy ------------------------------------- introduction mental health professionals must be flexible in their therapeutic approaches and interventions in order to accommodate the extensive psychological, behavioral, social, and emotional concerns of diverse clientele (erskine, 2015; international journal of integrative psychotherapy, vol. 9, 2018 57 erskine & trautmann, 1996; ratts & greenleaf, 2018). pairing evidenced-based approaches, such as cognitive-behavioral therapies that consist of collaborative therapeutic alliances and cognitive restructuring with culturally-responsive approaches that support egalitarian relationships and social context exploration, can help mental health professionals address the unique needs of diverse clients and demonstrate measurable treatment outcomes (crumb & haskins, 2017; erskine, 2015). nevertheless, there is a need for researchers and practitioners to provide illustrations of how to practically integrate established therapeutic approaches. in response to this need, the current article proposes the application of feminist narrative therapy (fnt), person-centered therapy (pct), and rational emotive behavior therapy (rebt) through an integrative framework that comprises elements from behavioral, humanistic, and postmodern paradigms. the integration of such approaches may help mental health professionals to address a host of personal and sociocultural matters that influence clients’ overall personal development and well-being. the following sections provide an overview of the theoretical composition and viability of fnt, pct, and rebt, and a case illustration demonstrating the use of the integrated approach. finally, limitations of the approach and implications for practice are provided. theoretical composition the integrative approach described in the current article was informed by prochaska’s (1995) transtheoretical therapy model which identified a series of stages that people pass through when changing their behavior. the transtheoretical model espouses that no one theory has the “monopoly of truth” (prochaska, 1995, p. 407). prochaska postulated that practitioners could systematically integrate insights and techniques from diverse therapies to meet the need of the client. the maximum impact strategy of integration was utilized to promote client growth that would influence change processes across the designated levels of change including symptom/situational, cognitions, and intra/interpersonal conflicts (prochaska, 1995). feminist narrative therapy (fnt) is an evolving approach to narrative therapy (white & epston, 1990) that incorporates feminist principles. grounded in a constructionist perspective, fnt posits that individual understandings of reality are socially constructed through stories used to make meanings out of everyday life experiences (brown, weber, & ali, 2008; lee, 1997). practitioners of fnt postulate that women’s self-narratives are embedded in gendered stereotypes and gendered scripts, influenced by the dominant culture (banker, 2010; gremillion, 2004; lee, 1997). the approach is critical of the power dynamics that devalue international journal of integrative psychotherapy, vol. 9, 2018 58 women’s voices and therefore intentionally strives to understand a woman’s unique narrative, in an effort to avoid universalizing women’s experiences in the counseling process (lee, 1997). person-centered therapy (pct) is a model of psychotherapy that shares concepts with humanistic and existential perspectives (corey, 2016). pct assumes that clients have an innate ability to change by altering their attitudes toward their problems (rogers, 1979). mental health professionals practicing pct value their client’s worldview and position the client as the expert (bohart, 2012). pct supports the client’s capacity for self-change by creating a growth-promoting climate through the instillation of three core conditions (a) empathy, (b) congruence, and (c) unconditional positive regard (rogers, 1979). rational emotive behavioral therapy (rebt) is a form of psychotherapy oriented around cognitions and behaviors. mental health professionals practicing rebt attend to clients’ thinking, judging, deciding, analyzing, and actions in therapy (ellis, 1996; corey, 2016). clinical problems are largely viewed as the result of irrational beliefs that consist of demands that clients place on themselves, others, and life conditions (ellis, 1996; guterman & rudes, 2005). rebt advances that clients intensify their distress by the way they interpret situations. mental health professionals who practice rebt utilize various techniques to promote positive change such as challenging absolutist beliefs, behavioral tasks, psychoeducation, and imagery exercises (ellis, 1996). theoretical viability literature has indicated that constructs from fnt, pct, and rebt can be coherently integrated into the therapeutic process. pct has been most prominent in demonstrating that the therapeutic relationship is essential to the process of change (erskine & trautmann, 1996; prochaska, 1995). fnt utilizes pct’s three core conditions of empathy, congruence and unconditional positive regard to build an egalitarian therapeutic relationship (brown & augusta-scott, 2007). both fnt and pct use the client’s frame of reference to promote empowerment and selfdirected change (bohart, 2012; brown et al., 2008). while sharing similar principles, fnt extends pct by allowing the mental health professional to be an active facilitator in the therapeutic process (lee, 1997). additional researchers and practitioners have supported the active role of the therapist (see erskine, 2015). a feminist narrative perspective also emphasizes clients’ strengths and allows for the integration of additional techniques to raise clients’ consciousness of their ability to resolve troublesome issues (brown et al., 2008). international journal of integrative psychotherapy, vol. 9, 2018 59 key principles from pct are utilized in rebt as well. practitioners of rebt advise that helping professionals unconditionally accept their clients, as in pct and fnt, as a precursor to encouraging clients to unconditionally accept themselves (ellis, 1996). rebt, however, expands the concept of acceptance by actively-directly teaching clients ways to unconditionally accept themselves, others, and life conditions that they cannot control (ellis, 1996). all three theories uphold the constructionist belief that there is no absolute way of determining reality (dryden & david, 2008; ellis, 1997; lee, 1997; rogers, 1979). similar to fnt, rebt posits that clients should be flexible in their interpretations of ideals based on dominant society and underscore how specific interpretations can lead to selfhelping or self-defeating behavior (brown et al., 2008; ellis, 1997; lee, 1997). case illustration the following clinical case offers an illustration of how the integration of fnt, pct, and rebt can be facilitated in a short-term therapy framework. the client’s identifiable information is modified in accordance with the american counseling association’s (aca) ethical standards (aca, 2014). the case conceptualization and session progression are documented below. the client anna, a 37-year-old female, received psychotherapeutic counseling services at a private counseling practice. anna was college-educated and had been gainfully employed for nine years. she was in a two-year romantic relationship with a male partner. she expressed that her co-workers and close friends recommended that she seek counseling, but she avoided following through on referrals for a year, stating she did not “like getting help.” the mental health professional anna was assigned to a female mental health practitioner (the primary author, referenced hereby as counselor), who was a licensed professional counselor with experience in clinical mental health. the counselor supported egalitarian, strength-based therapies that emphasize clients’ inherent strengths and respect clients’ self-definitions of reality (lee, 1997; ellis, 1997; moursund & erskine, 2004; rogers, 1979). the counselor supported the concept of sharing power with the client and owned the privilege of being trained in multiple therapeutic approaches that can facilitate the change process (lee, 1997). an international journal of integrative psychotherapy, vol. 9, 2018 60 integrative approach that demonstrated flexibility in incorporating insights and techniques from empirically supported theories to meet the client’s specific needs was most valued by the counselor. it was the counselor’s belief that psychotherapeutic change can be mediated by many methods ranging from selfdirected change (white & epston, 1990), the use of the therapeutic relationship (erskine, 2015; rogers, 1979), the use of teaching behavior tasks, or the use of psychoeducational material (ellis, 1997). finally, the counselor believed mental distress can originate from various origins such as biological/intrapersonal conditions or sociocultural factors (ellis, 1997; erskine, 2015; white & epston, 1990). each approach chosen (i.e., fnt, pct, and rebt) has constructs that are congruent with the counselor’s personal and therapeutic philosophy. initial clinical interview during the initial clinical interview, the counselor utilized a subjective method of history taking (carrey, 2007). a subjective approach involves allowing clients to share their personal accounts about experiences they perceive to influence their overall health and wellbeing (carrey, 2007). the counselor engaged anna in a collaborative conversation centered on reasons for seeking counseling, personal and family history, and counseling preferences. the counselor paid special attention to the language anna used while providing her history and noted anna’s strengths and availability of resources (lambie & milsom, 2010). the counselor provided a synopsis of the theoretical orientations that guided her practice and asked anna to complete the stages of change scales (mcconnaughy, diclemente, prochaska, & velicer, 1989). primary presenting issues from information attained through the clinical interview, anna’s primary presenting issues were identified as (a) resistance to seeking help, (b) upholding absolutist beliefs and demandingness of others, and (c) self-depreciation. the counselor speculated anna was in the precontemplation stage (see norcross, krebs, & prochaska, 2011). the precontemplation stage is a stage in which clients are unaware or underaware of their problems and would reasonably demonstrate resistance or apprehension to supportive services due to having less awareness of problems (norcross et al., 2011; prochaska, 1995). gold (2008) proposed that a client’s resistance may reflect a narrative that consists of beliefs about the legitimacy of seeking help or an opposition to problem solving with others. in order to move anna from the precontemplation stage and get her to commit to therapy, international journal of integrative psychotherapy, vol. 9, 2018 61 the counselor anticipated she would need to address anna’s beliefs associated with receiving and giving help (gold, 2008; prochaska, 1995). secondly, the counselor considered it important to address anna’s problemsaturated story. anna reported feelings of self-blame, unhappiness, resentment, and embitterment, which may have been resultant of distress due to positioning herself in a gendered prototype. anna’s dominant narrative appeared to be based on absolutist beliefs that stemmed from gendered roles prescribed by the dominant culture. finally, the counselor addressed anna’s self-deprecating attitude. anna stated she had not received the treatment she felt she deserved in most of her relationships. as a result of her dominant narrative, anna unremittingly helped others and suppressed her own needs. she appeared to exhibit low selfentitlement and the counselor believed she could potentially benefit from recognizing her voice and personal power in an expectation that such awareness would change her pattern of behavior. linking presenting issues to therapeutic approaches the counselor expected anna to exhibit resistance in the initial stages of counseling due to her delay in seeking mental health services that may possibly have been related to her under-awareness of her problems. the core conditions of pct could potentially be helpful to use to establish trust in the counseling relationship (gold, 2008; prochaska 1995). anna reported she had to “grudgingly” care for her younger siblings. anna also referenced that she acted like “mother theresa” in her current relationships. overall, anna’s personal narrative from past to present revealed that she positioned herself in a nurturing role, given the many examples she provided of supporting her boyfriends, co-workers, and friends. from a feminist narrative perspective, the counselor postulated that anna’s selfconcept was interwoven with the stories of others regarding a woman’s role in relationships. a feminist narrative approach would help anna develop an understanding of how dominant discourse may have influenced her problem description and help anna to reconstruct a more preferred personal narrative (brown et al., 2008; lee, 1997). from a rebt perspective, the counselor proposed that anna had specific absolutist beliefs reflected in her dominant narrative of feeling obligated to help others. thus, it could be implied that anna was exacerbating her distress by upholding the belief that she should and must subjugate her needs and wants to international journal of integrative psychotherapy, vol. 9, 2018 62 appease others. rebt was useful to assist anna in generating more flexible interpretations of the underlying beliefs that guide her actions. rebt also provides techniques that aid counselors in teaching methods to reduce distress and recognize patterns of behavior. relatedly, anna displayed a demandingness that others should live by her standards. for example, anna stated she had “insisted” that a boyfriend stop using drugs and told a boyfriend what he “should know” about himself. rebt suggests that demanding others must change is a self-defeating pattern of behavior (ellis, 1994). through the use of rebt perspectives, the counselor anticipated she could teach anna the philosophy of unconditional other acceptance (ellis, 1996) and help anna accept aspects of others that she cannot change. primary clinical themes two clinical themes framed anna’s presenting problems: (a) anna constructed her personal narrative from the position of received knowing (see below), thus the development of her own voice and personal value system has been restricted (belenky, clinchy, goldberger, & tarkle, 1986) and (b) anna’s moral stage of development reflected an under-awareness of her pattern of behavior which prompted anna to subjugate her wants to appease others (gilligan, 1982). women’s ways of knowing theory was used to conceptualize how anna’s knowledge and meaning-making systems were constructed. the theory designates a knowledge perspective termed received knowing in which a woman’s knowledge is constructed by identifying with and conforming to social norms, gender roles, and the expectations of others (belenky et al., 1986). received knowers model themselves after the sociocultural ideals of what a woman should be as communicated by outside entities, such as religious groups, family members, and other authorities (belenky et al., 1986). anna appeared to construct her knowledge and beliefs from a received knowing position as evidenced by her reports of obligations to care for others, having to be a “goody two shoes,” and receiving the message that she would “go to hell” if she demonstrated behavior that did not conform to the social norm for women. carol gilligan’s “ethics of care” theory was used to frame the clinical theme in relation to anna’s moral and personality development. ethics of care refers to the perspective that people value relational and context-bound approaches regarding moral development and decision making (gilligan, 1982). gilligan international journal of integrative psychotherapy, vol. 9, 2018 63 postulated that a woman’s development is heavily influenced by the values of her family and friends (gilligan, 1982). accordingly, a woman may center her thoughts and actions on the needs and interests of others. anna’s development appeared to align with the stage gilligan referred to as “overemphasis on others.” gilligan asserted that women in this stage equate goodness with self-sacrifice and often suppress their personal needs. anna displayed behaviors comparable to this stage, as evidenced by stating that she infrequently received mutual respect and satisfaction in her relationships and sharing how she obligated herself to help others while being reluctant to accept help in return. gilligan speculated that a woman may exhibit destructive behaviors if her wants are suppressed long-term. proposed counseling goals the goals and expectations of therapy were negotiated and co-constructed (brown et al., 2008) between the client and the counselor. the first counseling goal was to encourage anna to revise her relationship with her problems and develop a more preferred story. the aim of this goal was to increase anna’s awareness of the misogynous metanarrative that had possibly molded her dominant story (lee, 1997). the anticipated outcome was that anna would be able to identify personal values and strengths to re-construct a preferential and empowering personal narrative. the second goal was to help anna develop skills (e.g., assertive communication skills) to establish mutually satisfying relationships. the aim of this goal was to increase anna’s ability to identify self-helping and self-defeating behavior patterns (e.g., absolutist thinking, demandingness, selfdeprecating attitude) and move toward positive change. session progression sessions were scheduled weekly and progressed to bi-weekly as the client moved from the precontemplation stage to becoming more active and committed to therapy (prochaska, 1995). session 1. during the first session, the counselor utilized active listening skills, empathic responses, and conveyed unconditional positive regard to create a nurturing environment (ngazimbi, lambie, & shillingford, 2008). the counselor invited anna to share about herself. anna disclosed that she was apprehensive to seeking professional services due to stigmas associated with seeking mental international journal of integrative psychotherapy, vol. 9, 2018 64 health services. the counselor honored her feelings and helped her to normalize her thoughts regarding seeking professional support (gold, 2008; erksine, 2015). the counselor and anna negotiated how they could integrate anna’s preferred style of being with the counselor's style of helping (gold, 2008). anna stated she did not want to feel judged in therapy. the counselor assured anna that she would value her perspectives. the counselor also shared with anna the philosophy of the feminist narrative approach which values the subjective experiences of women (lee, 1997). the counselor did not engage in further questioning during this session to avoid overwhelming anna as she worked through resistance. the counselor asked anna to think about areas she wanted to explore in the next session. between session activity: the counselor wrote and mailed anna a letter thanking her for attending the session and being willing to share her story. writing letters personalizes the relationship and reduces professional distance with clients (white & epston, 1990). sessions 2-3. the counselor checked-in by asking anna to share her thoughts from the previous session. the counselor asked anna if she felt comfortable with the method of questioning because this would be her primary way of understanding anna’s experiences. anna stated she was open to questioning. the counselor posed circular questions from an exploratory position to demonstrate that she does not imply any privileged access to the truth and genuinely sought to understand anna’s experiences (erskine & trautmann, 1996; monk, 1997). the counselor asked anna to share more of her story and reflect on identifying her presenting problem. anna disclosed stories about her childhood, experiences in her workplace, and details about her romantic relationships. the counselor paid close attention to anna’s language and was careful to utilize anna’s language when paraphrasing and providing feedback (lee, 1997). anna identified her problem as assuming the helper’s role, which has impacted nearly all of her relationships. anna stated that she frequently felt feelings of unhappiness, resentfulness, embitterment, and dissatisfaction, although at times, she truly enjoyed helping others in need. at the conclusion of the sessions, the counselor asked anna to reflect on how the problem she identified had influenced her life and document them in a journal. between session activity: journaling. sessions 4-5. anna progressed to the preparation stage as evidenced by her journaling instances in which she was aware that problems existed and international journal of integrative psychotherapy, vol. 9, 2018 65 considered ways to address the issues (prochaska, 1995). the counselor continued to explore anna’s story and engaged anna in externalizing conversations to help her separate herself from the problem (lee, 1997). the counselor explored the meaning that anna attached to accepting and maintaining her helper’s role, in order to gain a greater depth of understanding. as anna shared her story, she became more aware of how the problem was affecting her life and relationships. the counselor supported anna in this process by co-identifying areas in anna’s story in which being the helper may have impacted her decision making. anna realized that she chose to move to a deteriorating home, in a drugladen neighborhood, so that she could attract people in need, even though with her yearly salary she was able to afford to live in another location. anna also acknowledged that she sought out her romantic partners in the community where she lived, as this is the reason why she has often attracted partners with substance abuse issues. by session six, anna’s awareness of how the helper’s role had affected her life was demonstrated by her ability to provide more details of how she had passed-up opportunities to date men with monogamous intentions who shared similar values and interest as her. the counselor mapped the influence of anna’s problem to support anna in exploring her dominant story (white & epston, 1990). between session activity: anna wrote about the pros and cons of maintaining the helper’s role in her journal. the counselor wrote anna a letter to support her efforts in deconstructing her story as a means of client-empowerment. sessions 6-7. anna demonstrated that she was in the contemplation stage by reporting that she had made a positive change by choosing not to give money to her boyfriend for drugs. anna stated that she was ready to make more changes in her life because she had gotten in trouble at work. anna also stated that her boyfriend was dating one of her friends and she was confused as to why she was still interested in seeing him. the counselor used these sessions to educate anna on rebt’s constructs of absolutist thinking and demandingness and highlighted how these beliefs may have contributed to anna’s discontent in relationships. the counselor reinforced how anna’s prior absolutist beliefs about maintaining the helper’s role may have derived from the wider social context and thus inhibited her willingness to prioritize her own needs (lindsley, 1994). the counselor helped anna identify instances in which she held absolutist beliefs and demanded others to change. anna was educated in various ways that the moral and personality development of women was often influenced by societal standards (brown & augusta-scott, 2007; gilligan, 1982). the counselor assisted anna in generating more flexible interpretations of international journal of integrative psychotherapy, vol. 9, 2018 66 how she could build her self-esteem and self-efficacy and help others without having to suppress her own needs. the counselor modeled assertive communication skills. the counselor engaged anna in the process of re-telling her story with the inclusion of ways that anna can value herself in her new story. the counselor encouraged anna to use her personal experiences and self-ideal as part of re-telling her story to avoid adopting generalizations of womanhood from wider societal contexts. between session activity: the counselor asked anna to identify historical unique outcomes (white & epston, 1990) in order to recall events from her past that contradict how the problem has affected her life and relationships. the counselor asked anna to document these situations and strategies she used to successfully resolve these situations in her journal. the counselor provided anna psychoeducational material related to communication skills, building self-esteem, and coping with stress to illustrate how distress influences the body, thoughts, feelings, and behavior (perlman, 2002; ussher, hunter, & cariss, 2002). sessions 8-9. anna was fully engaged in the action stage as evidenced by her ability to begin to re-author her story. anna used more positive language and asserted her own interpretations. she stated that she used assertive communication skills in a conversation with her romantic partner. she reported that she was able to express to him that she would no longer tolerate him dating her friend and requested that he value her as his girlfriend. anna displayed the capacity and agency to intervene in her own life and relationship as she reconstructed her story in a more preferred fashion (brown et al., 2008). anna continued to identify current unique outcomes. the counselor reinforced anna’s progress by asking her to continue to journal her experiences throughout the re-authoring process. the counselor proposed that together she and anna could create a self-help book of personal success stories with the journal entries and letters that were written throughout the counseling process. writing success stories transforms the relationship of the person or problem as well as enables a client to self-reflect should the problem re-emerge (white & epston, 1990). between session activity: anna started to gather content for her self-help book. sessions 10-11. anna and the counselor worked on composing her selfhelp book in session. the self-help book referenced anna's former problemsaturated story provided contradictions to the dominant plot and documented new interpretations of the problem (white & epston, 1990). the counselor worked toward identifying an audience to reinforce anna’s progress. narrative therapy international journal of integrative psychotherapy, vol. 9, 2018 67 practitioners believe that new stories take hold when there is an audience to appreciate and support them (white & epston, 1990). anna expressed that she had been working with elderly persons in the community. the counselor engaged in planning ways to connect anna with a network of community leaders who shared the same passion for caring for the elderly. the counselor informed anna that the group of community leaders had a structured process for raising money for elderly persons by hosting weekly fundraising activities. the counselor considered this group ideal for anna because she would have a chance to pursue her passion for helping people in a more constructive manner. between session activity: the counselor linked anna to the community organization. session 12-13. anna expressed how her participation in the community humanitarian group was helpful because she was involved in a worthy cause in which she felt valued by others. anna stated that she was ready to terminate therapy because she had a better understanding of how she had accepted and maintained the helper’s role and how this influenced her wellbeing. anna stated that she had learned how to value and voice her feelings by setting limits in her relationships. anna also stated that she did not demand others to live by her standards and recognized that everyone had their own reality.the counselor proposed that a definitional ceremony would provide a framework to facilitate a meaningful closure to the therapeutic relationship (lenz, zamarripa, & fuentes, 2012). a definitional ceremony offers clients the opportunity to tell parts of their stories to a carefully chosen audience audience members respond to the stories by emphasizing the positive impact of the stories, garnering witnesses to the clients’ worth, vitality, and being (leahy, o’dwyer, & ryan 2012; lenz et al., 2012; white, 1995). anna stated that she would make arrangements for the ceremony and the counselor agreed to attend. between session activity: anna chose to conduct her definitional ceremony during her humanitarian group meeting. during the ceremony, anna shared about the development of a new narrative toward helping, changes in valuing herself and others, her passions, and readiness to accept new responsibilities (lenz et al., 2012). termination session and follow-up. anna was in the action stage by the time of termination of therapy as evidenced by the reports in her definitional ceremony. anna verbally reinforced that she felt validated and supported in her relationships. anna agreed to use the self-help book as a means of reflection to continue international journal of integrative psychotherapy, vol. 9, 2018 68 progress once therapy was concluded. anna stated that she felt more empowered to follow her own destiny and more confident in her decision making. the counselor mailed anna a certificate of appreciation for completing therapy and welcomed her back if additional work was needed. the follow-up session was conducted two months after termination. anna stated that she was still involved in the humanitarian group weekly. anna stated that she was having fewer issues at her job and that her romantic relationship had improved. anna also stated that she was planning to move to another neighborhood that would be more conducive to her personal development. assessment of intervention effectiveness anna’s progress was assessed by her ability to start re-authoring her life story. by session termination, anna demonstrated the ability to recognize the sources of her problem and used a more empowering narrative. intervention effectiveness was also evaluated by anna demonstrating the ability to recognize risky thoughts such as absolutist thinking and demandingness and by her ability to use assertive communication skills to improve her relationships. the counselor also administered the post session stages of change scales, to measure anna’s progression through the stages of change since beginning therapy (mcconnaughy et al., 1995). the counselor concluded that anna had successfully navigated from the precontemplation stage to the action stage based on her pre and post responses on the scale. limitations literature has shown that each approach used has specific limitations. for example, pct has been criticized for its non-directedness (kahn, 1999). fnt’s emphasis on subjectivity and relativity has been critiqued by various scholars (brown & augusta-scott, 2007) and rebt has received much criticism for its forceful nature (guterman & rudes, 2005). despite these limitations, all three of the therapies are identified as successful in managing emotional distress in relation to psychological and emotional issues (banker, 2010; dryden & david, 2008; proctor, 2008). last, it is important to note that the case illustration encompassed a short-term counseling framework spanning 13 weeks and caution should be applied in generalizing the content to shorter or longer counseling processes as the beliefs, attitudes, behaviors, and resources of clients and counselors vary. implications for practice and conclusion international journal of integrative psychotherapy, vol. 9, 2018 69 this article illustrates how mental health professionals can integrate feminist, cognitive-behavioral, and person-centered principles and techniques into the therapeutic process. using a collaborative counseling relationship grounded in trust, empowerment, and compassion, mental health practitioners can help clients to claim their own voice and individuality and move toward positive change (crumb & haskins, 2017; moursund & erskine, 2004). however, when using integrative approaches, it is important to consider that clients may not be receptive to the principles espoused in each theory. mental health professionals should be careful not to pressure clients to adopt their personal values, which may contradict a client’s belief values and belief system. mental health professionals should engage in the process of practitioner reflexivity, in which the professional consciously separates his or her personal views from the clients’ worldviews (lee, 1997). attending to the client’s subjective experiences and establishing transparency throughout the therapeutic process is imperative. furthermore, clients and mental health professionals may not have consensus on issues such as (a) relative preferences for stability versus change, (b) investment in the change process, or (c) willingness to consider alternative explanations of the presenting problem (gold, 2008). these issues can potentially defeat attempts to resolve the client’s presenting problem. therefore, it is essential that mental health professionals remain flexible in their therapeutic approach. in order to enhance a client’s receptiveness to therapy, mental health professionals should utilize a variety of methods such as valuing the client’s thoughts and feelings, providing insight, providing psychoeducational material, and teaching the client communication and behavioral techniques, all of which are accomplished through therapeutic flexibility and integration (erksine, 2015; moursund & erskine, 2004). author: dr. loni crumb is an assistant professor in the counselor education program in the department of interdisciplinary professions at east carolina university and a licensed professional counselor. dr. crumb received her ph.d. in counseling and student personnel services from the university of georgia, m.a. in education and community counseling from clark atlanta university, and b.a. in psychology from north carolina state university. her research interests include counseling in rural areas, promoting retention and persistence of underserved students in higher education, college student mental health, and social justice and multicultural training. international journal of integrative psychotherapy, vol. 9, 2018 70 references american counseling association. (2014). aca code of ethics. alexandria, va: author. banker, j. r. (2010). dating is hard work: a narrative approach to understanding sexual and romantic relationships in young adulthood. contemporary family therapy: an international journal, 32(2), 173-191. belenky, m. f., clinchy, b. m., goldberger, n. r., & tarkle, j. m. (1986). women’s ways of knowing. new york, ny: basic. bohart, a. c. (2012). can you be integrative and a person-centered therapist at the same time? person-centered & experiential psychotherapies, 11(1), 113. doi:10.1080/14779757.2011.639461 brown, c., & augusta-scott, t. (2007). narrative therapy: making meaning, making lives. thousand oaks, ca: sage publications. brown, c. g., weber, s., & ali, s. (2008). women’s body talk: a feminist narrative. journal of systemic therapies, 27(2), 92-104. carrey, n. (2007). practicing psychiatry through a narrative lens: working with children, youth, and families. in c. brown, t. augusta-scott (eds.), narrative therapy: making meaning, making lives (pp. 77-101). thousand oaks, ca: sage publications. corey, g. (2016). theory and practice of counseling and psychotherapy (10th ed.). belmont, ca: cengage learning. crumb, l., & haskins, n. (2017). an integrative approach: relational cultural theory and cognitive behavior therapy in college counseling. journal of college counseling, 20(3), 263-277. doi:10.1002/jocc.12074 dryden, w., & david, d. (2008). rational emotive behavior therapy: current status. journal of cognitive psychotherapy, 22(3), 195-209. doi:10.1891/08898391.22.3.195 ellis, a. (1994). post-traumatic stress disorder (ptsd): a rational emotive behavioral theory. journal of rational-emotive and cognitive-behavior therapy, 12(1), 3-25. doi:10.1007/bf02354487 ellis, a. (1996). a social constructionist position for mental health counseling: a reply to jeffrey t. guterman. journal of mental health counseling, 18(1), 16-29. ellis, a. (1997). postmodern ethics for active-directive counseling and psychotherapy. journal of mental health counseling, 19(3), 211-226. erskine, r. g. (2015). relational patterns, therapeutic presence. concepts and practice of integrative psychotherapy. london, uk: karnac books. international journal of integrative psychotherapy, vol. 9, 2018 71 erskine, r. g., & trautmann, r. l. (1996). methods of an integrative psychotherapy.transactional analysis journal, 26(4), 316-328. doi:10.1177/036215379602600410 gilligan, c. (1982). in a different voice: psychological theory and women’s development. cambridge, ma: harvard university press. gold, j. m. (2008). rethinking client resistance: a narrative approach to integrating resistance into the relationship-building stage of counseling. journal of humanistic counseling, education & development, 47(1), 56-70. gremillion, h. (2004). unpacking essentialisms in therapy: lessons for feminist approaches from narrative work. journal of constructivist psychology, 17(3), 173-200. guterman, j. t., & rudes, j. (2005). a narrative approach to strategic eclecticism. journal of mental health counseling, 27(1), 1-12. kahn, e. (1999). a critique of nondirectivity in the person-centered approach. journal of humanistic psychology, 39(4), 94-111. lambie, g. w., & milsom, a. (2010). a narrative approach to supporting students diagnosed with learning disabilities. journal of counseling & development, 88(2), 196-203. leahy, m. m., o’dwyer, m., & ryan, f. (2012). witnessing stories: definitional ceremonies in narrative therapy with adults who stutter. journal of fluency disorders, 37(4), 234-241. doi:10.1016/j.jfludis.2012.03.001 lee, j. (1997). women re-authoring their lives through feminist narrative therapy. women & therapy, 20(3), 1-22. doi:10.1300/j015v20n03_01 lenz, a., zamarripa, m., & fuentes, s. (2012). a narrative approach to terminating therapy. journal of professional counseling: practice, theory & research, 39(2), 2-13. lindsley, j. r. (1994). rationalist therapy in a constructivist frame. behaviour therapist, 17(7), 160-162. mcconnaughy, e. a., diclemente, c. c., prochaska, j. o., & velicer, w. f. (1989). stages of change in psychotherapy: a follow-up report. psychotherapy: theory, research, practice, training, 26(4), 494-503. doi:10.1037/h0085468 monk, g. (1997). how narrative therapy works. in g. monk, j. winslade, k. crocket, d. epston (eds.), narrative therapy in practice: the archaeology of hope (pp. 3-31). san francisco, ca: jossey-bass. moursund, j., & erskine, r. g. (2004). integrative psychotherapy: the art and science of relationship. pacific grove, ca: brooks/cole. norcross, j. c., krebs, p. m., & prochaska, j. o. (2011). stages of change. journal of clinical psychology, 67(2), 143-154. doi:10.1002/jclp.20758 international journal of integrative psychotherapy, vol. 9, 2018 72 ngazimbi, e. e., lambie, g. w., & shillingford, m. (2008). the use of narrative therapy with clients diagnosed with bipolar disorder. journal of creativity in mental health, 3(2), 157-174. doi:10.1080/15401380802226661 perlman, a. (2002). rebt self esteem workbook. center city, mn: hazelden publishing. prochaska, j. o. (1995). an eclectic and integrative approach: transtheoretical therapy. in a. s. gurman, s. b. messer (eds.), essential psychotherapies: theory and practice (pp. 403-440). new york, ny: guilford press. proctor, g. (2008). gender dynamics in person-centered therapy: does gender matter? person-centered & experiential psychotherapies, 7(2), 82-94. ratts, m. j., & greenleaf, a. t. (2018). counselor–advocate–scholar model: changing the dominant discourse in counseling. journal of multicultural counseling and development, 46(2), 78-96. doi:10.1002/jmcd.12094 rogers, c. r. (1979). the foundations of the person-centered approach. education, 100(2), 98-107. ussher, j. m., hunter, m., & cariss, m. (2002). a woman-centered psychological intervention for premenstrual symptoms, drawing on cognitive-behavioural and narrative therapy. clinical psychology & psychotherapy, 9(5), 319-331. doi:10.1002/cpp.340 white, m. (1995). re-authoring lives: interviews & essays. adelaide, au: dulwich centre publications. white, m., & epston, d. (1990). narrative means to therapeutic ends. new york, ny: norton. international journal of integrative psychotherapy, vol. 12, 2021 114 the phenomenological use of self in integrative psychotherapy: applying philosophy to practice linda finlay abstract phenomenology is an umbrella term encompassing a philosophical movement and also a range of approaches applied to research and therapy. it is a way of seeing how things appear to us through experience, and it demands an open way of being—one that examines taken-for-granted human situations as they are experienced in everyday life. in this article, the author applies ideas from phenomenological philosophy to show how they are enacted in practice in our moment-to-moment therapeutic use of self. several case illustrations of therapeutic dialogues are offered along with philosophers’ original words to show the richness and potential of phenomenologically oriented relational integrative psychotherapy. keywords phenomenological philosophy, therapeutic use of self, integrative psychotherapy, phenomenological inquiry, existentialism, dialogic practice phenomenological inquiry is often seen as a foundational touchstone for integrative psychotherapy. this is particularly the case for those therapists who embrace erskine’s model (e.g. erskine, 2015, 2020a; moursund & erskine, 2003/2004; erskine & trautmann, 1996), which draws on transactional analysis, behaviorism, gestalt, systems theory, intersubjective psychoanalysis, and developmental attachment theory. international journal of integrative psychotherapy, vol. 12, 2021 115 the concept of phenomenological inquiry comes directly from phenomenological philosophy and involves a special kind of stance: one that is open, respectful, empathetic, compassionate, curious, and nonjudgmental and in which the practitioner is relationally present and attuned. such inquiry goes beyond asking questions; it involves a profound way of being, one that philosophers have been trying to articulate for over a century. in this article, i explore some of the complexities of this phenomenological inquiry and consider how therapists might embody and apply it in practice. three specific challenges confront us when we consider the use of phenomenological philosophy in integrative psychotherapy. first, practicing therapists are rarely philosophers, and few have studied philosophy in any depth. when we try to read primary sources—written in philosophers’ own words—we are likely to find the language dense, baffling, abstruse, and inaccessible. second, philosophers are given to articulating a dazzling range of ideas, including those that are ambiguous or even contradictory. the philosopher merleau-ponty (1945/1962) recognized this when he declared phenomenology to be a “problem to be solved and a hope to be realized” (p. viii). third, it is important to remember that the philosophers who first came up with particular ideas or concepts were grappling with purely philosophical questions, far removed from the world of therapy. it has been left to successive generations of scholarly therapists to work out what these complex, and sometimes mystifying, ideas mean and how they might be applied in practice. mindful of these challenges and the need to tread gingerly, i invite you to accompany me on a trek through some phenomenological philosophy. following a brief orientation, i guide you along my favored route using five key markers to help us as we seek to unite philosophy with practice. the five markers are: phenomenological inquiry, the phenomenological attitude, phenomenological description, dialogic relationality, and existentialism. as well as providing a map through this philosophical territory, i seek to apply the philosophical ideas we encounter and show how they are enacted in practice in our moment-to-moment relating. to this end, i offer several case illustrations of therapeutic dialogues. philosophers’ own words (especially those of merleauponty, as i am particularly drawn to his writings) accompany our journey. they add poetic resonance to our discoveries while giving us a taste of philosophers’ individual voices. international journal of integrative psychotherapy, vol. 12, 2021 116 philosophical foundations phenomenology calls for a special, open way of being and invites us to explore those aspects of experience that often go unquestioned. as a philosophical movement, phenomenology has spanned more than a century and has embraced many different ideas and theories. this is a rich tradition, involving many different strands, which have been applied to both research and therapy. writing in early 20th century germany, edmund husserl (1913/1962, 1936/1970)—often seen as the “father” of the movement—spelled out the phenomenological method as an attempt to look at the world with fresh eyes (finlay, 2013). he advanced phenomenology as the reflective study of the essential structures of consciousness, highlighting how acts of consciousness (perceiving, willing, thinking, remembering) arise prereflectively out of our self/world relationship. he sought to capture the essences and meanings of such phenomena. what is in question is not the world as it actually is but the particular world which is valid for the person. … the question is how they, as persons, comport themselves in action and passion—how they are motivated to their specifically personal acts of perception, of remembering, of thinking, of valuing. (husserl, 1936/1970, p. 317) husserl wrote and revised his ideas over many years. his work is often quite dense and hard to read. merleau-ponty (1945/1962) explained it poetically: “husserl’s essences are destined to bring back all the living relationships of experience, as the fisherman’s net draws up from the depths of the ocean quivering fish and seaweed” (p. xv). martin heidegger (1927/1962), husserl’s student, took phenomenology off into existential, ontological (about being and existence) and hermeneutic (interpretive) realms in order to explore the nature and totality of “being-in-the-world” or “to-bethere” (what he called dasein). he drew attention to the way being involves engaging in everyday activities and dwelling in a network of social relations embedded in a specific historical context. the basic structure of being is saturated international journal of integrative psychotherapy, vol. 12, 2021 117 by the world while the world is soaked through with meaning. arguably, heidegger’s biggest contribution was (and remains) his radical interpretive questioning of cartesian dualism (the split of mind from body and subject from object). he moved us to conceive of our existence as a field of openness into which things and the world reveal themselves. hans-georg gadamer (1960/1989) went further into the hermeneutic realm while arguing for dialogue to promote understanding instead of method. he identified the nature of the hermeneutic circle in which all meanings of texts need to be seen in their social, cultural, historical, and linguistic context. the work of the french philosopher maurice merleau-ponty (1945/1962) also built on husserl’s ideas by focusing on the nature of embodiment and emphasizing principles of nonduality (e.g., the intertwining of mind/body, person/world). merleau-ponty (1964/1968) described the process of phenomenological reflection as trying to find the meaning of our (and others’) embodied worldly existence: reflection must suspend the faith in the world only so as to see it, only so as to read in it the route it has followed in becoming a world for us; it must seek in the world itself the secret of our perceptual bond with it. … it must question the world, it must enter into the forest of references that our interrogation arouses in it, it must make it say, finally, what in its silence it means to say. (pp. 38–39) merleau-ponty’s french contemporaries jean-paul sartre (1943/1969) and simone de beauvoir (1949/1984) explored existential dimensions through their artful writing (both fiction and nonfiction), with de beauvoir adding a feminist perspective. two jewish survivors of the holocaust also journeyed deep into the nature of ethical relationships. martin buber (1923/1958) is best known for his work on the dialogic i-thou relationship, based on presence and inclusion, while emmanuel levinas (1961/1969) highlighted our responsibility to respect others by not reducing them to labels and categories. more recently, philosophers have made specific contributions to psychotherapy practice, notably eugene gendlin (1962/1970), who highlighted the wisdom of bodily felt sense and his use of what he called focusing. paul ricoeur (1976) foregrounded the importance of language/discourse, interpretation, and narrative, international journal of integrative psychotherapy, vol. 12, 2021 118 contrasting the hermeneutics of suspicion (for instance, as seen in psychoanalytic interpretation) with the hermeneutics of empathy (descriptive versions of the interpretation of phenomenological meanings). what links all of these philosophers is their profound curiosity and desire to describe the nature of prereflective, lived, intersubjective experience in its fullest, most holistic sense, uncontaminated by predetermining theories and explanations of behavior. they endeavored to view our “being-in-the-world” in ways that eschew dualisms and polarities: for example, individual-social, person-world, mind-body, self-other, inside-outside, and so on. since descartes, we have been conditioned to split mind from body (at least in the western world). phenomenology offers a radical challenge to this perspective by arguing for the interpenetration of mind, body, self, and world. as merleau-ponty (1964/1968) argued with reference to the nature of being (which he called “flesh”): where are we to put the limit between the body and the world since the world is flesh? … the world seen is not “in” my body, and my body is not “in” the visible world. … [it is] a participation in and kinship with the visible. … there is a reciprocal insertion and intertwining of one in the other. (p. 138) phenomenological inquiry phenomenological practitioners (be they philosophers, researchers, or therapists) generally agree that our central concern is to return to embodied, experiential meanings of the world as it is directly experienced. we ask, “what is this kind of experience like?” “how does the lived world present itself to me/my client?” the aim in psychotherapy when using phenomenological inquiry is to ask questions that enable clients to make their own choices and find their own way through their specific life situation. in a real sense, this form of inquiry is geared to self-discovery. richard erskine et al. (1999) have asserted that phenomenological inquiry, an essential component of full interpersonal contact, begins with the assumption that “the therapist knows nothing about the client’s experience” (p. 19). none of our past experiences, understandings, theories, or even our observations tell us enough about what it is like to live in another person’s skin (erskine, 2001). here therapists “exercise an expertise in asking questions from a position of ‘not international journal of integrative psychotherapy, vol. 12, 2021 119 knowing’ rather than asking questions that are informed by method and that demand specific answers” (anderson & goolishian, 1992, p. 28). it is about constantly focusing on the client’s experience rather than on their observable behavior alone. it is about seeing them as a person in their life context rather than as a problem to be solved. to engage in phenomenological inquiry, erskine has recommended using questions or statements that focus on the client’s experience. the inquiry can focus on a range of dimensions: bodily ones (“what’s happening in your body just now?”), cognitive ones (“what sense do you make of that?”), affective ones (“what are you feeling?”), and/or relational ones (“what’s it like to be sitting here telling me that story?”). with relationally orientated phenomenological inquiry, erskine (2021) suggested asking explicitly about the client’s experience of the therapist’s tone of voice or what it is like when the therapist reacts a certain way or draws attention to the client’s behavior. in another version of relational inquiry, spinelli (2007) explicitly invited clients to recognize similarities and differences between the here-and-now therapy relationship and what happens outside in “real life.” through such inquiry, the client becomes more aware of their needs and more choiceful about their actions while taking in the relational nourishment being offered. the aim, always, is to raise the client’s awareness of their experience, meanings, needs (current and archaic), and issues—all aspects that may have been pushed down or defensively disowned. affect, thoughts, fantasy, memories, hopes, core beliefs and values, and bodily experience (movement, posture, tensions) that have all been kept from full awareness are opened up through the relational dialogic process. through the therapist’s respectful questioning and listening, the client can develop self-curiosity and gain new insights, the first step toward self-acceptance and growth. žvelc and žvelc (2021, pp. 139–140) showed this engaged witnessing in the following dialogue: client: my father was like a nazi; we were all terrified of him. i remember that i was strange already back then. i started to avoid social contacts and had my own world. … in my world everything was fine. therapist: you were strange? international journal of integrative psychotherapy, vol. 12, 2021 120 client: yes, i felt different from others. i didn’t tell you about my inner world; for a long time i felt that you would think i am crazy and will put me in a psychiatric hospital. therapist: so you were very afraid of your father, who was often drunk and violent. and at that time you started to live on the other side where everything was ok. so this “other world” in which everything was fine helped you to survive and keep you sane in the “insane world.” the therapist acknowledges and validates the client’s coping mechanisms, which promotes the client’s awareness and acceptance. client: yes, it helped me to survive, definitely. therapist: (with a kind and compassionate voice) let’s appreciate this strategy of a five-year old that helped you to survive. another validation, which helps the client to experience self-compassion. client: i feel touched, i never thought about this in this way … therapist: maybe this strategy was the most clever strategy to survive in a family where there was no one to hold on to … (short pause)[.] what do you feel now? the therapist conveys the normalisation of the client’s past coping strategy. client: i feel like i would embrace this younger part of me … telling him i love him and care for him. therapist: just do this, take your time. international journal of integrative psychotherapy, vol. 12, 2021 121 client: (crying) i feel sad for what i have gone through … (pause)[.] now i understand that having my own world actually saved my life[.] … i also understand that i am not there anymore, i am safe now. in this dialogue, the therapist draws on the work of erskine et al. (1999). they explained the way inquiry, attunement, and involvement are facets of the overall empathic frame within which the client’s growth is nurtured. the therapist demonstrates “contact-in-relationship” by taking a compassionate approach that encourages the client to connect with a younger part of themselves (žvelc & žvelc, 2021). at the start, the pace is slow: the therapist listens, attunes, and validates the client’s experience and offers time for reflection (attunement). this enables the client to make contact with their grief and acknowledge the value of their own coping mechanisms. by compassionately asking about the client’s way of coping and surviving (inquiry), the therapist is modeling acceptance and being present to the grief. this, in turn, encourages the client to honor (or even let go of) their protective mechanisms (involvement). by normalizing what has happened, the therapist helps the client appreciate and embrace the defensive strategies that have helped them cope. such phenomenological inquiry (combined with attunement and involvement) requires the therapist’s genuine interest, curiosity, and care. it forms the core of the therapist’s use of themselves in relational integrative psychotherapy, even as other therapeutic techniques may be employed. “our use of self is not something we do to the client. instead, it emerges within the specific relationship and evolves as we adapt—over time—to the client’s needs and the relational context while they adapt to us” (finlay, 2022, p. 9). central to the practice of phenomenological inquiry is the fundamental stance or attitude we adopt. that is the focus of the next section. phenomenological attitude the key to practicing the phenomenological attitude (in therapy, in research, or in life) is to adopt a particular open, nonjudgmental approach—one filled with wonder and curiosity about the world—while simultaneously holding at bay prior assumptions and knowledge. the immediate challenge for a therapist entering a international journal of integrative psychotherapy, vol. 12, 2021 122 therapeutic encounter is to remain open to new understandings, to be both present and empathically open to the client in order to go beyond what is already known or assumed (finlay, 2008, 2016a, 2016b). engaging with a phenomenological attitude, we strive to leave our worlds behind and enter into our clients’ worlds in order to reflect on their meanings and experience. this attitude involves a special attentiveness and presence, an ability to dwell with the situations the client describes, to listen with an ear attuned to detail, nuance, and turns of phrase. this involves separating ourselves as far as possible from value judgments and theoretical constructs. we try instead to focus on the meaning of the situation purely as it presents to our client (wertz, 2005). commonly, the term bracketing is used as shorthand for the broader way of being that forms the phenomenological attitude. a concept from phenomenological philosophy, it means putting previous understandings/assumptions into metaphorical brackets that can be held aside—reflexively, in awareness. husserl, the philosopher who is particularly associated with the term, was a mathematician, and he saw the brackets like mathematical brackets where things are put aside but held—as a whole—in awareness. he developed these ideas with reference to what he called the epoché (pronounced “eepokay”), which can be translated as “suspension of judgment.” applied in practice, the process of bracketing is often misunderstood and misused. some make the mistake of seeing bracketing as simply putting aside their subjectivity in an attempt to be unbiased or objective. but subjectivity can never be renounced or hived off in this fashion. rather, the challenge for therapists is to recognize the impact of their subjectivity. it is our very (inter)subjectivity that we must engage. taking its cue from phenomenological philosophy, bracketing is best understood as nonjudgmental, focused openness in which we try to see clients and their lives with “fresh eyes” (finlay, 2008, p. 29, 2016a, 2016b). we bracket in order to be open to the other (the client). in this sense, “bracketing is enacted alongside a genuine, mindful sense of curiosity and compassion. as therapists, we strive to maintain a genuinely unknowing stance in which we remain modest about our claims to understanding” (finlay, 2022, p. 47). we try to bracket what we might know or assume to be present to what is emerging in the here and now. we bracket to engage in genuine phenomenological inquiry. after all, what is the point of asking the questions if we feel we already know the answers (finlay, 2022)? there is much that we bracket in practice. bracketing is an ongoing, continuous process that occurs moment to moment as we become aware of a new thought, understanding, or emotion that bubbles up. specifically, we bracket: international journal of integrative psychotherapy, vol. 12, 2021 123 • our knowing. by not jumping to conclusions and by holding lightly to interpretations or judgments about someone’s mental state. • the truth (or otherwise) of what a client is saying. for instance, if a client tells us their dream, we do not say, “it was only a dream, it wasn’t real.” instead, we acknowledge that the dream was experientially real for that person, so we attend to it as we would to any recounting of experience in so-called “real” life. • our feelings/needs. foregrounding clients’ interests, we try to avoid unduly leaking our emotions (or at least minimize their negative impact), so as not to drown out our clients. it is destructive, exploitive and unethical for therapists to use the client’s therapy for their own support. • cultural assumptions and values. if a person says they want to engage in … [certain behaviors and] practices outside of our beliefs or cultural norms, we respect their preference and bracket our own values. (finlay, 2022, p. 46) whereas bracketing is explicitly practiced by integrative psychotherapists who lean toward existential-phenomenological practice, it also is enacted in other ways when different theoretical frameworks are employed as part of the integrative work. for instance, psychoanalyst wilfred bion (2005) argued that therapists should work without desire or memory and with a quiet mind open to making contact with clients’ unconscious communications: “forget” what you know and “forget” what you want, get rid of your desires, anticipations and also your memories so that there will be a chance of hearing these very faint sounds that are buried in this mass of noise. (p. 17) winnicott (1971) agreed when he advocated a “not knowing” stance: the patient’s creativity can be only too easily stolen by a therapist who knows too much. it does not really matter, of course, how much the therapist knows provided he can hide this knowledge, or refrain from advertising what he knows. (p. 67) international journal of integrative psychotherapy, vol. 12, 2021 124 whatever psychotherapy theory is adopted as part of an integrative framework, what is called for is an especially attentive attitude of nonjudgmental, curious receptivity. there is an emptying of the self while being present in the moment in order to be filled by the other and what is occurring between the clinician and the client. “although it is not easy to let go and enter this space, the results can be rewarding” (finlay, 2022, p. 48). in practice, therapists often have to keep adapting. they catch themselves when they fall into undue knowing or start pushing forward their own agenda. methodically suspending our commonsense assumptions about the shared world, wrote fuchs et al. (2019), “enables psychotherapists to transpose themselves … into fundamentally different ways of finding oneself in the world” (p. 63). to understand this process in action, it is helpful to turn to erskine’s touching story about his work with violet, a 52-year-old woman with a schizoid process. when she started therapy, violet seemed depressed. she would spend her sessions going into great detail about her day-to-day life while avoiding talking about her feelings. erskine (the therapist) felt talked “at” rather than “to”: i realized that i was not making full interpersonal contact with violet. just like her, i was not fully present. i was confused by her. i did not understand how she functioned. no wonder i periodically felt drowsy or found my mind wandering to other situations. it was evident to me that in the absence of any emotional connection between the two of us, i compensated by becoming more and more behavioral in my interventions. eventually i became aware of a parallel process: my focus on behavior change mirrored both her mother’s and her husband's attempts to control her behavior. my countertransference was in my wanting something to happen … so i focused on expressive methods, cognitive understanding, and behavioral change to ward off my worry about not being an effective psychotherapist. (erskine, 2020b, p. 16) erskine (2020b) realized that he needed to change his approach. after some months of working with violet, he began to understand there was a need to respect and be with her in her “quiet place”—a space involving long periods of silence during which she self-stabilized and self-regulated. erskine recognized her need for him to be less invasive by gently reflecting back and describing her internal experience: international journal of integrative psychotherapy, vol. 12, 2021 125 i invited violet to withdraw to her safe bed. there were about 15 minutes of silence during which i watched over her in the same way that i watched over my children as i sat by their bed at night when they were sick. i watched violet’s labored breathing and the tension in her clenched hands. i said, “you must be so scared. … it is important to have a safe hiding place.” she again nodded her head. after another 2 minutes of silence, i offered, “it is so important to hide in your quiet place, particularly when you are sad.” she again nodded, her breathing returned to normal, she unclenched her hands. when violet opened her eyes, she said my description of her internal experience was important because it meant that i understood her and that she was not all alone. … we discussed how my description of her internal sensations was different from her mother’s and her husband’s criticizing definitions of her. she described my voice as “tentative” and my tone soft, “not a definite, authoritarian voice” like those she was used to in her family. (p. 24) phenomenological description instead of explanation, theorizing, or interpretation, phenomenologists value and prioritize description. merleau-ponty (1960/1964) explained phenomenological description as needing to “stick close to experience, and yet not limit itself to the empirical but restore to each experience the ontological cipher which marks it internally” (p. 157). phenomenological research typically involves the participant describing their lived experience of, for instance, a particular trauma or disability. together, participant and researcher dialogue and try to make sense of the phenomenon as seen from the participant’s point of view. similarly, in therapy the aim is to invite the client to simply describe their experience, to put words to their feelings. if words are hard to find, perhaps the person can find a metaphor or say what color or texture the experience has. if the client struggles to describe the experience, the therapist can go slower with the phenomenological inquiry. the point is to stay with the manifest material in active, curious ways rather than passively reflecting it back. by this means clients can edge forward to making or finding their own meanings rather than being fed the therapist’s meanings or interpretations. international journal of integrative psychotherapy, vol. 12, 2021 126 for example, we might ask a client to describe an experience as it happened in real time: “can you describe this experience as it happened?” some prompts to help return the client to the specific scene may be helpful: “put yourself in that place and look around. what do you see/hear/smell?” often when a person recalls an experience in detail, it can be vividly evoked, almost reexperienced. then it becomes about staying with this: standing with the client, encouraging more description, and not foreclosing too quickly (for example, avoiding interpretations or assuming a clear understanding). this is an opportunity to go deeper, to ask for more textured description: “as you’re now feeling a little of how it was for you, how are you experiencing it in your body?” “stay with that body feeling. what is it saying?” inviting more metaphorical description is also a possibility: “what would its color/sound be if it had one?” (spinelli, 2007). the process of describing involves us slowing down. when seeking to describe, we focus in an attempt to uncover sediments of meaning or reveal nuance and texture. wertz (1985) described it well: “when we stop and linger with something, it secretes its sense, and its full significance becomes … amplified” (p. 174). this attitude, he said, involves an extreme form of care that savors the situations described in a slow, meditative way and attends to, even magnifies, all the details. this attitude is free of value judgments … and instead focuses on the meaning of the situation purely as it is given in the participant’s experience. (p. 172) this process is illustrated in the following verbatim dialogue between a client and existential psychotherapist ernesto spinelli (2007, p. 161): client: when he finally told me that he didn’t want to stay in the marriage and that he’d found a new life-partner, i just felt so sick and angry. i hated my self more than i hated him. therapist: can you say a bit more about what it was like for you to hear him say these things? how was that sense of feeling sick and angry, for instance? client: i can just feel it, you know? it’s hard to put words to it. therapist: [accessing his own experiences of being rejected and the feelings that arise in him regarding this] would it be ok for me to try to speak the words? international journal of integrative psychotherapy, vol. 12, 2021 127 client: yeah … therapist: now, i’m just guessing here. so anything i say that feels wrong to you, that’s fine. you let me know. ok, so what i’m imagining when i put myself in your experience is: i get an overwhelming dizziness; a tightness in my gut; a restriction in my throat so that i can’t even reply to him; i see flashes of all sorts of earlier moments in our life together: happy moments, sad ones, silly ones, private ones; and as i see them i hear his voice saying over and over: “it’s finished. this is the end.” i feel a rage that is almost murderous directed toward him, but oddly it’s also directed toward my self. how’s that so far? is it at all close to your experience? client: yes, a lot of it is. but as you were talking, what mainly came up for me was a sense of failure. that was the main thing. “i’ve failed and i’m not worthy.” therapist: ok. so let’s stay with that. “a lot of those statements ernesto made are correct and they’ve provoked my overwhelming sense of failure.” are you feeling it now? client: yes. therapist: so what’s it like to feel it right here with me present? client: it’s like i felt with harry when he told me he was leaving me. therapist: ok. so that feeling with harry is right here in the room with us. can you access any words for that feeling? as this exploratory dialogue reveals, the phenomenological description of lived experience takes priority over focusing on pathological symptoms, analyzing unconscious motivations, or attempting to explain and modify behavior. rather than seeking to educate, repair, change, analyze, or explain, phenomenologically oriented therapists celebrate the value of simply describing (finlay, 2016a). bringing one’s world into focus, and dwelling there, often alters one’s being itself. as new awareness arises, subtle shifts occur. along with other existential phenomenologists, i believe that i just have to be there with the client, perhaps in their dark place, for the combined power of the relational context and the process of description to reveal its transformative potential. (p. 178) international journal of integrative psychotherapy, vol. 12, 2021 128 dialogic relationality contemporary dialogic and relational approaches to therapy place the focus on the therapeutic relationship rather than simply on the individual client. the therapist tries to be present in the moment to both the client and to their own feelings (which, through countertransference, may offer important clues about the client’s experience). therapists are encouraged to foster a client’s sense of self by maintaining an affirming, holding, relationally responsive presence (finlay, 2016b). there is a growing emphasis on the mutuality of the therapeutic relationship. but how we bring this relational dimension into therapy varies according to perspective and context (paul & charura, 2015). a key debate revolves around the extent to which we emphasize the here-and-now intersubjective relationship rather than the intrasubjective one, where past developmental relationships are accessed transferentially. in the field of integrative psychotherapy, the work of erskine and his colleagues has engaged a process that involves simultaneously attending to client and self (in terms of being emotionally available and self-aware). the therapist decenters from their own needs, making the client’s process the primary focus. the therapist is mindful of the client’s experience, watching every gesture, listening to each word, and/or being with the client’s silence. at the same time, the therapist’s history, relational needs and sensitivities, theoretical stance, and professional experience all enter into building therapeutic presence (erskine, 2011; moursund & erskine, 2003/2004). similarly, with reference to dialogic gestalt therapy, yontef and jacobs (2005) wrote that contactful dialogue is the basis of the therapeutic relationship: “in dialogue, the therapist practices inclusion, empathic engagement, and personal presence (for example, self-disclosure). the therapist imagines the reality of the patient’s experience and, in so doing, confirms the existence and potential of the patient” (p. 362). hycner (2017) also talked of the “artistry” involved in maintaining a three-way attuned focus: on what the client needs, on our own needs, and on the needs of the relationship. immersed in the relationship, therapists engage in an intricate dance, one that involves being present to all three dimensions while also being curious, attentive, open, and able to step back and think. in the fluid moments international journal of integrative psychotherapy, vol. 12, 2021 129 between intimacy and distance, the nature of our holding as clinicians shifts, as do our points of focus. in one moment, we might be deeply immersed in holding a client’s story or literally holding them; in the next, we might be holding on to ourselves, struggling to anchor ourselves by stepping back reflectively to avoid being caught up in a relational maelstrom. some gestalt therapists have built on the significant work of the phenomenological philosopher martin buber (1923/1958, 1951/1965) and his ideas about i-thou versus i-it relationships. in i-thou, the therapist surrenders an instrumental desire for control or validation and eschews habitual ways of interacting that are found in instrumental i-it relationships. the i-thou relationship is “free from judgment, narcissism, demands, possessiveness, objectification, greed, and anticipation” (finlay, 2016a, p. 127; see also hycner, 1991/1993). in the authentic, open relationship of i-thou, each person gives of themself without manipulating the other or controlling the impression being created. the direct experience of such presence with another is comforting (by showing us we are not alone) and threatening (by challenging us to be more). treating another as a “thou” rather than an “it” has important ramifications: buber (1923/1958, 1951/1965) saw the holocaust as a particularly horrendous example of the ethical consequences of seeing others as “its.” ultimately, the i-thou relationship is mutually revealing (hycner, 1991/1993). recognizing the value of the other’s personhood helps us renew our own personhood (finlay, 2019). buber’s dialogic philosophy also guides therapists to embrace both presence and inclusion. presence is the capacity to be present emotionally and bodily; inclusion is the capacity to put oneself into the experience of the other with attuned empathy while holding on to oneself and one’s own presence (i.e., not getting lost in confluence) (finlay, 2016b). when we have the courage to be fully present, we are met and affirmed by the other through what hycner called an “embrace of gazes” (hycner & jacobs, 1995, p. 9). another key idea in buber’s philosophy is what he called the interhuman, that is, the deep contact that can be found in the relational between: where the dialogue is fulfilled in its being, between partners who have turned to one another in truth … there is brought into being a memorable common fruitfulness. … the world arises in a substantial way between men [sic] who have been seized in their depths and opened out by the dynamic of an international journal of integrative psychotherapy, vol. 12, 2021 130 elemental togetherness. the interhuman opens out what otherwise remains unopened. (buber, 1951/1965, p. 86) in relational-dialogic work, decisions about interventions—such as whether to make an interpretation or to confront and challenge the client—necessarily take into account the client, the therapist, and the context. for example, a therapist would not just start to hold (either metaphorically or physically) a client. the client needs to be receptive; they need to accept and take in that holding and feel held. the question becomes, what level of holding can the client tolerate? and, in turn, the therapist needs to be alert to when the client is accepting (or resisting) being held. how does that impact the therapist and how do they respond back to the client? (finlay, 2019). therapists need to factor in their own needs and readiness. if the therapist is uncomfortable using touch yet still pushes ahead with it, this may have negative implications for the relationship. if you are feeling pulled to physically hold a client, it might be useful to ask yourself why: “am i intuiting the client’s needs? or does this feeling have something to do with my own needs? could it be something that is emerging from the relationship? in whose interest is this holding?” (finlay, 2019, p. 115). in the dialogue below, the therapist (ken evans, an integrative psychotherapist) holds on to his presence while containing his client’s rage. for instance, rather than reacting in anger when feeling “wiped out,” evans used his awareness of his own experience and what seems to be happening between him and the client to attune to his client’s experience. he also showed the impact the client’s experience was having on him. therapist: “tell me some more about what that was like for you phillip, to witness your brother get beaten?” … “it must have been really tough for you.”… at this point there is a dramatic physical change in phillip’s presence, from a sad slumped body posture to an erect and rigid position and with a face contorted with rage and disdain ... “you haven’t a fucking clue what it was like for me.”… i imagine i experience something of what it must have been like for him as a child – sarcasm, dismissal, humiliation and a deep sense of being “wiped out.”… therapist: “phillip, i was listening intently to you talk about your father beating up on your brother, and feeling a lot of compassion[.] i reached out to you in international journal of integrative psychotherapy, vol. 12, 2021 131 your obvious distress. i then experienced you responding to me with sarcasm and angry disdain, which impacted me deeply. i experienced being dismissed by you and feel unseen, fearful and angry. i want to ask you ‘who did this to you?’ ” phillips’s posture instantly deflated, as did his seething anger, and with eyes filled with tears he replied sorrowfully, “that’s just how it was for me.” (evans & gilbert, 2005, pp. 118–119) here, evans attempted to be attentive to the client’s experience, his own, and what was happening between them. he made himself both present and transparent to phillip, inviting him to recognize his projections. although some therapist self-disclosure was involved (he owns feeling dismissed, unseen, fearful, and angry), we can also see how he contained his personal reactive responses. his hurt/anger/shame was not the issue; it was about being in the process and being alert to the source and meanings of those emotions (finlay, 2016a). gestaltist lynne jacobs (1989) provided another example that involved reflexively adjusting her approach: the patient was argumentative and critical. she claimed to be desperate for help, but disparaged my attempts to understand her and to be helpful. i tended to react with unaware defensiveness by taking a particularly superior, authoritative stance toward her. the meeting—the momentary i-thou— occurred after i realized that i was defensive, and decided to be more attentive to my own defensiveness. the next hour, i found myself again reacting defensively. i began to “disclose” this to the patient, while still operating from my defensive authoritative stance. suddenly i realized that at that moment i was still protecting myself by pushing against the patient. i brightened and exclaimed, “see! oh my, i’m doing it right now! damn it, e—, you are just too good. i give up!” i began laughing at my own absurd attempts to coerce the patient. the patient, surprised, also laughed heartily. she admitted she was very good at what she was doing, and enjoyed it, although she always left feeling bitter and dissatisfied. what ensued was our first authentically cooperative exchange of ideas. both of us had gained a renewed respect for the anxieties that had driven us into defensive styles at the expense of presence with each other. (pp. 3–4) international journal of integrative psychotherapy, vol. 12, 2021 132 existentialism existentialism is concerned with questions about human experience and existence. it addresses shared human concerns relating to authentic being and becoming, meaningfulness and meaninglessness, belonging and needs, free will/choice and autonomy versus oppression and constraints, and so on. importantly, existentialism calls us to face the fact of our death in order to make us focus on our life. paraphrasing heidegger’s often-cited words: if i take death into my life, acknowledge it, and face it squarely, i will free myself from the anxiety of death and the pettiness of life—and only then will i be free to become myself. these questions can become the focus of therapy as the client is encouraged to become aware of what it means to be alive, to own one’s choices, and to embrace the special capacity of humans to be reflexive (self-aware) about our identity and relationships with others. existentially oriented therapy aims to examine ways in which each (unique) individual comes to claim their way of being. the focus is on questions such as: “who am i?” “what gives my life meaning?” and/or “how do i want to live my life?” (deurzen, 2014). a central existential concept philosophers have written about is authenticity. heidegger (1927/1962) referred to inauthenticity as “forgetting” to take ownership of one’s life/world. the inauthentic being is “tranquillized” and “flees,” for instance, into bingeing on tv, food, online gaming, consumer products, and so on. heidegger pointed to our daily experience of being-at-home where we are tranquillized and “fall into” the taken-for-granted certainties and familiarities of the anonymous “they” (das man). with these ideas brought to the fore, the key aim of existential psychotherapy is to claim one’s authentic being and become more selfaware, to embrace one’s possibilities and limits, and to be present to one’s existential anxieties while facing the horizon of our death squarely (yalom, 1980). another existential phenomenological concept, which was highlighted originally by husserl (1936/1970), is the notion of lifeworld (lebenswelt) as the taken-forgranted world that is experienced. it is our meaningful subjectivity in relation to the experienced world—not the material world out there but the humanly relational lived world of being. we all have a lifeworld, one that is both unique and also somewhat shared with others (for instance, through our use of language/discourse and culture). international journal of integrative psychotherapy, vol. 12, 2021 133 different interlinking existential “fragments” (ashworth, 2003) of the lifeworld can be identified as universal themes (van manen, 2014): • first, we all have a sense of embodiment. rather than being about our biological body, it is about our experiencing, lived body, which we may be attuned to or disconnected from. it is always there, whether we feel slothful and flabby or energized and potent, and so on. applied to therapy, for instance, we might invite a client to tune into their bodily sense of feeling “hollow,” perhaps opening up a dialogue about what the body in its wisdom is saying about what it needs. • second, our lifeworld is constituted by our lived relationships with others. here, we might embody our loving “motherly” presence or be a passive-aggressive “stroppy teenager,” or we might set out to please and charm, or we might even withdraw from contact and close down. • our lived world also involves a sense of lived time and space (temporality and spatiality). lived time is not clock time but our experience of time, perhaps as creeping slowly when we are bored and rushing ahead when we are stimulated. lived space similarly involves our experience of spaces: for instance, whether they feel safe or threatening, oppressive or free, large or confined, and so on. therapy is geared to exploring the person’s lifeworld. as part of this, existential feelings (ratcliffe, 2008) can be explored: for instance, when we feel fulfilled or safe and secure or distant and outside a group or have a sense of depersonalization. existential feelings are more than emotions we direct somewhere (such as the anger we might feel toward a particular person). they are more like background orientations involving our bodily relationship with the world. describing the experience of a mental health disorder, for instance, the psychiatrist van den berg (1972) talked of how a person’s world can “collapse” or feel “unbalanced”: “the depressed patient speaks of a world gone gloomy and dark. the flowers have lost their color. … the patient is ill; this means that his world is ill” (pp. 25–26). the notion of the lifeworld is rooted in nondualism. as merleau-ponty (1945/1962) famously said, “there is no inner man. man is in the world and only in the world does he know himself” (p. xi). body and world are intertwined; people need to be understood in the context of their world and their meanings. our lifeworlds (individual and shared) are endowed with particular meanings and international journal of integrative psychotherapy, vol. 12, 2021 134 emotional tones. in heidegger’s (1927/1962) terms, we can speak about mooded disposedness or affectivity (befindlichkeit), which discloses what matters to us, and the brute facticity of dasein’s there-ness. in other words, feelings are not located inside of us but involve a felt sense of ourselves in a situation. heidegger’s befindlichkeit discloses how we are always already delivered over to a situation. applied to developmental trauma, for instance, the child feels unbearable pain in a context in which there is an absence of relational attunement. engaging the body more specifically and explicitly, madison (2014) argued for palpable existentialism—a term for a model of experiential-existential therapy that draws on gendlin’s focusing practice. this practice works through the therapeutic relationship and phenomenological description, prioritizing the client’s bodily experiencing over therapeutic technique or inference. rather than necessarily addressing the manifest content of what is being said, the therapist responds in a way that brings into awareness the embodied feeling process that is there in the moment for the client. the forward movement of bodily process feels right. it comes through the person-in-relation; not arbitrarily constructed by the person from their preexisting biases. it comes with a deep breath, the release of tears, laughter … some bodily indication of relief and expansion, even if what was realised was an unpleasant fact. acknowledging our existential reality usually feels better, even if it’s not what we would wish for. (p. 29) applying all of these existential ideas to psychotherapy practice, we can say that phenomenology is a holistic approach that “captures human existence in all its dimensions, from self-awareness and embodiment (including their prereflexive and ‘unconscious’ forms), to spatiality, temporality, narrativity and intersubjectivity” (fuchs et al., 2019, p. 64). existentially focused therapy puts the human condition front and center, engaging with all its complexity, ambivalence, paradox, tragedy, and wonder. it recognizes this human experience as inseparable from our being-in-the-world. such an approach reminds us to engage the individual’s experience of their wider life-as-lived and relationships with others, not just restrict ourselves to exploring what is happening internally. for dahlberg et al. (2009), “lifeworld-led care” should be applied beyond therapy to health care in general, replacing consumerist patientled, client-centered, or medical-model-driven care. international journal of integrative psychotherapy, vol. 12, 2021 135 an integration the process of phenomenologically orientated integrative psychotherapy is experiential, with an embodied, relational, here-and-now focus. it turns away from reductionist diagnostic labels and cognitive approaches that categorize and explain the person simply in terms of their thinking/behavior, which thereby locates the “problem” in the individual. there is also a turn away from psychoanalytic “archaeological” and inferential explorations of the unconscious and early life. the focus, instead, is on the implicit past that structures the individual’s current phenomenal field of self-other relating (fuchs et al., 2019). in this article, i have offered a map of how phenomenological philosophy is, or might be, applied in integrative psychotherapy. each of the landmarks discussed (phenomenological inquiry, attitude, description, dialogic relationality, and existentialism) has been presented as a distinct process. in practice, however, these processes intertwine and blur into one another. the following case illustration shows something of that holistic intertwining (nb: the bolded terms are not in the original passage, but i include them here to highlight the five markers of phenomenological work discussed in this paper.) i had been seeing gillian (aged 28) weekly for a couple of months. she had come for help with anxiety and panic attacks, specifically relating to swimming in deep water. … then, one session she mentioned her uncle. … his presence had brightened the family home one summer when she was about 10 years old. he took on the responsibility of reading to her at night and tucking her in. gillian described his attentions as making her “feel special” [description]. she started to say something more and then went quiet. … the silence between us stretched out. gillian seemed frozen in a nowhere land as she gazed sightlessly out of the window, and i felt her withdrawal [dialogic relationality]. i tried to reach out by asking what was happening to her [phenomenological inquiry]. she replied that she didn’t know and just felt “empty.” at that point i, too, lost my words and joined her in feeling blank. … international journal of integrative psychotherapy, vol. 12, 2021 136 i sensed a large blockage in my throat. … was this mine or did it belong somehow to gillian’s experience? could it be that my body was vibrating to something occurring between us? [existentialism] … i shared with gillian my sense that my throat felt blocked and how i was feeling the opposite of her emptiness, being choked up with unshed tears [dialogic relationality]. she turned to me in surprise saying that her throat too was feeling like it had a “fist-size blob in it.” ... i invited gillian to focus on her throat sensation, utilising the technique of focusing (gendlin, 1996). “what might your blob throat be saying?” i asked [existentialism, phenomenological inquiry]. … “get out … [pause] i don’t want it,” she eventually whispered. she tried to clear her throat and then said, “it’s not, it’s not … cc … coming out.” she started to get tearful and began to look visibly anxious. “i don’t want to speak anymore. stop this.” at this point i did not know whether she was still talking from her throat or expressing her own desire to not explore further or pleading with me to stop her pain somehow… [phenomenological attitude]. it took two more sessions for her story of being sexually molested to emerge more fully. together [dialogic relationality], we came to understand gillian’s sense of her blobby throat as partly representing the re-membered experience of the oral sex and partly her own fearful pushing down of her desperate emotions relating to that unspeakable experience. (finlay, 2015, pp. 347–348) the art of therapy comes in those exquisitely delicate moments of contact when we make clinical judgments about when and how to intervene. it surfaces as we move in and out of varying levels of support/challenge, separation/distance, connection/intimacy, self-containment/self-disclosure, nondirectiveness/directiveness, silence/active presence, and more (finlay, 2022). therapy involves responding in the moment and going with relational flow and the client’s readiness to explore (moursund & erskine, 2003/2004). together, client and therapist then find themselves immersed in a duet of cocreated music. such moments of connection can feel magical. even so, our craft skills and phenomenological dialogic practices can be reflected on, observed, and learned (finlay, 2022). and, if we listen to the original teachers, philosophy can be our guide. international journal of integrative psychotherapy, vol. 12, 2021 137 references anderson, h., & goolishian, h. (1992). the client is the expert: a not-knowing approach to therapy. in s. mcnamee & k. j. gergen (eds.), therapy as social construction (pp. 25–39). sage. ashworth, p. d. (2003). an approach to phenomenological psychology: the contingencies of the lifeworld. journal of phenomenological psychology, 34, 145–156. bion, w. r. (2005). the tavistock seminars 1976-1979. karnac. buber, m. (1958). i and thou (r. g. smith, trans.). charles scribner’s sons. (original work published 1923) buber, m. (1965). the knowledge of man: a philosophy of the interhuman (m. s. friedman & r. g. smith, trans.) harper & row. (original work published 1951) dahlberg, k., todres, l., & galvin, k. t. (2009). lifeworld-led healthcare is more than patient-led care: an existential view of well-being. medicine, health care and philosophy, 12, 265–271. de beauvoir, s. (1984). the second sex (h. m. parshley, trans.). penguin. (original work published 1949) deurzen, e. (2014). existential psychotherapy and counselling in practice (3rd ed.). sage. erskine, r. e. (2001). the psychotherapist’s myths, dreams, and realities. international journal of psychotherapy, 6(2), 133–140. https://www.integrativetherapy.com/en/articles.php?id=33 erskine, r. g. (2011). attachment, relational-needs, and psychotherapeutic presence. https://www.integrativetherapy.com/en/articles.php?id=73 erskine, r. g. (2015). relational patterns, therapeutic presence: concepts and practice of integrative psychotherapy. karnac. erskine, r. g. (2020a). compassion, hope, and forgiveness in the therapeutic dialogue. international journal of integrative psychotherapy, 11, 1–13. international journal of integrative psychotherapy, vol. 12, 2021 138 erskine, r. g. (2020b). relational withdrawal, attunement to silence: psychotherapy of the schizoid process. international journal of integrative psychotherapy, 11, 14–29. erskine, r. g. (2021). a healing relationship: commentary on therapeutic dialogues. phoenix. erskine, r. g., moursund, j. p., & trautmann, r. l. (1999). beyond empathy: a therapy of contact-in-relationship. brunner/mazel. erskine, r. g., & trautmann, r. l. (1996). methods of an integrative psychotherapy. transactional analysis journal, 26(4), 316–328. https://doi.org/10.1177/036215379602600410 www.integrativetherapy.com/en/articles.php?id=63 evans, k. r., & gilbert, m. (2005). an introduction to integrative psychotherapy. palgrave macmillan. finlay, l. (2008). a dance between the reduction and reflexivity: explicating the “phenomenological attitude.” journal of phenomenological psychology, 39, 1– 32. finlay, l. (2013). unfolding the phenomenological research process: iterative stages of “seeing afresh.” journal of humanistic psychology, 53(2), 172–201. finlay, l. (2015). sensing and making sense: embodying metaphor in relationalcentered psychotherapy. the humanistic psychologist, 43(4), 338–353. finlay, l. (2016a). relational integrative psychotherapy: engaging process and theory in practice. wiley. finlay, l. (2016b). ‘therapeutic presence’ as embodied, relational ‘being.’ international journal of psychotherapy, 20(2), 17–30. finlay, l. (2019). practical ethics in counselling and psychotherapy: a relational approach. sage. finlay, l. (2022). the therapeutic use of self in counselling and psychotherapy. sage. fuchs, t., messas, g. p., & stanghellini, g. (2019). more than just description: phenomenology and psychotherapy [editorial]. psychopathology, 52, 63–66. international journal of integrative psychotherapy, vol. 12, 2021 139 gadamer, h. g. (1989). truth and method (2nd ed. rev.) (j. weinsheimer & d. g. marshall, trans.). sheed and ward. (original work published 1960) gendlin, e. t. (1970). experiencing and the creation of meaning: a philosophical and psychological approach to the subjective. free press of glencoe. (original work published 1962) gendlin, e. t. (1996). focusing-oriented psychotherapy: a manual of the experiential method. guilford. heidegger, m. (1962). being and time (j. macquarrie, & e. robinson, trans.). blackwell. (original work published 1927) husserl, e. (1962). ideas pertaining to a pure phenomenology and to a phenomenological philosophy. book one: general introduction to pure phenomenology (w. r. b. gibson, trans.). nijhoff. (original work published 1913) husserl, e. (1970). the crisis of european sciences and transcendental phenomenology. northwestern university press. (original work published 1936) hycner, r. (1993). between person and person: toward a dialogical psychotherapy. gestalt journal press. (original work published 1991) hycner, r. (2017, 8 september). what does it mean to be a relational psychotherapist? [lecture]. scarborough counselling and psychotherapy institute, scarborough, united kingdom. hycner, r., & jacobs, l. (1995). the healing relationship. gestalt journal press. jacobs, l. (1989). dialogue in gestalt theory and therapy. http://www.gestaltpsychotherapie.de/jacobs1.pdf levinas, e. (1969). totality and infinity (a. lingis, trans.). duquesne university press. (original work published 1961) madison, g. (2014). the palpable in existential counselling psychology. counselling psychology review, 29(2), 25–33. https://gregmadison.net/documents/crrmadison.pdf merleau-ponty, m. (1962). phenomenology of perception (c. smith, trans.). routledge & kegan paul. (original work published 1945) international journal of integrative psychotherapy, vol. 12, 2021 140 merleau-ponty, m. (1964). signs (r. c. mccleary, trans.). northwestern university press. (original work published 1960) merleau-ponty, m. (1968). the visible and the invisible (a. lingis, trans.). northwestern university press. (original work published 1964) moursund, j. p., & erskine, r. g. (2004). integrative psychotherapy: the art and science of relationship. brooks/cole-thomson learning. (original work published 2003) paul, s., & charura, d. (2015). an introduction to the therapeutic relationship in counselling and psychotherapy. sage. ratcliffe, m. (2008). feelings of being: phenomenology, psychiatry and the sense of reality. oxford university press. ricoeur, p. (1976). interpretation theory: discourse and the surplus of meaning. christian university press. sartre, j-p. (1969). being and nothingness (h. barnes, trans.). routledge. (original work published 1943) spinelli, e. (2007). practising existential therapy: the relational world. sage. van den berg, j. h. (1972). a different existence: principles of phenomenological psychopathology. duquesne university press. van manen, m. (2014). phenomenology of practice: meaning-giving methods in phenomenological research and writing. left coast press. wertz, f. j. (1985). methods and findings in an empirical analysis of “being criminally victimized.” in a. giorgi (ed.), phenomenology and psychological research (pp. 155–216). duquesne university press. wertz, f. j. (2005). phenomenological research methods for counseling psychology. journal of counseling psychology, 52(2), 167–177. https://doi.org/10.1037/0022-0167.52.2.167 winnicott, d. w. (1971). playing and reality. pelican books. yalom, i. d. (1980). existential psychotherapy. basic books. yontef, g., & jacobs, l. (2005). gestalt therapy. in r. j. corsini & d. wedding (eds.), current psychotherapies (pp. 342–382). brooks/cole-thompson learning. international journal of integrative psychotherapy, vol. 12, 2021 141 žvelc, g., & žvelc, m. (2021). integrative psychotherapy: a mindfulness and compassion-oriented approach. routledge. international journal of integrative psychotherapy, vol. 7, 2016 1 psychotherapy integration via theoretical unification warren w. tryon abstract: meaningful psychotherapy integration requires theoretical unification because psychotherapists can only be expected to treat patients with the same diagnoses similarly if they understand these disorders similarly and if they agree on the mechanisms by which effective treatments work. tryon (in press) has proposed a transtheoretic transdiagnostic psychotherapy based on an applied psychological science (aps) clinical orientation, founded on a biopsychology network explanatory system that provides sufficient theoretical unification to support meaningful psychotherapy integration. that proposal focused mainly on making a neuroscience argument. this article makes a different argument for theoretical unification and consequently psychotherapy integration. the strength of theories of psychotherapy, like all theory, is to focus on certain topics, goals, and methods. but this strength is also a weakness because it can blind one to alternative perspectives and thereby promote unnecessary competition among therapies. this article provides a broader perspective based on learning and memory that is consistent with the behavioral, cognitive, cognitive-behavioral, psychodynamic, pharmacologic, and existential/humanistic/experiential clinical orientations. it thereby provides a basis for meaningful psychotherapy integration. key words: clinical orientations; theoretical unification; psychotherapy integration ______________________ a major strength/benefit of basing one’s clinical practice on a particular psychological theory is that it focuses attention, investigation, and intervention onto specific topics, goals, and methods. this focus is also a major weakness because theory can blind one to alternative perspectives. for example, behavioral therapies such as applied behavior analysis focus on behavior change. cognitive and cognitive-behavioral therapies focus on symptom reduction/removal. psychodynamic therapies focus on narrative modification and insight via psychological mindedness. psychopharmacological therapies focus on symptom reduction/management via neuroscience rather than psychology. these highly focused therapeutic approaches mostly compete rather than cooperate with each other because there is no broader perspective from which international journal of integrative psychotherapy, vol. 7, 2016 2 they can be seen as special cases. in my view, the current horserace competition concerning which therapy is more effective is proxy for a battle among theories where the attempt to prove which theory is “right” is based on the false assumption that superior clinical success can prove which underlying theory is correct despite the possibility that one can be right for the wrong reasons. this competitive motivation promotes exclusivity and loyalty to a particular therapeutic approach. take for example, leahy’s (2009) “confessions of a cognitive therapist” where he admitted that in addition to being a cognitive therapist, he also sometimes uses behavioral and existential methods depending upon the presenting clinical issues. the term “confession” implies that previously hidden wrongdoing is now revealed and forgiveness is sought. psychologists have long desired psychotherapy integration but according to rychlak (1981a, 1993) have not been able to obtain it due to what appear to be irreconcilable theoretical differences. another major reason why substantive theoretical unification has eluded psychologists is that the claims made by various theorists are too numerous and conflicting to ever find a perspective from which all of them can be unified (rychlak, 1981a, 1993), even if they were all empirically supported, which they are not (tryon 2008). while it is desirable to find a unified position that retains all of the original features of all of the conflicting theories, including preserving the emphasis and priority associated with each of the concepts that characterize these conflicting theories, the degree of conflict involved has precluded achieving the required theoretical unification. the degree of conflict among theories of psychotherapy has also given rise to the view that psychotherapy integration based on theoretical unification is not possible (castonguay, 2011; goldfried, 1980). a fresh approach that entails thinking outside of the box is required. meaningful psychotherapy integration requires a theoretical orientation/perspective that is sufficiently general that it can span, incorporate, authorize, and justify behavior change, symptom reduction/removal, narrative modification, insight via psychological mindedness and be consistent with psychopharmacology. undoubtedly, every client can benefit from treatments directed at all of these goals/approaches to some degree. this article provides the required general theoretical perspective needed to support effective psychotherapy integration. all psychology, including the proposed theoretical perspective, is based on learning and memory (kalat, 2011). this broader theoretical foundation will enable clinicians to address the full scope of their client’s needs using diverse methods. stated otherwise, i am proposing psychotherapy integration at a conceptual rather than methodological level that authorizes clinicians to provide more comprehensive treatment. absent a unifying theory, some clinicians have favored an eclectic orientation where they attempt to borrow from and or switch among conflicting theoretical orientations. the lack of an integrative theory to support these efforts has led to criticism of this approach. hence, the term eclectic has fallen from international journal of integrative psychotherapy, vol. 7, 2016 3 favor. this article provides the required theoretical basis for the comprehensive treatment that these clinicians have sought. it complements and extends a related proposal made by tryon (in press). the remainder of this article is organized as follows. i distinguish clinical orientations from the underlying theories that authorize them and identify five of the most prominent clinical orientations. they are: 1) behavioral, 2) cognitive, 3) cognitive-behavioral, 4) psychodynamic, and 5) pharmacologic. i focus on the least by way of content that needs to be granted in order to achieve theoretical unification. i ask: what are the critical core concepts that define the conceptual kernel of each of the five identified clinical orientations. i distinguish key concepts from critical core concepts. key concepts are those that are commonly associated with a clinical orientation, can be derived from critical core concepts, but are not critical to the clinical orientation. i recognize that a unified clinical orientation may alter the original emphasis placed on critical core and key concepts. such conceptual modifications appear to be unavoidable. i focus on mechanisms because they are central to natural science explanations. otherwise, we are left with interpretations that may be based on data but are still just personal opinions. i recognize that there is no evidence that a purely psychological substrate exists for putative psychological mechanisms to operate on. i focus on what all five identified clinical orientations share in common and note that all of them are already theoretically unified in that they all lack mechanisms that can explain how and why their psychotherapies work. i address the missing links represented by the hyphens in the terms psychobiology and biopsychology and note that neural network models provide important missing mechanism information. i refer to and briefly summarize previously identified (tryon, in press; tryon, hoffman and mckay, 2016) neural network properties that have been formulated as psychological principles. these principles have already received extensive empirical support and are fully consistent with all five identified clinical orientations and with the existential/humanistic/experiential clinical orientations. they authorize operating at an emergent psychological rather than a reductionist biological level. collectively, this material provides a cognitive neuroscience foundation for all six clinical orientations that unifies them theoretically and supports meaningful psychotherapy integration. clinical orientations clinical orientations are the broad conceptual bases that every psychotherapist uses to guide and structure their assessment and therapy sessions. clinical orientations include the explanatory narratives that psychotherapists use to understand what troubles their patients and what can be done to help them. tryon (in press) mentioned that clinical orientations have at least the following important properties that collectively cause them to differ from the underlying theories that authorize them: breadth, selectivity, and flexibility. here i elaborate on these three properties. international journal of integrative psychotherapy, vol. 7, 2016 4 breadth clinical orientations are typically informed by the work of multiple theorists. often this means that several theorists within the same clinical tradition contribute to a psychotherapist’s clinical orientation. this is especially true of psychotherapists who claim to have an eclectic and/or integrative clinical orientation. the crucial points here are: a) multiple theorists contribute to every clinician’s clinical orientation to some degree, and b) clinical orientations are considerably broader than any of the specific theories that support them. selectivity clinical orientations are selective. for example, one does not have to accept every cognitive-behavioral claim in order to have a cognitive-behavioral clinical orientation. cognitive-behavioral psychotherapists hold diverse opinions regarding a broad spectrum of issues. similarly, one does not have to accept every psychodynamic claim in order to have a psychodynamic clinical orientation. psychodynamic psychotherapists also hold diverse opinions regarding a broad spectrum of issues. this diversity of clinical orientations is not new. psychotherapists have always selectively endorsed parts, features, and aspects of the theories that underlie their clinical orientation and rejected others (rychlak, 1981b). the selectivity of clinical orientations is diverse in that clinicians who claim the same clinical orientation often hold different subsets of positions taken by supporting theories. these subsets can differ remarkably even to the point where some psychotherapists may question the identity of others who claim to have the same clinical orientation. this diversity augments the breadth of the clinical orientations mentioned above. all of these selective subsets are sufficient to justify claiming to have a particular clinical orientation. this is because professional identification is a claim that individuals make for their own reasons. their professional identification is legitimized by the professional organizations that they join and the journals and books that they choose to read. while professional organizations certify competencies, i do not believe that they certify clinical orientations. flexibility clinical orientations are flexible in that they allow for developmental change over time within practitioners. it has been my clinical experience over the past 45 years, and the clinical experiences of many of my colleagues, that the selections that constitute the clinical orientation of a psychotherapist when they first begin to practice are not necessarily the same as the selections they will make when they become a seasoned professional. what is incorporated and what is left out of a clinical orientation may well change over time despite the fact international journal of integrative psychotherapy, vol. 7, 2016 5 that the clinician in question will claim to have the same clinical orientation. it has also been my clinical experience and that of my colleagues, that clinical orientations are dynamic rather than static and reflect professional growth and development over time. the big five clinical orientations tryon (2014, in press) identified the following “big five” clinical orientations on the basis that they share a natural science orientation: 1) behavioral clinical orientation as exemplified by applied behavior analysis (martin & pear, 2014); 2) cognitive clinical orientation as exemplified by leahy (2003); 3) cognitive-behavioral clinical orientation as exemplified by beck (2011); 4) psychodynamic clinical orientations – a) the narrative-based form exemplified by angus and greenberg (2011) and b) the emotion-focused form as exemplified by greenberg (2002); 5) pharmacologic clinical orientation as exemplified by katzung and trevor (2015). tryon (2014) did not directly address the existential/humanistic/experiential1 (ehe) clinical orientation because it understands psychology as a human science whereas the previously mentioned five clinical orientations entirely or substantially identify with natural science (rychlak, 1981a). the fundamental philosophical differences in values and methods between human and natural science have prevented finding any way to fully integrate them (rychlak, 1981a). that said, i offer a rapprochement as part of my discussion below concerning narrative-based therapies. tryon (2014, in press) provided a unifying applied psychological science (aps) clinical orientation. it is based on an integrative biopsychology network explanatory system that consists of a dozen properties of parallel-distributed processing connectionist neural network brain-like models (o’reilly & munakata, 2000) formulated as psychological principles (tryon, in press; tryon, hoffman and mckay, 2016). these principles explain a wide variety of psychological phenomena including learning and memory. all normal, abnormal, and therapeutic psychological phenomena involve learning and memory, which means that the aps clinical orientation is consistent with all clinical orientations. specifically, the aps clinical orientation is consistent with core and key concepts associated with the big five clinical orientations. i show below that it is also consistent with the existential/humanistic/experiential orientation. this article applies the aps clinical orientation to psychotherapy integration. critical core concepts of the big five clinical orientations the breadth, selectivity, and flexibility properties of clinical orientations described above makes them easier to unify than the underlying theories that authorize them but obstacles remain. these obstacles are minimized, by asking what is the least that must be granted and still have a particular clinical 1 identifying one approach as humanistic unfortunately pejoratively implies that at all other approaches are not humanistic. international journal of integrative psychotherapy, vol. 7, 2016 6 orientation. what are the critical core concepts that define the conceptual kernel of each of the five identified clinical orientations? a core concept is foundational when other concepts and constructs are based upon and can be derived from them. core concepts function like assumptions in that arguments and explanations begin with them. a core concept is critical to a clinical orientation when one cannot have that clinical orientation without accepting the concept in question. for example, one cannot have a psychodynamic clinical orientation without accepting unconscious processing. behavioral clinical orientation the behavioral clinical orientation presently comes primarily in two main forms. the applied behavior analysis (aba) form appears to be the most popular behavioral orientation that is currently practiced (martin & pear, 2014). it is based on the experimental analysis of behavior developed by skinner and his associates (e.g., martin & pear, 2014). the critical core concept of the aba form of behaviorism is the operant. the operant defines each behavior as a class of actions characterized by variation and whose components are subject to selection (reinforcement). for example, a rat can press a bar in a skinner box in many different ways involving various degrees of effort but all of these variations define the operant “bar press”. operants can be shaped by selectively reinforcing one or more of their components. for example, bar presses that requires more than a certain force can be shaped by programming the apparatus to provide access to food only if this force requirement is gradually satisfied. all other phenomena discovered through the experimental analysis of behavior, such as the matching law and schedules of reinforcement, derive from, can be explained by, the critical core concept of the operant; i.e., by variation and selection. one cannot have an aba clinical orientation without endorsing the critical core concept of the operant and its ontogenetic evolution via variation and selection. the applied psychological science clinical orientation is consistent with this behavioral clinical orientation because it is founded on neural network models that must be trained because they cannot be programmed. their functional characteristics, like those of operant conditioning, are heavily dependent upon their learning history. this property of the applied psychological science clinical orientation is fully consistent with the aba form of the behavioral clinical orientation. there are, and have been, other forms of the behavioral clinical orientation such as the orientation that wolpe (1958) used. his clinical method of systematic desensitization, and its contemporary variants known as exposure and response prevention, are based on the critical core concepts of learning via memory formation. all assessments and therapies that derive from the generic behavioral clinical orientation are grounded in learning and memory. one cannot international journal of integrative psychotherapy, vol. 7, 2016 7 have this form of the behavioral clinical orientation without an explanatory narrative that is based on learning and memory. the aps clinical orientation is consistent with this form of the behavioral orientation because it is based on natural science experience-dependent plasticity (bear, connors, & paradiso, 2007) mechanisms that explain learning as the result of memory formation (carlson, 2010). these mechanisms also explain why reinforcers strengthen behavior and how and why shaping via variation and selection works. the aps clinical orientation is therefore fully consistent with these alternative forms of the behavioral clinical orientation. cognitive clinical orientation the cognitive clinical orientation developed in reaction to the behavioral clinical orientation (dember, 1974; gardner, 1985; mahoney, 1974). it emerged as part of the general cognitive revolution within psychology that rebelled against what was perceived to be the black box of behaviorism where stimuli went in and responses came out without any explanation as to what happened inside the box which was metaphor for the brain. the cognitive clinical orientation is based on the single critical core concept that cognitions cause emotions and behaviors. hence, the entire focus of therapy is on correcting cognitions. leahy’s (2003) practitioner guide to cognitive therapy techniques is a good example of the cognitive clinical orientation. my colleagues, including a past president of the association for cognitive and behavioral therapies, and i realize that it is increasingly rare to find clinicians who practice exclusively from this clinical orientation given the rapprochement that has taken place between the cognitive and behavioral clinical orientations. the aps clinical orientation is cognitive because the neural network models upon which it is based transforms stimulus inputs in ways that extract latent constructs that function as schemas (rumelhart, smolensky, mcclelland, & hinton, 1986). further evidence that these models are cognitive is that they effectively simulate personality (read & miller, 2002; read et al., 2010). cognitive-behavioral clinical orientation the aps clinical orientation is consistent with the cognitive-behavioral clinical orientation because it is consistent with the critical core concepts that characterize both the cognitive and behavioral clinical orientations discussed above. the cognitive-behavioral clinical orientation is not an equal mix of the cognitive and behavioral clinical orientations. it began more behavioral (bandura, 1969) and became more cognitive (beck, 2011). psychodynamic clinical orientation international journal of integrative psychotherapy, vol. 7, 2016 8 unconscious processing is a critical core concept of the psychodynamic clinical orientation (summers & barber, 2010). one cannot have a psychodynamic clinical orientation without it. all of the other psychodynamic concepts such as ego defense mechanisms and transference are derived from, depend upon, and entail unconscious processing. the aps clinical orientation is consistent with the psychodynamic clinical orientation because it is firmly founded on unconscious processing. activations that flow through real and artificial neural networks do so unconsciously and automatically including when neural impulses propagate down axons and cross synapses. no greater emphasis can be placed on unconscious processing than is reflected in the aps clinical orientation. the developmental perspective and its emphasis on the effects of early experience and attachment on subsequent personality formation are additional critical core concepts of the psychodynamic clinical orientation2. one cannot have a psychodynamic clinical orientation without taking a developmental perspective that emphasizes the importance of early experience. the aps clinical orientation is consistent with the psychodynamic clinical orientation because the neural network models that form the basis of the aps clinical orientation are inherently and thoroughly developmental. this is because their “adult” properties result from an extensive developmental training process. neural network models must be trained because no one knows how to program them. it is now well documented that the functional “adult” properties of “mature” neural network models depend critically upon their training history (o’reilly, & munakata, 2000). no greater emphasis can be placed on development than is reflected in the neural network models that support the aps clinical orientation. the aps clinical orientation further emphasizes the effects of early experience by recognizing epigenetic effects that begin at birth. epigenetics refers to the attachment of methyl, acetyl, and other chemical tags to dna based on experience with the physical and social environment (zhang, & meaney, 2010). these chemical tags function as genetic switches. they activate or deactivate dna segments and thus turn genes on or off in response to environmental events. epigenetic effects constitute what tryon (2014) referred to as “a second experience-dependent plasticity mechanism” (p. 189). tryon (2014) reviewed epigenetic evidence that early maternal care in the form of licking and grooming rat pups epigenetically modifies the hypothalamic-pituitary-adrenal (hpa) axis that regulates the stress response (weaver, meaney, & szyf, 2006; zhang, & meaney, 2010). rat pups who receive attentive maternal care during infancy respond less to and recover more rapidly from stress than pups who do not receive such care. child abuse in humans appears to create adverse epigenetic effects (mcgowan et al., 2009). evidence indicates that compensatory mothering can reverse some harmful developmental experiences (kaufman, & weder, 2010). collectively, this epigenetic evidence, which is fundamental to the 2 the author wishes to thanks nate thoma for identifying these critical core concepts. international journal of integrative psychotherapy, vol. 7, 2016 9 aps clinical orientation, strongly supports the psychodynamic emphasis on caregiver attachment as an important early formative experience. this developmental emphasis makes the aps clinical orientation consistent with the psychodynamic clinical orientation. tryon’s (2014) discussion of subcortical emotions is another way that the aps clinical orientation is consistent with the psychodynamic clinical orientation. one of these subcortical neural networks generates lust. other subcortical neural networks generate care and play as well as rage, fear, panic, and grief. these emotions can seem to arise on their own. emotional regulation therefore becomes an important clinical objective of the aps clinical orientation. this emphasis on emotional regulation makes the aps clinical orientation consistent with the psychodynamic clinical orientation. pharmacologic clinical orientation chemical neurotransmission across synapses is a critical core concept of the pharmacological clinical orientation (katzung, & trevor, 2015). neurotransmitter modification is the mechanism by which psychoactive medications exert their effects (katzung, & trevor, 2015). one cannot have a pharmacologic clinical orientation without accepting and emphasizing the causative role that neurotransmitters play in modifying the properties of synapses that interconnect neurons. seung (2012) used the term connectome to refer to all of the synapses that interconnect all of the neurons in the brain. the neural network models upon which the aps clinical orientation is based simulate drug effects by modifying the properties of simulated synapses analogous to how psychotropic medications modify real synapses. the crucial role that simulated synapses play in the neural network models that support the aps clinical orientation makes the aps clinical orientation fully consistent with the pharmacologic clinical orientation. key concepts of the big five clinical orientations key concepts are those that are commonly characteristic of a clinical orientation. logic does not require that a unified clinical orientation include key concepts because they are not part of the conceptual kernel that defines each clinical orientation. however, incorporating key concepts makes a unified clinical orientation more complete, satisfactory, and generally acceptable. the following sections identify some of the key concepts of the big five clinical orientations that are included in, consistent with, the aps clinical orientation. behavioral clinical orientation tryon (1995) identified the following list of behavioral phenomena that constitute key concepts for the behavioral clinical orientation. neural network international journal of integrative psychotherapy, vol. 7, 2016 10 models that support the aps clinical orientation that simulate these behavioral phenomena have been available for more than two decades (tryon, 1995). ‘stimulus summation, blocking, unblocking, overshadowing, partial reinforcement effects, inter-stimulus interval effects, second order conditioning, conditioned inhibition, extinction, reacquisition effects, backward conditioning, compound conditioning, discriminative stimulus effects, inverted-u as a function of inter-stimulus interval, anticipatory conditioned responses, secondary reinforcement, attentional focusing by conditioned motivation feedback, super-conditioning, and learned helplessness’ (p. 302). this list could be expanded but the point should be secure by now that many key concepts associated with the behavioral clinical orientation are fully consistent with the aps clinical orientation. the ability of the aps clinical orientation to include so many key behavioral concepts shows that the aps clinical orientation is wholly consistent with the behavioral clinical orientation. cognitive clinical orientation the following key concepts that are associated with the cognitive clinical orientation are consistent with the aps clinical orientation. these major key concepts show that the aps clinical orientation is consistent with the cognitive clinical orientation. personality the concept of personality is a key concept of the cognitive clinical orientation (rychlak, 1981b). read and miller (2002) used neural network models upon which the aps clinical orientation is based to develop virtual personalities. read et al. (2010) improved these neural network virtual personality models by enabling them to learn from their environment. these models unify the nomothetic and ideographic approaches to personality (rychlak, 1981b). schemas the concept of schema is a key concept of the cognitive clinical orientation (young, klosko, & weishaar, 2006). rumelhart, smolensky, mcclelland, and hinton (1986) developed neural network models upon which the aps clinical orientation is based to better understand schemata and sequential thought processes. mcclelland (2013) advanced neocortical network models for learning new schema-consistent information. attitude formation and change cognitive psychologists who have specialized in social psychology have long been interested in attitude formation and change (kalat, 2011). international journal of integrative psychotherapy, vol. 7, 2016 11 monroe and read (2008) developed neural network models upon which the aps clinical orientation is based that inform our understanding of attitude formation and change. health decisions the cognitive clinical orientation includes the field of health psychology (suls, davidson, & kaplan, 2010). orr, thrush, and plaut (2013) developed a neural network model upon which the aps clinical orientation is based that understands reasoned action regarding health behavior as a parallel constraint satisfaction process. this neural network model of health decision-making is fully consistent with the cognitive clinical orientation. multicultural effects the cognitive clinical orientation is multicultural (hays, 1995). hong, morris, chiu, and benet-martinez (2000) have shown how a connectionist perspective upon which the aps clinical orientation is based can help us better understand how bicultural people are able to think in two ways. aging the cognitive clinical orientation includes gero-psychology and the process of aging (schaie & willis, 2011). li, lindenberger, and sikström (2001) presented a neural network model of aging upon which the aps clinical orientation is based that accurately predicted the behavior of young and old people by modifying a single parameter. cognitive-behavioral clinical orientation the key concepts of the cognitive-behavioral clinical orientations are those of the cognitive and behavioral clinical orientations, which we have seen are consistent with the aps clinical orientation. the “third wave” (ӧst, 2008)3 of the cognitive-behavioral clinical orientation added the additional key concept that one’s attitude toward and acceptance of their thoughts and emotions influences the degree of suffering that they experience (thoma, pilecki, & mckay, 2015). this attitude of accepting and nonjudgmental awareness of the present moment is also called mindfulness. this new cbt wave shares much in common with the existential/humanistic/experiential clinical orientation (hayes, strosahl, & wilson, 2011). a central therapeutic goal of this form of cbt is to shift the patient’s attitude towards acceptance and support of their thoughts and feelings. the monroe and read (2008) network model of attitude formation and change mentioned above is part of the aps clinical orientation and provides mechanism information that helps us to better understand how mindfulness therapies work. 3 the “first wave” focused on the behavioral clinical orientation. the “second wave” focused on the cognitive clinical orientation. international journal of integrative psychotherapy, vol. 7, 2016 12 the current cognitive-behavioral focus and emphasis on attitudes and acceptance is closely related to the psychodynamic clinical orientation discussed next. clinicians who explore patient attitudes soon realize that thoughts and feelings are rooted in the patient’s explanatory narrative. how one explains events in their life strongly influences their attitudes and consequently their behavior. the narrative-based therapies discussed next seek to change the ways that patients explain events in their lives (angus & greenberg, 2011). these alternative explanations can be based on any psychological theory or philosophical system including any one of the big five clinical orientations and the aps clinical orientation because it is consistent with all of them. psychodynamic clinical orientation this section considers three key concepts that are associated with the psychodynamic clinical orientation that are consistent with the aps clinical orientation. narrative-based interventions a key psychodynamic concept is that people develop and use explanatory narratives to understand their social and physical worlds (angus & greenberg, 2011). psychodynamic therapy frequently focuses on these explanatory narratives with the aim of modifying them so that they become easier to live with. this form of the psychodynamic clinical orientation is exemplified by the work of angus and greenberg (2011). the aps clinical orientation embraces the concept of narrative therapy because the learning and memory mechanisms upon which it is based provide clinicians with alternative explanations that can be used to reframe explanations that client’s present. tryon (in press) provided supporting clinical examples. i stated above that the existential/humanistic/experiential (ehe) clinical orientation was not formally included in tryon’s (2014) effort to achieve the theoretical unification required for meaningful psychotherapy integration because it understands psychology as a human rather than as a natural science. however, a rapprochement of sorts is available through narrative-based therapies that are central to the ehe clinical orientation. this rapprochement is founded on the fact that all theories explain and therefore all theories can be used to understand, support, and/or modify the explanatory narratives that people bring to psychotherapy (rychlak, 1981a). cognitive-behavior therapy routinely uses psychoeducation to modify the explanatory narratives that patients bring to therapy. behavioral and/or pharmacological explanations can also be used to modify explanatory narratives. this means that the big five, ehe, and the aps clinical orientations are all theoretically integrated because they all encourage understanding, supporting, and modifying explanatory narratives (angus & greenberg, 2011). the ehe and aps clinical international journal of integrative psychotherapy, vol. 7, 2016 13 orientations are also unified in that the aps clinical orientation includes learning and memory mechanisms by which ehe treatments work even though the aps clinical orientation does not share the philosophy upon which the ehe is based. therapies do not have to work for the reasons that their authors specified. one can be right for the wrong/different reasons (tryon, 2014). emotion-focused interventions emotion regulation is a key psychodynamic concept (maroda, 2012). blatt and bers (1993), two psychodynamic clinicians, objected to what they saw as a heavy if not exclusive cbt emphasis on cognition. they objected to the cbt view that emotions are singularly and wholly caused by cognitions. the emotion-focused form of the psychodynamic clinical orientation is concerned with affect and its regulation. this form of the psychodynamic clinical orientation is exemplified by the work of greenberg (2002). chapter 5 of tryon (2014) concerns emotion and its unconscious subcortical origins (panksepp, 1998, 2008). understanding that emotions arise unconsciously from subcortical brain centers means that the aps clinical orientation recognizes the importance of emotional regulation (panksepp, 1998, 2008). transference transference is a key psychodynamic concept (gerber, & peterson, 2006). wachtel (1980) quoted freud, who described transference as a “false connection” (p. 59) made by a patient between his or her therapist and a figure from the past. stated otherwise, transference occurs when the patient responds to the therapist as if the therapist was some emotionally significant person in their past. the traditional emphasis is on how irrational, inappropriate, and undeserved such attributions are. wachtel (1980) noted that some aspects of the therapist and/or their behavior are almost certainly involved in eliciting transference. nevertheless, the primary psychodynamic feature of transference is that the patient treats the therapist as if he or she were someone else. there are at least two reasons why transference is consistent with the aps clinical orientation (tryon, in press). the first reason is that transference is largely an unconscious process (gerber, & peterson, 2006). we have already established that unconscious processing is fully consistent with the aps clinical orientation because of its basis in neural network models and the fact that activations propagate unconsciously from one neuron to another. hence, transference is consistent with the aps clinical orientation. the second reason why transference is consistent with the aps clinical orientation is that transference can be understood in piagetian terms of assimilation and accommodation; both of which are consistent with the aps clinical orientation as explained in the following two subsections. international journal of integrative psychotherapy, vol. 7, 2016 14 assimilation and accommodation wachtel (1980) clarified the relevance of piaget’s explanation of cognitive schemas to the psychodynamic concept of transference as follows. piaget (1983) explained that equilibration generates schemas and other cognitive structures. equilibration entails two interdependent biologically general processes: assimilation and accommodation. assimilation is the process by which people understand and respond to the world in terms of their schemas. people are said to assimilate experience to existing schemas. our schemata are not continuously active but are activated by relevant circumstances. on the other hand, psychological growth requires that we learn from experience. learning requires that schemas change to accommodate new information and experiences. equilibration refers to the process whereby people oscillate between assimilation and accommodation. equilibration is said to drive cognitive development. wachtel (1980) observed that transference can be understood as a condition where assimilation greatly predominates over accommodation. the patient’s cognitive schemas are dominated and activated by an emotional memory of a significant person in the patient’s past. these schemata guide how the patient relates to other people including their therapist. the patient’s inappropriate, irrational, and undeserved response to the therapist is how they responded to this person in the past. however, given that the patient is not completely psychotic, some degree of reality contact, accommodation, remains with which the therapist can work. neural networks assimilate and accommodate neural network models are used to explain learning and memory within the aps clinical orientation. the ability of neural networks to explain assimilation and accommodation enables them, as explained above, to account for transference and that makes the aps clinical orientation consistent with the psychodynamic clinical orientation. bechtel and abrahamsen (1991) equated the process of assimilation with the network's tendency to "settle into the most appropriate of its stable (attractor) states when input is presented to it" (p. 271). without any change to the networks “connectome” (seung, 2012) structure, repeated stimulus presentations will be responded to in exactly the same way. such behavior represents an extreme form of transference. pure assimilation cannot exist anymore than a coin can have but one side. accommodation is the other side of our coin. "assimilation and accommodation are the two poles of the same activity of adaptation that characterizes any biological organism" (piaget 1927/1995, p. 216). accommodation occurs because real neural networks are changed by the processing that they do because processing activates experience-dependent neuroplasticity mechanisms that modify the functional properties of synapses and that changes how international journal of integrative psychotherapy, vol. 7, 2016 15 they process subsequent activations (bear, connors, & paradiso, 2007). it is through such changes that new memories are formed, learning occurs, and transference can be treated. individual differences in the rate and extent to which these experience-dependent changes occur are to be expected. the ability of neural networks upon which the aps clinical orientation is based to assimilate and accommodate in combination with a way to understand transference in terms of assimilation and accommodation make the aps clinical orientation consistent with the psychodynamic clinical orientation. prototypes prototype formation is another key psychodynamic concept (schwartz, bleiberg, & weissman, 1995). the psychodynamic clinical orientation has long been concerned with prototypes such as “mother”, “father”, and “authority figures”. knapp and anderson (1984) discussed a parallel-distributed processing model of category learning that forms prototypes from repeated exposure to stimuli. anderson and murphy (1986) presented a mathematical explanation of neural network prototype formation. an essential part of their proof is that the hebb rule (mcleod, plunkett, & rolls, 1998), which is used to modify connection weights to simulate experience-dependent synaptic plasticity mechanisms, is mathematically equivalent to: a) an average composite of common stimulus components and b) unique deviation features from this average. the common components reinforce one another and form the prototype while the unique deviations tend to cancel each other out (mcleod, plunkett, & rolls, 1998). it is more nearly correct to view the prototype as a running average over time. for example, each dog we see has four legs, a head with two eyes, two ears, a nose, a torso, and a tail. these common features reinforce our dog prototype. the different lengths of the dog’s legs and ears, their varying eye color, etc. are unique features that tend to cancel each other out and therefore do not contribute to our dog prototype beyond their average properties. neural network models are typically trained on variants of a prototype; the exact form of the prototype is never presented during training. for example, if the prototype is an equilateral triangle, the variants will be slightly different shaped triangles. if the model is presented with the exact prototype stimulus after training has finished, it will respond more strongly to this never before seen stimulus than to any of the previously seen training stimuli. it is remarkable that a never before seen stimulus can produce a greater response than any of the stimuli previously seen during training. it is important to note that neural networks automatically and intrinsically form prototypes; no additional properties are required to explain prototype extraction. prototype extraction facilitates generalization in that commonalties between the prototype and the novel stimulus provide a basis for a generalized response. neural network models assimilate novel stimuli to the prototype in this international journal of integrative psychotherapy, vol. 7, 2016 16 way. these several ways in which the aps clinical orientation accounts for prototypes makes the aps clinical orientation consistent with the psychodynamic clinical orientation. ego defense mechanisms ego defense mechanisms are key psychodynamic concepts (summers, & barber, 2010). all ego defense mechanisms entail unconscious processing. the aps clinical orientation has a strong unconscious-centric orientation. therefore, the aps clinical orientation is consistent with ego defense mechanisms and the psychodynamic clinical orientation. other features olds (1994) noted that the neural network models upon which the aps clinical orientation is based provide the psychodynamic clinical orientation with a neuroscience-based brain model that is both more current and relevant than the outdated steam and hydraulic models that freud used (rychlak, 1981b). this change also makes the aps clinical orientation consistent with the psychodynamic clinical orientation. pharmacologic clinical orientation i mentioned above that pharmacologic clinical orientation is based on the fact that psychotropic medications modify the functional properties of the synapses that connect one neuron with another (katzung & trevor, 2015). i mentioned above that the aps clinical orientation is consistent with the pharmacologic clinical orientation because its neural network models simulate the synaptic changes that psychotropic medications produce. brain damage is another way that the brain is physically changed that can alter cognition, affect, and/or behavior. the neural network models upon which the aps clinical orientation is based are especially able to simulate brain damage because they specify a neural network wiring diagram that can be selectively damaged. hinton, plaut, and shallice (1993) simulated the effects of brain damage on reading. they first developed a neural network model that could read english sentences. then they “lesioned” the simulated neural network by removing some of the simulated synapses. the result was that symptoms of surface or deep dyslexia emerged depending upon where in the model “lesions” occurred. this ability of a neural network model upon which the aps clinical orientation is based to simulate the effects of synaptic modification/damage makes the aps clinical orientation consistent with the pharmacologic clinical orientation. unification alters emphasis ideally, successful theoretical unification would preserve the explanatory emphasis of all critical core and key concepts associated with the theories being international journal of integrative psychotherapy, vol. 7, 2016 17 unified. for example, ego defense mechanisms might be accorded the same central explanatory status in a unified theory that they have been given in psychodynamic theories. this need not be the case because synthesis is more about inclusion than it is about preservation of emphasis. inclusion with altered emphasis is still synthesis. requiring preservation of emphasis adds an additional constraint that although desirable greatly complicates synthesis and substantially reduces the likelihood of success. i therefore chose to relax this requirement. natural science mechanisms explain tryon (2014) reported that “the second definition returned by the google command “define:mechanism” reflects the natural science orientation: “a natural or established process by which something takes place or is brought about” (p. 25, bold emphasis in the original). tryon (in press) focused on natural science mechanisms because they allow for scientific explanations (pennington, 2014) rather than personal interpretations (teo, 2012). pennington (2014) asked and answered the question of what is required to provide a natural science explanation as follows: “what does it mean to explain something? basically, it means that we identify the cause of that thing in terms of relevant mechanisms” (p. 3). my out of the box approach led me to realize that the absence of explanatory mechanisms unified the big five plus the existential/humanistic/experiential clinical orientations. this focus on a common attribute that was absent from existing clinical orientations contrasts sharply with the traditional focus on common attributes that are present across clinical orientations. it then occurred to me that providing explanatory mechanisms regarding learning and memory that are consistent with all identified clinical orientations would theoretically unify them in a way that would support meaningful psychotherapy integration. neuroscience mechanisms psychologists appear to have a lot of mechanism information. a psycinfo search for “psychological mechanism” in the first search box without quotes on 01/12/16 returned 2,587 references. strictly speaking, genuine psychological mechanisms require a psychological substrate to operate on just as neuroscience mechanisms require a biological substrate to operate on. unfortunately, there is no evidence that a psychological substrate exists. hence, there cannot actually be any purely psychological mechanisms. only a biological substrate exists. psychological phenomena must therefore be mediated by neuroscience mechanisms. for example, it is now well known that learning and memory are mediated by experience-dependent synaptic plasticity, glial, and epigenetic mechanisms (tryon 2014; bear, connors, & paradiso, 2007). international journal of integrative psychotherapy, vol. 7, 2016 18 i am not making a reductionist claim here. the concept of emergence is crucial. the explanatory system upon which the aps clinical orientation rests is not reductionist; on the contrary, it is emergent4. the aps clinical orientation maintains that all psychological phenomena are emergent properties of active complex neural networks (tryon, 2014). unlike computers that remain unchanged by the processing they do, real neural networks are changed by the processing that they do. synaptic properties change with every processing cycle in complex ways that can only be studied via simulation at this time. these physical changes mediate psychological changes. the missing explanatory link the term psychobiology generally refers to the influence of psychology on biology whereas the term biopsychology generally refers to the effects of biology on psychology. the hyphens in these terms symbolize explanatory gaps concerning how biology and psychology are connected and interact. this knowledge gap has hampered theory construction in psychology ever since its official beginning in 1879 (brennan, 2013). the neural network models and principles that comprise the aps clinical orientation help to fill these knowledge gaps and thereby promote theoretical unification across clinical orientations. this information is foundational for the following sections in which i express neural network properties as psychological principles. how psychology emerges from biology descartes’s unfortunate distinction between mind and brain created an apparent problem of how the mind and brain interact (damasio, 1994). neural network simulations solve this problem by: a) not distinguishing mind from brain in which case the mind-body problem does not exist, and b) doing psychology with brain-like neural network models. learning and memory are the basis of all psychological phenomena (kalat, 2011). if infants could not form memories they would not learn and develop psychologically. neural network models show that learning and memory can be effectively simulated by modifying the connections, simulated synapses, among layers of simple neuron-like processing nodes. these connectionist neuropsychological models simulate5 the functional effects of experience-dependent plasticity mechanisms that modify the synapses in biological neural networks thereby enabling them to form memories and learn (o’reilly, & munakata, 2000). 4 appropr iatel y, the free neur al netwo rk sim ulation software is called em ergent https://gre y.colorado.edu/em ergent/index.php/com par ison_of_n eural_n etwork _sim ulators 5 simulations are not exact reproductions. software simulations use mathematics to reflect functional properties. hardware simulations use transistors to simulate neurons. https://grey.colorado.edu/emergent/index.php/comparison_of_neural_network_simulators https://grey.colorado.edu/emergent/index.php/comparison_of_neural_network_simulators international journal of integrative psychotherapy, vol. 7, 2016 19 how biology alters psychology how do psychoactive medications alter our psychology; the ways that we think, feel and act? neural network models provide an overarching framework for understanding how and why this happens. we know that psychoactive medications alter synaptic function (katzung, & trevor, 2015). we also know that psychoactive medications alter psychology. but what is the causal connection between synapses and psychology? the short answer to this question is that neural network models bridge this knowledge gap by showing how the modification of connections, simulated synapses, among layers of simple neuronlike processing nodes results in memories, learning, and the latent constructs that constitute psychology (o’reilly, & munakata, 2000). our memories of family, friends, and life experiences define who we are. the ravages of alzheimer’s disease and other dementias that rob us of our memories prove that much of our personality is memory based. these memories reside in our neural networks. neural network models of memory and learning therefore enable us to understand how changes to these neural networks alters psychology. network properties and psychological principles: the ability of neural network models to bridge the explanatory gaps identified by the hyphens in the terms psychobiology and biopsychology warrant describing neural network properties as psychological principles. tryon (2012) introduced and tryon (2014) elaborated these neural network properties as core and corollary psychological principles. tryon (2014; in press) derived cognitive principles from fundamental neural network properties that enable effective simulation of psychological phenomena. i briefly review them below. these principles permit psychologists to operate at an emergent psychological level rather than at a reductionist biological level while preserving an explanatory path to hard neuroscience. these psychological principles also enable narrative modification therapy because they provide an alternative way to explain psychology and behavior. they explain why empirically supported treatments derived from all of the big five and the existential/humanistic/experiential clinical orientations work. they enable clinicians to customize therapy to their patient’s needs and characteristics. they provide a conceptual basis for a comprehensive clinical practice that is grounded in cognitive neuroscience. neural architecture property/principle: psychological phenomena emerge as network activations cascade across a suitably complex neural architecture (tryon, 2014, in press). this mechanism is fundamental to all other mechanisms listed below. constraint satisfaction property/principle: excitatory and inhibitory network activations jointly constrain each other. health decisions can be understood as a constraint satisfaction process (orr, thrush, & plaut, 2013). thagard (1989, international journal of integrative psychotherapy, vol. 7, 2016 20 2000, 2006) applied this constraint satisfaction principle to law, medicine, ethics, psychology, and everyday life. memory and learning property/principle: psychotherapies differ mainly with regard with what needs to be learned and how best to teach it (tryon, 2014, in press). the ability of neural network models to simulate and thereby explain learning and memory enable them to explain how and why all psychotherapies work. memory superposition property/principle: all visual aspects of every memory are superimposed within the visual cortex. all auditory aspects of every memory are superimposed within the auditory cortex. memory superposition can readily explain many memory errors (tryon, 2014; in press). priming property/principle: the processing pathways taken through neural networks automatically activate experience-dependent neuroplasticity mechanisms that strengthen these pathways thereby making them more probable processing routes in future (tryon, 2014; in press). transformation property/principle: network activations are necessarily transformed as they traverse synaptic connections. mcclelland (2013) and rogers and mcclelland (2014) provide details regarding how the brain extracts latent psychological constructs. part-whole pattern completion property/principle: neural networks can create a more complete image or thought through auto-association. this process explains how we form both perceptual and cognitive gestalts (tryon, 2014; in press). dissonance/consonance property/principle: it has long been known that people seek consonance (heider, 1958) and avoid dissonance (festinger, 1957). kunda (1990) documented that people reach the conclusions that they want to reach; i.e., conclusions that are consonant with their emotions. neural networks effectively simulate and thereby provide mechanism information regarding this psychological process. prototype formation property/principle: the transformation property mentioned above enables neural networks to automatically form prototypes. they do so by extracting and averaging common features (tryon, 2014; in press). graceful degradation property/principle: that processing and storage are distributed across neural networks makes them both resilient to damage/insult and responsive to rehabilitation through activating alternative pathways (tryon, 2014; in press). international journal of integrative psychotherapy, vol. 7, 2016 21 conclusions meaningful psychotherapy integration requires substantial theoretical unification because therapists will only treat people with the same diagnoses similarly when they share a common understanding of what is wrong and what needs to be done. can we agree that an explanatory system that incorporates all of the critical core concepts and some of the key concepts of the major clinical orientations constitutes meaningful theoretical unification? if so, then the evidence and argument presented here and elsewhere (tryon, 2012, 2014; in press; tryon, hoffman and mckay, 2016) supports the conclusion that the proposed aps clinical orientation has achieved meaningful theoretical unification. the claim of psychotherapy integration follows directly from the achieved theoretical unification because that common understanding authorizes treating the full range of patients presently treated by all of the big five and now the existential/humanistic/experiential clinical orientation as well. the main impact of the proposed theoretical unification on psychotherapy integration will occur in the following three ways. first, clinical interventions will be based on the psychological principles presented above and elsewhere by tryon (in press) and tryon, hoffman and mckay (2016) instead of on manuals. they will enable treatments to be customized to client needs. they will also facilitate doctoral and post-doctoral training because there are far fewer principles than there are published manuals. second, clinical practice will become more comprehensive. clinicians will broaden the goals and objectives that they establish with their clients. these therapeutic goals will now include increasing psychological mindedness, augmenting emotional regulation, and modifying personal narratives in addition to symptom reduction/removal. the best methods of reaching these goals and objectives will be used because clinicians will accept all empirically supported treatments regardless of the clinical orientation from which they were developed because the aps clinical orientation supports all of these goals and objectives. clinicians are now free to use methods developed from alternative clinical orientations without endorsing any of those clinical orientations because they now have a transtheoretic transdiagnostic clinical perspective to operate from. clinicians will use more than one treatment as necessary. clinicians who previously identified as eclectic will now have a coherent theoretical basis for their practice. third, applied behavior analytic interventions are now justified as cognitive methods because conditioning is cognitive (tryon, 2014). hence, behavioral methods of diagnosis and assessment are also now justified for general clinical use. international journal of integrative psychotherapy, vol. 7, 2016 22 author: warren w. tryon received his ph.d. in clinical psychology from kent state university (ohio, us) in1970. he joined the clinical faculty of fordham university (new york – us) in 1970, where he served first as an associate, assistant and eventually full professor. he was appointed professor emeritus in 2015. dr. tryon is licensed by new york state and is listed in the national register of health service providers in psychology, is a diplomat in clinical psychology with the american board of professional psychology, and a fellow of division 12 (clinical) of the american psychological association. references anderson, j. a., & murphy, g. l. (1986). psychological concepts in a parallel system. physica, 22d, 318-336. doi: 10.1016/0167-2789(86)90302-2 angus, l. e., & greenberg, l. s. (2011). working with narrative in emotionfocused therapy: changing stories, healing lives. washington, d. c.: american psychological association. bandura, a. (1969). principles of behavior modification. new york: holt, rinehart, & winston. bear, m. f., connors, b. w., & paradiso, m. a. (2007). neuroscience: exploring the brain (3rd ed.). baltimore, md: lippincott, williams & wilkins. bechtel, w. & abrahamsen, a. (1991). connectionism and the mind: an introduction to the parallel processing in networks. cambridge, ma: blackwell. beck, j. s. (2011). cognitive behavior therapy: basics and beyond (2nd ed.). ny: guilford. blatt, s. j., & bers, s. a. (1993). commentary on "a cognitive perspective on self-representation in depression". in z. v. segal, & s. j. blatt, (eds.), the self in emotional distress: cognitive and psychodynamic perspectives (pp. 131-170). ny: guilford press. brennan, j. (2013). history and systems of psychology (6th ed.). new york: pearson. carlson, n. r. (2010). physiology of behavior (10th edition). boston: allyn & bacon. castonguay, l. g. (2011). psychotherapy, psychopathology, research and practice: pathways of connections and integration. psychotherapy research, 21 (2), 125-140. doi 10.1080/10503307.2011.563250 castonguay, l. g., & beutler, l. e. (eds.). (2006). principles of therapeutic change that work. new york: oxford university press. damasio, a. (1994). descartes’ error: emotion, reason, and the human brain. new york: harpercollins. dember, w. n. (1974). motivation and the cognitive revolution. american http://dx.doi.org/10.1016/0167-2789(86)90302-2 international journal of integrative psychotherapy, vol. 7, 2016 23 psychologist, 29, 161-168. festinger, l. (1957). a theory of cognitive dissonance. stanford, ca: stanford university press. gardner, h. (1985). the mind's new science. ny: basic books. goldfried, m. r. (1980). toward the delineation of therapeutic change principles. american psychologist, 35, 991-999. doi 10.1016/j.appsy.2009.10.015 greenberg, l. s. (2002). emotion-focused therapy: coaching clients to work through their feelings. washington, dc: american psychological association. hayes, s. c., strosahl, k. d., & wilson, k. g. (2011). acceptance and commitment therapy: the process and practice of mindful change (2nd ed.). new york: guilford. hays, p. a. (1995). multicultural applications of cognitive-behavior therapy. professional psychology: research and practice, 26, 309-315. heider, f. (1958). the psychology of interpersonal relations. ny: wiley. hinton, g. e., plaut, d. c., & shallice, t. (1993). simulating brain damage. scientific american, 269, 76-82. hong, y. –y., morris, m. w., chiu, c. –y., & benet-martinez, v. (2000). multicultural minds: a dynamic constructivist approach to culture and cognition. american psychologist, 55, 709-720. doi: 10.1037//0003066x.55.7.709 kalat, j. w. (2011). introduction to psychology (9th edition). belmont, ca: wadsworth. katzung, b., & trevor, a. (2015). basic and clinical pharmacology (13th ed.). ny: guilford. kaufman, j., & weder, n. (2010). neurobiology of early life stress: evolving concepts. in a. martin, l. s. scahill, c. kratochvil (eds.). pediatric psychopharmacology: principles and practice (2nd ed. pp: 112-123). new york: oxford university press. knapp, a. g., & anderson, j. a. (1984). theory of categorization based on distributed memory storage. journal of experimental psychology: learning, memory, and cognition, 10, 616-637. doi: 10.1037/02787393.10.4.616 kunda, z. (1990). the case for motivated reasoning. psychological bulletin, 108, 480-498. doi 10.1037/0033-2909.108.3.480 laplanche, j. & pontalis, j. b. (1973). the language of psycho-analysis. nicholson-smith, d., translator. ny: norton. (original work published in 1967) leahy, r. l. (2003). cognitive therapy techniques: a practitioner’s guide. ny: guilford. leahy, r. l. (2009). the confessions of a cognitive therapist. the behavior therapist, 32, 1, 3. li, s.-c, lindenberger, u., & sikström, s. (2001). aging cognition: from neuromodulation to representation. trends in cognitive science, 5, 479486. doi: 10.1016/s1364-6613(00)01769-1 http://dx.doi.org/10.1016/j.appsy.2009.10.015 http://psycnet.apa.org/doi/10.1037/0278-7393.10.4.616 http://psycnet.apa.org/doi/10.1037/0278-7393.10.4.616 international journal of integrative psychotherapy, vol. 7, 2016 24 mahoney, m. j. (1974). cognition and behavior modification. cambridge, ma: ballinger publishing co. maroda, k. j. (2012). psychodynamic techniques: working with emotion in the therapeutic relationship. new york: guilford. martin, g. l., & pear, j. (2014). behavior modification: what it is and how to do it (10th ed.). upper saddle river, new jersey. mcclelland, j. l. (2013). incorporating rapid neocortical learning of new schemaconsistent information into complementary learning systems theory. journal of experimental psychology: general, 142(4), 1190-1210. doi: 10.1037/a0033812 mcgowan, p. o., sasaki, a., d’alessio, a. c., dymov, s., labonte, b., szyf, m., turecki, g., & meaney, m. j. (2009). epigenetic regulation of the glucocorticoid receptor in human brain associates with childhood abuse. national neuroscience, 12, 342-348. doi: 10.1038/nn.2270. mcleod, p., plunkett, k., & rolls, e. t. (1998). introduction to connectionist modelling of cognitive processes. oxford: oxford university press. monroe, b. m. & read, s. j. (2008). a general connectionist model of attitude structure and change: the acs (attitudes as constraint satisfaction) model. psychological review, 115, 733-759. doi: 10.1037/0033295x.115.3.733. olds, d. d. (1994). connectionism and psychoanalysis. journal of the american psychoanalytic association, 42, 581-611. doi: 10.1177/000306519404200211 o’reilly, r. c., & munakata, y. (2000). computational explorations in cognitive neuroscience: understanding the mind by simulating the brain. cambridge, ma: the mit press. orr, m. g., thrush, r., & plaut, d. c. (2013). the theory of reasoned action as parallel constraint satisfaction: towards a dynamic computational model of health behavior. plos one 8(5): e62490. doi:10.1371/journal.pone.0062490 ӧst, l. g. (2008). efficacy of third wave behavior therapies: a systematic review and meta analysis. behaviour research and therapy, 46, 296-321. panksepp. j. (1998). affective neuroscience: the foundations of human and animal emotions. new york: oxford university press. panksepp, j. (2008). the affective brain and core consciousness: how does neural activity generate emotional feelings? in m. lewis, j. m. havilandjones, & l. f. barrett (eds.). handbook of emotions (3rd ed.) (pp. 47-67). new york: guilford. pennington, b. f. (2014). explaining abnormal behavior: a cognitive neuroscience perspective. ny: guilford. piaget, j. (1983). piaget's theory. in p. h. mussen (ed.), handbook of child psychology, vol. 1.: history, theory, and methods (4th ed., pp. 103-128). ny: wiley. piaget, j. (1995). the first year of life of the child. in h. e. gruber and j. j. voneche (eds). the essential piaget: an interpretive reference and guide international journal of integrative psychotherapy, vol. 7, 2016 25 (pp. 198-214). northvale, nj: aronson. (original work published in 1927 and reprinted from the british journal of psychology, 1927-28, 18, 97-120. read, s. j., & miller, l. c. (2002). virtual personalities: a neural network model of personality. personality and social psychology review, 6, 357-369. doi: 10.1207/s15327957pspr0604_10 read, s. j., monroe, b. m., brownstein, a. l., yang, y., chopra, g., & miller, l. c. (2010). a neural network model of the structure and dynamics of human personality. psychological review, 117, 61-92. doi: 10.1037/a0018131 rogers, t. t. & mcclelland, j. l. (2014). parallel distributed processing at 25: further explorations in the microstructure of cognition. cognitive science, 6, pp. 1024-1077. doi: 10.1111/cogs.12148 rumelhart, d. e., smolensky, p., mcclelland, j. l. & hinton, g. e. (1986). schemata and sequential thought processes in pdp models. in j. l. mcclelland, d. e. rumelhart & the pdp research group. parallel distributed processing: explorations in the microstructure of cognition (vol. 2, pp. 7-57). cambridge, ma: mit press. rychlak, j. f. (1981a). a philosophy of science for personality theory (2nd ed.). malabar, fl, robert e. krieger. rychlak, j. f. (1981b). introduction to personality and psychotherapy: a theoryconstruction approach. boston: houghton mifflin co. rychlak, j. f. (1993). a suggested principle of complementarity for psychology: in theory, not method. american psychologist, 48, 933-942. schaie, k. w., & willis, s. l. (eds.) (2011). handbook of the psychology of aging (7th ed.). new york: academic press. schwartz, h. j., bleiberg, e., & weissman, s. h. (ed.) (1995). psychodynamic concepts in general psychiatry. washington, d. c.: american psychiatric press, inc. seung, s. (2012). connectome: how the brain’s wiring makes us who we are. boston: houghton mifflin harcourt. suls, j. m., davidson, k. w., & kaplan, r. m. (eds.) (2010). handbook of health psychology and behavioral medicine. new york: guilford. summers, r. f., & barber, j. p. (2010). psychodynamic therapy: a guide to evidence-based practice. new york: guilford. teo, t. (2012). psychology is still a problematic science and the public knows it. american psychologist, 67 (9), 807-808. doi 10.1037/a0030084 thagard, p. (1989). explanatory coherence. behavioral and brain sciences, 12, 435-502. doi 10.1017/s0140525x00057046 thagard, p. (2000). coherence in thought and action. cambridge, ma: mit press. thagard, p. (2006). evaluating explanations in law, science, and everyday life. current directions in psychological science, 15, 141-145. doi 10.1111/j.0963-7214.2006.00424.x thoma, n., pilecki, b., & mckay, d. (2015). contemporary cognitive behavior therapy: a review of theory, history, and evidence. psychodynamic psychiatry, 43, 423-462. doi: 10.1521/pdps.2015.43.3.423 http://psycnet.apa.org/doi/10.1207/s15327957pspr0604_10 http://philpapers.org/go.pl?id=thaecp&proxyid=&u=http%3a%2f%2fdx.doi.org%2f10.1017%2fs0140525x00057046 international journal of integrative psychotherapy, vol. 7, 2016 26 tryon, w. w. (1995). neural networks for behavior therapists: what they are and why they are important. behavior therapy, 26, 295-318. doi 10.1016/s0005-7894(05)80107-8 tryon, w. w. (2008). whatever happened to symptom substitution? clinical psychology review, 28, 963-968. doi 10.1016/j.cpr.2008.02.003 tryon, w. w. (2012). a connectionist network approach to psychological science: core and corollary principles. review of general psychology, 16, 305-317. doi: 10.1037/a0027135 tryon, w. w. (2014). cognitive neuroscience and psychotherapy: network principles for a unified theory. ny: elsevier/academic press. tryon, w. w. (2016). transtheoretic transdiagnostic psychotherapy. journal of psychotherapy integration, 26, 273-287. doi 10.1037/a0040041 tryon, w. w., hoffman, j., & mckay, d. (in press). neural networks as explanatory frameworks of psychopathology and its treatment. in d. mckay, j. s. abramowitz, & e. storch (eds.), mechanisms of syndromes and treatment for psychological problems. chichester, uk: wiley. wachtel, p. (1980). transference, schema, and assimilation: the relevance of piaget to the psychoanalytic theory of transference. the annual of psychoanalysis, 8, 59-76. weaver, i. c. g., meaney, m. j., & szyf, m (2006). maternal care effects on the hippocampal transcriptome and anxiety-mediated behaviors in the offspring that are reversible in adulthood. proceedings of the national academy of sciences, 103 (9), 3480-3485. doi 10.1073pnas.0507526103 wolpe, j. (1958). psychotherapy by reciprocal inhibition. stanford, ca: stanford university press. young, j. e., klosko, j. s., & weishaar, m. e. (2006). schema therapy: a practitioner’s guide. new york: guilford. zhang, t-y., & meaney, m. j. (2010). epigenetics and the environmental regulation of the genome and its function. annual review of psychology, 61, 439-466. doi 10.1146/annurev.psych.60.110707.163625 date of publication: 12.1.2017 http://dx.doi.org/10.1016/j.cpr.2008.02.003 alcoholism is such a common condition that therapists must be exposed to clients who suffer from it, whether the therapist is mindful processing in psychotherapy – facilitating natural healing process within attuned therapeutic relationship gregor žvelc abstract: mindfulness is non-judgmental, accepting awareness of what is going on in the present moment. the author proposes that mindfulness promotes natural healing of the organism, where the change comes spontaneously by acceptance and awareness of internal experience. such process the author describes as ‘mindful processing’, because with mindful awareness disturbing experiences can be processed and integrated. the author’s interest in how mindfulness can be systematically applied in psychotherapy led to the development of the ‘mindful processing’ method, which invites the client to become aware of the moment-tomoment subjective experience. the method is used within attuned therapeutic relationship and the theoretical framework of integrative psychotherapy. mindful processing is not goal-oriented and doesn’t strive to achieve a positive outcome. such an outcome is a natural by-product of accepting awareness of both pleasant and unpleasant inner experience (body sensations, affects and/or thoughts). the method is illustrated with a transcript of a session with commentary. key words: mindfulness, meditation, psychotherapy, mindful processing, integrative psychotherapy _________________ it is remarkable how little we know about experience that is happening right now… this relative ignorance is especially strange in light of the following: first we are subjectively alive and conscious only now. now is when we directly live our lives. everything else is once or twice removed. the only time of raw subjective reality, of phenomenal experience, is the present moment. (daniel stern, 2004, p. 3) mindfulness has become a very important concept in psychology and psychotherapy in recent years (siegel, 2007). mindfulness is non-judgmental, accepting awareness of what is going on in the present moment. kabat-zinn (1994) defines it as “paying attention in a particular way: on purpose, in the international journal of integrative psychotherapy, vol. 3, no. 1, 2012 42 present moment and non-judgmentally” (p.4). mindfulness-based interventions are becoming increasingly used in mental health settings. there has been an increasing amount of research about mindfulness over the last 10 years in clinical and health psychology. siegel (2007) reports that mindfulness training helps to reduce subjective states of suffering, improve immune functioning, accelerate rates of healing, nurture interpersonal relationships and an overall sense of well being. mindfulness has been shown to change brain function in positive ways, increasing activity in areas of the brain associated with positive affect (davidson et al., 2003). mindfulness training is also associated with changes in gray matter concentration in brain regions involved in learning and memory processes, emotion regulation, self-referential processing, and perspective taking (hölzel et al., 2011). mindfulness approaches have been shown to decrease stress and improve quality of life (e.g. nyklíček & kuijpers, 2008; shapiro, astin, bishop, & cordova, 2005). mindfulness interventions are used with success with different mental health issues including depression (e.g. ma & teasdale, 2004; kenny & williams, 2007), anxiety disorders (e.g. miller, fletcher, & kabat-zinn, 1995), borderline personality disorder (e.g. bohus et al., 2000), binge eating disorder (telch, agras, & linehan, 2001), and even psychosis (bach & hayes, 2002; gaudiano & herbert, 2006). mindfulness based cognitive therapy prevents relapse in cases of chronic depression (teasdale et al., 2000; ma & teasdale, 2004; williams, duggan, crane, & fennell, 2006). martin (1997) proposed that mindfulness is a common factor which underlies different psychotherapy approaches. there are several specific approaches that explicitly emphasize the cultivation of mindfulness. the most known of these approaches are: • mindfulness based stress reduction (mbsr; kabat-zinn, 1990) • mindfulness-based cognitive therapy (mbct; segal, williams, & teasdale, 2002; crane, 2009) • acceptance and commitment therapy (act; hayes, strosahl, & wilson, 1999), • dialectical behavioral therapy (dbt; linehan, 1993), • sensorimotor psychotherapy (ogden & minton, 2000; ogden, minton, & pain, 2006). germer (2005) proposed three different ways of integrating mindfulness into psychotherapy. the therapist may: 1) personally practice mindfulness, thus bringing the quality of mindful presence into the therapy room with the client; 2) use a theoretical frame of reference informed by research and mindfulness practice; 3) explicitly teach the client how to practice mindfulness. germer (2005) collectively refers to this range of approaches as mindfulnessoriented psychotherapy. international journal of integrative psychotherapy, vol. 3, no. 1, 2012 43 mindfulness and integrative psychotherapy integrative psychotherapy developed by erskine and colleagues (erskine, moursund, & trautmann, 1999) integrates theories and methods from psychoanalytic, humanistic and behavioral traditions of psychotherapy into a new theoretical framework. while the word ‘mindfulness’ is not explicitly mentioned in their writings, i think that mindfulness practice and research are very compatible with the framework of integrative psychotherapy (žvelc, 2009). theories and methods of integrative psychotherapy are based upon the philosophy of accepting awareness within attuned therapeutic relationship. main methods of integrative psychotherapy are inquiry, attunement and involvement, which invite the client in contact with self and others and promote integration of dissociated states of self. these methods invite the client into state of awareness and acceptance of his/her internal experience, which is the main mechanism of mindfulness. inquiry involves respectful exploration of the client's phenomenological experience. the therapist asks the client to reveal to him his subjective perspective; in doing so, the client becomes increasingly aware of his relational needs, feelings, behaviour and thoughts (erskine et al., 1999). the therapist invites the client to search for answers, to think in new ways and to explore new avenues of awareness. for an effective inquiry, there is no expectation that the client will come to some predetermined goal or insight (erskine et al., 1999). inquiry promotes awareness and increases internal and external contact. with respectful inquiry we are actually inviting the client to be aware of his/her experience. mindfulness can be defined as nonjudgmental, accepting awareness of one’s own experience in the current moment (černetič, 2011). such awareness can include internal experience (thoughts, feelings, and physical sensations) and/or external stimuli (e.g. sounds, colors, odors) that an individual becomes aware of in an allowing manner, without trying to avoid or suppress them (žvelc, černetič, & košak, 2011). with respectful inquiry the client may become increasingly aware of aspects of his experience which he/she often tries to avoid. therapeutic inquiry alone is often not enough, it should be coupled with involved therapist’s response which invites the client to accept his/her experience. for healthy contact that promotes integration, full awareness is not enough; it should be coupled with acceptance of our experience (žvelc, et al., 2011). involvement means that the therapist is willing to be affected by what happens in the relationship with the client (erskine et al., 1999). therapeutic involvement includes acknowledgment, validation, normalization, and presence. with acknowledgment, the therapist demonstrates that he is aware of what the client is feeling and experiencing. validation is the acknowledgment of the international journal of integrative psychotherapy, vol. 3, no. 1, 2012 44 significance of the client’s experience. normalization depathologises the clients’ definition of their internal experiences or their coping mechanisms. in this manner, the therapist communicates to the client that his experience is a normal, and not pathological or defensive reaction. the next aspect of the involvement is presence, which is described by erskine & trautmann (1996) in the following way: ‘presence is enhanced when the therapist decenters from his or her own needs, feelings, fantasies, or hopes and centers instead on the client’s process. presence also includes the converse of decentering, that is, being fully contactful with his or her own internal process and reactions. the therapist’s history, relational needs, sensitivities, theories, professional experience, own psychotherapy, and reading interests all shape unique reactions to the client. presence involves both bringing the richness of the therapist’s experiences to the therapeutic relationship as well as decentering from the self of the therapist and centering on the client’s process.’ (p. 325). i think that with these words authors express the essence of mindfulness of the therapist within therapeutic relationship. the third method of integrative psychotherapy is attunement. erskine and trautmann (1993/1997) describe attunement as a two-part process: 'the sense of being fully aware of the other person's sensations, needs, or feelings and the communication of that awareness to the other person.' (p. 90). attunement goes beyond empathy – it provides a reciprocal affect and/or resonating response. therapist can be attuned to a wide variety of client behaviours and experiences, but especially to his rhythm, nature of affect, cognition, developmental level of psychological functioning and relational needs. inquiry, attunement and involvement provide the therapeutic framework within which the client is invited to become mindful of his/her experience. these methods provide the basic framework for processing of dissociated and unresolved experiences. mindful processing method (mp) mindfulness may be an important mechanism for processing of disturbing emotional experiences. ogden, minton and pain (2006) state that with mindful awareness ‘retraumatisation is minimized because the prefrontal cortex remains ‘online’ to observe inner experience, thus inhibiting escalation of subcortical activation’ (p. 195). they describe the important therapeutic skills which invite the client into mindfulness: tracking of the client’s moment to moment experiences, bodyreading and contact statements. within integrative psychotherapy these skills are part of therapeutic inquiry, attunement and involvement. international journal of integrative psychotherapy, vol. 3, no. 1, 2012 45 example: client: i feel like there is a hole in my stomach. therapist: just close your eyes and pay attention to that hole in the stomach. just observe what is happening with curiosity. client (with tears in her eyes): i feel sad now for this little girl who was all alone and nobody was there for her. therapist: simply take time and make space for this feeling. just stay with it… i think that mindfulness is the main mechanism of integration of disturbing experiences. no matter which technique or method is used, i believe it is important for clients to be in a mindful state when processing their traumatic events. on the one hand, they are re-experiencing traumatic memories, and on the other, they are observing them. this process also takes place in emdr treatment, and i think that the effects of emdr may be significantly related to the mindfulness component. shapiro writes (2001, p. 233): ‘it may thus be that the effectiveness of emdr arises from its ability to evoke exactly the right balance between re-experiencing emotional disturbances and a non-evaluative ‘observer’ stance with respect to emotion and to the flow of somatic, affective, cognitive and sensory associations that arise when this observer stance is maintained continuously for 30 seconds, or minutes at a time, without interruptions from the therapist or from an excessive level of arousal.‘. in emdr, this process is called ‘dual awareness’, as it enables a client to stay present while simultaneously experiencing elements of past traumatic memories. i propose that mindfulness promotes natural healing of the organism, where the change comes spontaneously by acceptance and awareness of internal experience. such process we previously described as ‘mindful processing’, because with mindful awareness disturbing experiences can be processed and integrated (žvelc & žvelc, 2008, 2009). i think that mindful processing is the main mechanism of change in many schools of psychotherapy that are concerned not only with cognitive-behavioral change, but with processing of emotional and somatic experience. in my psychotherapy practice, i became increasingly interested in how to apply mindfulness within the framework of integrative psychotherapy. the basic question was how to invite clients into a mindful mode of processing in the therapy that involves awareness of the present moment with acceptance. clients who come for psychotherapy or counseling are often distanced from their experiencing and are trying to control or repress difficult emotions, disturbing thoughts and body sensations. therefore, they develop an aversive stance toward their experience, which eventually brings additional pressure, symptoms and self-criticism. many psychological problems originate in non-acceptance of inner experience (hayes, et al., 1999). so inviting clients into a mindful processing mode can reverse the cycle of avoidance of inner experience. these international journal of integrative psychotherapy, vol. 3, no. 1, 2012 46 considerations lead to the development of a method called mindful processing (žvelc & žvelc, 2008, 2009). the method is used within overall framework of integrative psychotherapy. inquiry, attunement and involvement are foundations within which mindful processing method is used. the mindful processing method invites the clients to become aware of their moment-to-moment subjective experience with acceptance. the role of the therapist is to facilitate a mindful stance in the client. he/she invites the client into a state of awareness and acceptance. the therapist is also supposed to be in a mindful state of mind, aware of what is happening within him/her and what is happening with the client. the method is client-centered, which means that the therapist is not trying to change or modify the client's experience. the therapist’s role is to offer an accepting space to all of the client's experiences that are emerging from moment to moment. the therapist is not trying to change anything, s/he has to be curious and open to whatever experience is arising. his/her role is to contain the process and emotions that are arising. only such a stance can actually promote mindfulness in the client. if the therapist cannot stay with what is, and is oriented toward a goal, this will have an impact on the client. the therapist's embodiment of a mindful stance is crucial. this is congruent with bruce, manber, shapiro and constantino (2010) who proposed that a psychotherapist’s ability to be mindful positively impacts his or her ability to relate to patients. the method could also be called relational mindfulness. there are two mindful people in the room and the therapist is constantly inviting the client to pay attention to the present moment. clients who come for therapy because of mental health problems often have difficulty accepting their inner experience. they find it hard to tolerate and stay with disturbing thoughts and emotions. mindfulness meditation is sometimes ‘too hard’ for them, they become lost in their experience and have great difficulty in developing de-centered perspective to their experience. in mindful processing the therapist helps them establish a mindful stance which involves capacity to observe inner experience. we can say that 'two aware minds are more powerful than only one aware mind'. the therapist’s presence can actually promote a mindful stance in the client that would be difficult to achieve alone. moreover, such a stance actually promotes processing and integration of disturbing experience. mindful processing starts with focusing on body sensations connected to the issue the client is bringing to the therapy. this is taken from gendlin's (1981) focusing approach. mindful processing involves a lot of attention to body-felt experience from which other elements of subjective experience arise (emotions, cognitions, memories…). after focusing on the body sensation connected to the issue, the client is invited to report his/her inner experience to the therapist. in next steps the client alternates between awareness of internal experience and description of his/her experience to the therapist. the client is invited to pay attention to any experience that emerges from moment to moment. international journal of integrative psychotherapy, vol. 3, no. 1, 2012 47 there are two important processes happening in mp: 1.) internal contact (the client becomes increasingly aware of his/her emotions, body sensations, thoughts…. in this phase the client usually has closed eyes and is centered on his/her internal experience.). 2.) external contact (the client is invited to find words for his/her inner experience and report that to the therapist. in this phase, the client is looking at the therapist. the therapist is attuned to the client and gently invites the client to accept and be aware of whatever is present.) these two processes can also be described as intrapersonal and interpersonal attunement (siegel, 2007). in intrapersonal attunement client attends to himself or herself with compassion, kindness and acceptance. interpersonal attunement is crucial in the phase of external contact, when clients reports his/her inner experience to psychotherapist. presence, acceptance and attunement of the therapist promote a new ‘relational’ experience, which is an antidote to previous relationships ruptures, in which the client had to deny and repress his/her inner experience. in mindful processing, every little moment is valuable and meaningful. siegel (2007) used the acronym coal to refer to attitudes of mindfulness: curiosity, openness, acceptance and love. psychotherapist’s task is to embody these qualities in relation to client’s experience and to invite the client to do the same in relation to his/her own inner experience. the therapist facilitates the whole process and offers different types of instructions based on the client’s process. teasdale (1999) describes three modes of processing emotional material: 'mindless emoting'; 'conceptualizing/doing' and 'mindful experiencing/being'. he concludes that only the last of these facilitates emotional processing. in mp when the client is in another two modes of processing the task of the therapist is to facilitate the client into mindful processing state. sometimes clients are distanced from their emotions, body sensations (conceptualizing/doing state). in this case the therapist may gently invite the client to find body sensation again. the task is to focus and attend to body sensations and emotions. sometimes the clients are overwhelmed with their emotional experience and have difficulty with decentering from their experience (mindless emoting mode). in this case the task is to develop appropriate distance to experience. the therapist may say: 'make a little distance between you and emotions, just observe what you are experiencing'. not all clients are immediately ready for mindful processing. some clients have difficulty attending to their inner experience even for a short time. these clients typically suffer from high emotional arousal, which they are trying to control. these are clients who often suffer from unresolved traumatic experiences and have difficulty regulating their emotions. international journal of integrative psychotherapy, vol. 3, no. 1, 2012 48 therefore, it is important to assess their ability to be in a mindful state of mind before introducing mindful processing. such clients would need a preparation phase of treatment that would focus on developing their ability to contain difficult emotions. integrative psychotherapy methods of inquiry, attunement and involvement are very helpful in this regard. they help clients to develop the capacity to stay present with their emotions and provide regulation of affects. these methods are also crucial for developing a good therapeutic alliance which is the foundation for using mindful processing method. sufficient trust in the therapeutic relationship is needed, so that a client really feels free to experience whatever s/he experiences. in working with different clients i have found that mindful processing actually promotes integration and processing of client’s disturbing experience. sometimes just a few moments of mindful processing bring new awareness or a new perspective on the issue. mindful processing is not a standalone method, but should be integrated within overall psychotherapy framework. i use it within integrative psychotherapy approach, however i think that mindful processing can be integrated also into other psychotherapy schools. method can be used widely in different contexts: psychotherapy, counseling and coaching. we use it also in supervision for the exploration of therapists’ counter-transference. in psychotherapy and counseling, the mindful processing can be used for experiential exploration and processing of current issues, processing of past painful experiences and developing positive resources for future use. we have devised a mindful processing procedure, which describes eight phases of the method and helps new psychotherapists/counselors to learn about the method (žvelc & žvelc, 2008, 2009). these steps are just orientation and not a rule. we encourage therapist to use method flexibly within ongoing therapeutic relationship with their clients. mindful processing procedure phase 1: description of mindful processing to the client in the first phase it is important to describe the method to the client and to make an agreement about the use of mindful processing. possible instructions given by the therapist: ’at the beginning i will invite you to close your eyes and focus on the body sensation which you experience when you think about the disturbing issue. your task is just to close your eyes and observe what is happening inside. you just gently notice what is happening. maybe some thoughts, images, emotions or international journal of integrative psychotherapy, vol. 3, no. 1, 2012 49 body sensations will arise. or maybe nothing special will happen. there is no plan for what should happen. the task is just to notice and be aware of your experiences. after some time you can open your eyes again and share with me what has occurred. you will just tell me what has happened. after that i will invite you to close your eyes again and observe and notice what is happening at that moment. and then again you can open your eyes and report on your subjective experiencing. so we will alternate between your inner process of experiencing and reporting on your experience. there is no plan for what should happen. the task is just to be mindful and in contact with your inner experience. maybe sometimes nothing will happen, you just report on that nothingness. if some thoughts or emotions arise that you don't want to share, you just tell me that you don't want to share that. if you would like to stop this exercise you just tell me or lift up your hand.' phase 2: description of the issue in this step we invite the client to describe the issue he would like to explore and process. this could be anything the client is interested in exploring and understanding better. it can be a particular problem or an issue s/he is struggling with. therapist: 'what issue would you like to work on?' phase 3: finding a body sensation connected to the whole problem the basic entry point in mindful processing is a body sensation connected to the issue. therapist: ‘when you think about the whole problem, how do you feel in your body now?’ 'where do you feel it in your body now?' phase 4: focusing on the body sensation related to the whole problem 'close your eyes and focus on that body sensation. just observe what is happening.' the therapist is attuned to the client and to his experiencing. s/he observes the nonverbal signs of the client and also observes his own process of experiencing. the therapist is also fully aware and present. cycle of processing phase 5: description of inner experience (making external contact) if the client doesn’t open his/her eyes for prolonged time we can gently invite him/her to do this. we use our attunement skills to know when it is the right time to ask the client to make external contact. example: international journal of integrative psychotherapy, vol. 3, no. 1, 2012 50 'just open your eyes and tell me what has happened.' (empathically) or 'o.k. slowly open your eyes and tell me what occurred. ' the therapist is attuned and listens. s/he accepts the client's experience and sometimes offers validating response. the idea is to stay with the moment-to-moment experience. phase 6: intrapsychic contact and mindfulness 'stay with that __________ (sensation, thought, feeling)’ or 'be aware of ___________ (sensation, thought, feeling)' or 'observe that' the therapist, with his/her nonverbal attitude gives encouragement to the client to experience whatever the client is experiencing. repeat phases 5 and 6 as many times as needed/desired. phase 7: end of processing or returning to the cycle of processing you can check after some time how the client experiences the original issue. ‘if you bring the original issue in your awareness, what comes? ‘ if the issue is processed then you can stop the processing phase and go to step 8. if there is still disturbance and/or new aspects emerge you can continue processing cycle. phase 8: relational and cognitive processing mindful processing occurs in the presence of attuned therapist. the aim of this step is to bring to client’s awareness the relational context of the work and also to promote further cognitive processing. the therapist may ask: ’how was that for you? how was it telling me this?’. in this step it is essential phenomenological inquiry (erskine, et al., 1999) about client’s experience. the client also integrates newly emerged experience with his previous experience. this step provides closure to mindful processing or can be stimulus for further tasks in psychotherapy (including possible new mindful processing). a transcript of mindful processing the following transcript demonstrates the mindful processing method. from the transcript it is observable how the client processes her troubling issue by attending to her moment-to-moment experience. before this transcript was made, mindful processing was explained and an agreement to proceed with the mp was achieved. the mp lasted 20 minutes. when reading the transcript it is important to note that mp proceeds in a very slow tempo. there is a lot of space international journal of integrative psychotherapy, vol. 3, no. 1, 2012 51 for the client to become aware of her inner experience. whenever the transcript says ‘mindful processing’, that means that the client has closed eyes and is contacting her inner experience. these are moments of silence which usually lasted 30-40 seconds. therapist: what would you like to discover more about today? client: in a few days, an old friend is visiting slovenia and i will meet him after a long time. so i feel a bit nervous about this meeting, and i would like to look more closely at what's going on with this. therapist: aha, what is going on with the anticipation of your old friend? client: yes. therapist: ok. when you think about this whole issue with your friend, what do you feel in your body? client: (mindful processing) it is a warm feeling in my body and it is like rising energy, it's connected with joyfulness and laughter. therapist: ok, just close your eyes and focus on that. client: (mindful processing) it keeps as a feeling in my stomach. it was, first it was more sort of dark and sort of like an object. then slowly it went softer and was a trace of sadness in it. it was connected with a memory. i do not meet this friend very often now. it is sadness of not being together as much as we used to be. commentary: client through mindful processing becomes aware of joyfulness and then sadness connected to the issue. therapist: ok, just stay with that. client: (mindful processing) it keeps being as a feeling in my stomach and it was a thought of how precious that person is for me and how i would like to hold that person, how i would like to hold him in my arms and not to let go, or to just be, to keep him for myself. commentary: the underlying meaning slowly emerges out of emotional experience. therapist: ok, just be with that. client: (mindful processing) now it's like… it's still feeling in my stomach. it’s sort of trembling and it's an image of a bridge, of going forth and back and forth and back, like holding and letting go, holding and letting go. it is like this, and excitement about this. commentary: the client is fully in contact with her bodily experience out of which cognitive meaning emerges. the client senses two polarities: holding on to the person and letting go. therapist: ok, just stay with that. client: (mindful processing) international journal of integrative psychotherapy, vol. 3, no. 1, 2012 52 now it has moved higher. here (points to her chest). and i feel as..., still a wish to keep, to hold, not to let it just flow… and connected with a feeling of missing and perhaps losing. mixed feelings. and trying to hold back a bit. therapist: just focus on that feeling in your body. client: (mindful processing) it came as a sort of understanding what this excitement i feel about this meeting really is. and it's an understanding that is not... i don't let it be very normal, like an everyday meeting, because i meet this person very seldom. an understanding of how i keep this excitement very high. it's my own doing somehow. therapist: ok, just stay with that. observe what is happening. client: (mindful processing) now i feel it is a sort of trembling, a very soft one, and a memory of saying goodbye. because that always happens with that person, because we don't live in the same country, we have to say goodbye after some time. and it's sort of, i don't like this saying goodbye. that's a part of excitement. commentary: in these narratives insight about the issue emerges more clearly. the client becomes aware of how difficult is for her to say goodbye to her friend. therapist: ok, just focus on that sensation and what you have told me. client: (mindful processing) i feel much more peaceful now in my body. and it came with an understanding of how i hold this excitement or keep this excitement, with this not liking, not wanting of saying goodbye. now i accept this more and am getting more peaceful. commentary: with full awareness and acceptance of newly emerged meaning comes also a change in body sensations (client feels more peaceful). therapist: just focus on that peacefulness. client: (mindful processing) now i just feel more of this joy and sort of laughter and happiness of meeting and a... yeah, sort of naughty excitement. it is more on this side, not so much on the goodbye but more on meeting and seeing each other. therapist: more on meeting this person? client: yeah. therapist: ok, just stay with that. client: (mindful processing) yeah, it's still peaceful inside in my body and a new thought like – this joyfulness and happiness will stay with me even after saying goodbye. so it’s ok this way, it's just a nice feeling i know that person and that i like that person very much and that is... (mindful processing) i just feel like smiling somehow and i have an easy feeling in my body and, yeah, satisfaction somehow. international journal of integrative psychotherapy, vol. 3, no. 1, 2012 53 (mindful processing) now it's a like light, very light feeling in my body and some in my head. and i'm more involved in myself, not in relation with that person but more like just myself. being happy and feeling good. commentary: processing of positive affects takes place. client reports joyfulness, happiness and satisfaction. this is the usual experience with mindful processing. when negative affects and related meaning are clearly in awareness and the client accepts them, then transformation of affects occurs. during the process so far the client has moved from nervousness, clearly felt sadness to positive affects of happiness and joy. therapist: aha, good. client: (mindful processing) i feel peaceful inside and very aware of myself. getting more and more empty somehow. therapist: aha, empty? client: empty, but it's not..., it's a good taste of emptiness. it's like a, like a... just nice emptiness. like i have nothing special within my mind. it's just awareness and being present and being alive. commentary: the original issue is clearly not in the foreground anymore. this is a sign that the original issue may have been processed. what comes is emptiness of content, client is momentary free from different thoughts. she is clearly in a mindful state of mind, fully present and feeling alive. processing of positive affects of joyfulness and happiness brings another level of experience – an almost ‘zen’ like state of emptiness and inner peace. therapist: ok. client: (mindful processing) i feel like i would sit so for long time. like sitting and waiting. and i feel something new is emerging in my stomach. but doesn't have really a shape yet, but somehow could be something new that emerged just inside. therapist: so would you like to go to the next step or stop here? client: i don't know. we can stop here too. as if i feel as one phase is over, like one circle is completed. therapist: so how was it telling me this? how was that for you? commentary: here the client is invited to tell the therapist how she experienced mindful processing. this phase is very important, because it brings into awareness the relational aspect of the process and also an opportunity to conceptualise the mp on a cognitive level. further integration with relational and cognitive aspects takes place. client: to tell? therapist: yeah, and to be in this process? client: it was just nice to tell what's going on in me. and it was much contact with myself, like going to the sensations of my body, thoughts which came with these sensations. what i can say is that i am more in contact with international journal of integrative psychotherapy, vol. 3, no. 1, 2012 54 myself now. that is like i'm getting much more peaceful but not as a goal, more as a consequence of doing this. therapist: ok. is there anything else you would like to explore more? if not, we will stop in a few minutes. what would you like? client: i feel that have i explored the excitement about this meeting through this being in touch with what is going on and that this somehow came to an end. i'm just ok with this. and it's less excitement and it's more awareness of what excitement was, where it came from... i haven’t been aware before that it's connected in this way. like meeting and being afraid or not liking to say goodbye then. and those two parts equate this higher level of excitement. and now it's more like nice and happiness with this. but it's not nervousness. commentary: the client summarises the process and shows good cognitive understanding of the process. therapist: it's not so nervous? client: no, it's more acceptable and it's more... perhaps even more open in this way. more fluent. therapist: more fluent? client: yeah. therapist: aha. so this was... so you find it's like something new emerging through this process? like this was new for you, these two parts? client: yes. this was new for me that they... that i was somehow caught between two polarities really. and then when i've seen them together, they both vanished somehow or they integrated in something new. with more peacefulness really in me and... commentary: the client explains the curative power of mindful processing in her own words. when the client is aware of different poles connected to the issue, integration takes place. when seen from the beginning to the end, the transcript shows how the client’s experience transformed without any attempt on the part of the therapist to interpret or change the client’s experience. transformation comes through the accepting awareness of the present moment, and the role of the therapist is to facilitate this process. conclusion mindful processing is eventually not a 'new' approach. its principles are already part of several psychotherapy schools. different psychotherapy schools are already using these principles under different labels. we believe that the mindful processing mode can be achieved through different techniques and methods (such as emdr, focusing, two chair work…). what is new is a structured method that is entirely focused on developing mindfulness in psychotherapy. making this process more structured has important implications for further understanding of this process and research. international journal of integrative psychotherapy, vol. 3, no. 1, 2012 55 author: assist. prof. gregor žvelc, phd is clinical psychologist and doctor of psychology. he is international integrative psychotherapy trainer & supervisor (iipa). gregor is director of the institute for integrative psychotherapy and counseling in ljubljana, where he has a private practice and leads trainings in integrative psychotherapy and transactional analysis. he is co-editor of international journal of integrative psychotherapy. he can be reached at institute ipsa, stegne 7, 1000 ljubljana, slovenia. e-mail: gregor.zvelc@guest.arnes.si homepage: www.institut-ipsa.si references bach, p., & hayes, s. c. (2002). the use of acceptance and commitment therapy to prevent the rehospitalization of psychotic patients: a randomized controlled trial. journal of consulting and clinical psychology, 70, 11291139. bruce, n. g., manber, r., shapiro, s. l., & constantino, m. j. (2010). psychotherapist mindfulness and the psychotherapeutic process. psychotherapy theory, research, practice, training, 47(1), 83–97 bohus, m., haaf, b., stiglmayr, c., pohl, u., böhme, r., & linehan, m. (2000). evaluation of inpatient dialectical-behavioral therapy for borderline personality disorder a prospective study. behaviour research and therapy, 38, 875-887. crane, r. (2009). mindfulness-based cognitive therapy. london and new york routledge. černetič, m. (2011). odnos med anksioznostjo in čuječnostjo [relationship between anxiety and mindfulness. (unpublished dissertation). university of ljubljana, ljubljana, slovenia. davidson, r. j., kabat-zinn, j., schumacher, j., rosenkranz, m., muller, d., santorelli, s. f., urbanowski, f., harrington, a., bonus, k., sheridan, j. f. (2003). alterations in brain and immune function produced by mindfulness meditation. psychosomatic medicine, 65, 564-570. erskine, r. g., moursund, j. p., & trautmann, r. l. (1999). beyond empathy. a therapy of contact-in-relationship. philadelphia: brunner/mazel. erskine, r. g., & trautmann, r. l. (1996). methods of an integrative psychotherapy. transactional analysis journal, 26, 316-328. gaudiano, b. a., & herbert, j. d. (2006). acute treatment of inpatients with psychotic symptoms using acceptance and commitment therapy: pilot results. behaviour research and therapy, 44, 415-437. gendlin, e. (1981). focusing. new york: bantam books. germer, c. k. (2005). mindfulness. what is it? what does it matter? in germer, c. k., siegel, r. d., & fulton, p. r. (eds.), mindfulness and psychotherapy. new york, london: the guilford press. international journal of integrative psychotherapy, vol. 3, no. 1, 2012 56 hayes, s. c., strosahl, k. d., & wilson, k. g. (1999). acceptance and commitment therapy: an experiential approach to behavioural change. new york: guilford press. hölzel, b.k., carmody, j., vangel, m., congleton, c., yerramsetti, s. m., gard, t., lazar, s.w. (2011). mindfulness practice leads to increases in regional brain gray matter density. psychiatry research: neuroimaging, 191, 36-43. kabat-zinn, j. (1990). full catastrophe living. how to cope with stress, pain and illness using mindfulness meditation. london: piatkos. kabat-zinn, j. (1994). wherever you go, there you are: mindfulness meditation in everyday life. new york: hyperion. kenny, m. a., & williams, j. m. g. (2007). treatment-resistant depressed patients show a good response to mindfulness-based cognitive therapy. behaviour research and therapy, 45, 617-625. linehan, m. m. (1993). cognitive-behavioral treatment of borderline personality disorder. new york: guilford press. ma, s. h., & teasdale, j. d. (2004). mindfulness-based cognitive therapy for depression. replication and exploration of differential relapse prevention effects. journal of consulting and clinical psychology, 72, 31-40. martin, j. r. (1997). mindfulness: a proposed common factor. journal of psychotherapy integration, 7(4), 291-310. miller, j. j., fletcher, k., & kabat-zinn, j. (1995). three-year follow-up and clinical implications of a mindfulness meditation-based stress reduction intervention in the treatment of anxiety disorders. general hospital psychiatry, 17, 192-200. nyklíček, i., & kuijpers, k. f. (2008). effects of mindfulness-based stress reduction intervention on psychological well-being and quality of life: is increased mindfulness indeed the mechanism? annals of behavioral medicine, 35, 331-340. ogden, p., & minton, k. (2000). sensorimotor psychotherapy: one method for processing traumatic memory. traumatology, vol. 6, num. 3. retrieved 22.11.2010 from: http://www.fsu.edu/~trauma/v6i3/v6i3a3.html ogden, p., minton, k., & pain, c. (2006). trauma and the body. a sensorimotor approach to psychotherapy. new york, london: w.w. norton v company. segal, z. v., wiliams, j. m. g., & teasdale j. d. (2002). mindfulness-based cognitive therapy for depression. a new approach to preventing relapse. new york, london: the guilford press. shapiro, s. l., astin, j. a., bishop, s. r., & cordova, m. (2005). mindfulnessbased stress reduction for health care professionals: results from a randomized trial. international journal of stress management, 12, 164-176. shapiro, f. (2001). eye movement desensitization and reprocessing: basic principles, protocols and procedures. 2nd ed. new york: guilford press. siegel, d. j. (2007). the mindful brain. reflection and attunement in the cultivation of well-being. new york, london: w.w. norton & company. international journal of integrative psychotherapy, vol. 3, no. 1, 2012 57 http://www.fsu.edu/%7etrauma/v6i3/v6i3a3.html international journal of integrative psychotherapy, vol. 3, no. 1, 2012 58 stern, d. n. (2004). the present moment in psychotherapy and everyday life. new york, london: w.w. norton & company. teasdale, j. d. (1999). emotional processing, three modes of mind and the prevention of relapse in depression. behaviour research and therapy, 37, suppl 1, 53-77. teasdale, j.d., segal, z.v., williams, j.m.g., ridgeway, v., soulsby, j., & lau, m.a. (2000). prevention of relapse/recurrence in major depression by mindfulness-based cognitive therapy. consulting and clinical psychology, 68, 615-623. telch, c. f., agras, w. s., & linehan, m. m. (2001). dialectical behavior therapy for binge eating disorder. journal of consulting and clinical psychology, 69, 1061-1065. williams, m. duggan, d. crane, & fennell, m. & (2006) mindfulness-based cognitive therapy for prevention of recurrence of suicidal behavior. journal of clinical psychology, 62, 201-10. žvelc, g. & žvelc, m. (2008). the power of present moment. mindful processing in psychotherapy and counseling. workshop presented at 4th european conference on positive psychology, 1.–4. july, rijeka, opatija. book of abstracts. žvelc, g. (2009). present moment in integrative psychotherapy. keynote speech delivered at the 4th international integrative psychotherapy conference, bled, slovenia. april 17, 2009. žvelc, g. & žvelc, m. (2009). loss and regain of ‘now’: transforming trauma through mindful processing. workshop delivered at the 4th international integrative psychotherapy conference, bled, slovenia. april 17, 2009. žvelc, g., černetič, m., & košak, m. (2011). mindfulness-based transactional analysis. transactonal analysis journal, 41, 241-254. date of publication: 25.6.2012 it is both a pleasure and an arduous task to write this series of rejoinders to the commentaries on the borderline trilogy international journal of integrative psychotherapy, vol. 4, no. 1, 2013       53 intrapsychic conflict, transference, and a healing relationship. richard g. erskine abstract: in this rejoinder to “responses to relational healing of early affectconfusion: part 3 of a case study trilogy”, the author defines an integrative psychotherapy perspective of transference and addresses the significance of working within a transference-countertransference milieu. descriptions of how to understand and therapeutically use client’s “idealization” are provided. the concept of avoidant and disorganized attachment is related to a clinical case. key words: avoidant attachment, disorganized attachment, affect-confusion, interpersonal-contact, borderline personality disorder, integrative psychotherapy, case study, healing relationship, transference, intrapsychic conflict. ______________________ response to maša žvelc maša žvelc begins her commentary on relational healing of early affectconfusion: part 3 of a case study trilogy by identifying several significant therapeutic points in the psychotherapy of early affect-confusion. each of the points masa outlined reflects an important aspect of an in-depth relational psychotherapy: differentiating the past from the present; inquiring about physiological sensations and helping the client make sense of them; helping the client get in contact with unconscious and vulnerable experiences; redirecting the client’s complaints about current events by inquiring about the physiological and affective reactions; the recognition of introjection and the therapist’s use of interpositions. there are certainly many other aspects to a relational and in-depth psychotherapy that neither time nor space allows us to describe in these short discourses. masa, you said in this response, as you also did in your second response, that the presentation of the transference-countertransference matrix was not discussed in my case study. it seems to me that this case is about using both the transferential enactments of every-day-life and the various forms of transference in relationship to the psychotherapist. it is also about the use of phenomenological and relational inquiry (corresponding to the transference and international journal of integrative psychotherapy, vol. 4, no. 1, 2013       54 informed by countertransference) to uncover neglect, ridicule, and physical abuse. the relational inquiry facilitates the creation of an interpersonal-contact wherein the client can finally put words to her physiological sensations and implicit memories. the whole therapy with theresa was about making conscious what was previously unconscious. your concern may be based on my failure to write a more detailed explanation about how i make therapeutic use of theresa’s transferences of every-day-life as well as her various forms of transference with me to uncover and resolve her early childhood neglect and trauma. i think that the largest percentage of our client’s unconscious transferences is enacted in their day-to-day life with the partners, children, siblings or parents, with people at work, with friends, and even with strangers on the street or in a store. a smaller percentage of unconscious transference is actually enacted with the psychotherapist. in my practice of psychotherapy i am listening for the muted versions of unconscious transferential dramas that may be encoded in the client’s stories and reports about what happened at home or at a party. i am frequently asking myself, “what relational experiences are being revealed through the content and style of the client’s narrative?” both the content and affect of the client’s stories about their day-by-day life experience provide the fabric for forming my phenomenological inquiries and the many inquiries about how the client perceives our interpersonal relationship. i would like to take this opportunity to explain what i think about the concept of transference. i presume that it is similar to your concept. my understanding of transference is multifaceted and incorporates concepts from child development, psychoanalysis, transactional analysis, gestalt theapy, existential philosophy, as well as a relational perspective. i think of transference as the means whereby a client can demonstrate the subsymbolic and procedural memories of his or her past, the relational-needs that have been thwarted, and his or her archaic ways of self-reparation and selfstabilization that were established to compensate for repeated relational disruptions. transference may also be an expression of a person’s inability to form explicit memory while, paradoxically, being an emotionally-laden expression of childhood pre-symbolic and implicit memories. transference includes the expression of intrapsychic conflicts (what ray little, in his 2006 article, calls “relational units”) and the desire to achieve intimacy in relationships. therefore, transference is the expression of a universal psychological striving to organize experience and create meaning (erskine, 1991/1997). we are all well aware that in any psychotherapeutic relationship the unsatisfied childhood needs may be projected onto the therapist who will be experienced by international journal of integrative psychotherapy, vol. 4, no. 1, 2013       55 the client as the source of possible needs satisfaction (what steven stern calls the “needed relationship” and michelle novellino calls the “positive pole of transference”) as well as the source of frustration and rejection (what stern calls the “repeated relationship” and novellino calls the “negative pole of transference”). it seems wise to assume that in every case the transference will be characterized by the simultaneous presence of both poles: the needed and the repeated relationship (novellino, 1985; stern, 1994). psychotherapy is effective when the intrapsychic conflict or dialogue (what little has referred to as internal “relational units”) is externalized and transferred to the psychotherapist, allowing for the identification, exploration, and resolution of relational conflicts and traumas. the more the client’s memories are composed of pre-symbolic, sub-symbolic, and implicit affect-laden experiences, the more actively the psychotherapist needs to take on the transference relationship, to be stimulated and impacted by it, and to convert it into a healing relationship. the psychotherapy of unconscious transference is facilitated when the therapist does not simply take the client’s words or behavior at face value but also looks for the unaware meaning of what patients are saying or not saying, doing or not doing, their affective communication, and body gestures. masa, my other comments about working with theresa (and other clients) within a transference-countertransference milieu are articulated in my rejoinders to parts 1 and part 2. reiteration here does not seem necessary. response to james allen jim, you said, “i think i would have put more emphasis on theresa’s taking more responsibility for providing herself with the internal dialogues and external relationships that would better support her relational needs.” although i may not have emphasized this point as much as you may have, theresa’s taking responsibility for her own welfare was an important aspect to our work together each spring as i prepared her for our twelve-week summer recess. my going away was always a time to highlight my message to her that she was capable and competent and could change her old ways of being in relationship. it was essential in providing such a message that i made clear distinctions between her archaic organizing functions and current mature organizing functions. for years theresa had relied on archaic forms of self-reparation, selfstabilization, and self-regulation as reflected in her “crying spells”, making demands on her boyfriend, and getting into conflicts at work. throughout these last two years of therapy she increasingly transferred her archaic forms of selforganization to her relationship with robert and to me. she was then learning to depend on her two intimate relationships to provide mature relational reparation, international journal of integrative psychotherapy, vol. 4, no. 1, 2013       56 stabilization, and regulation. she put energy into developing a “loving relationship” with her boyfriend, she actively changed her relationships at work, and she called me for support. although there was not space to say it in my case study, theresa also developed a close friendship with a woman she met at work. during this period of time she was increasingly engaging in mature forms of responsibility i appreciate your comment, jim, about, “validating health, growth, and development.” your statement reflects eric berne’s use of the greek word physis to describe a person’s inherent “capacity to challenge the forces of acquiescence” and aspire to new personal horizons (cited in cornell, 2010, p. 244). it was not until our fifth year that i sought opportunities to inquire about theresa’s aspirations. by then she had healed from much of her affect-confusion and it was time to stimulate her vitality, support her innate desire to grow, and celebrate her desire to expand her potential. as i planned ahead i kept her words “i am just like my mother” in mind; there was still a need for more psychotherapy to resolve theresa’s internal criticism. response to ray little ray, you wondered about the psychological organization of theresa’s mother. along with the “developmental images” i had of theresa as an infant, toddler, pre-school and school age child, i had several impressionistic images of her mother’s personality that were formed from theresa’s stories. i kept in mind that such impressions were created from her stories and my resulting associations about someone i have never met. if i had the opportunity to do psychotherapy with theresa’s introjected mother, i would have used my impressions and associations to form many inquiries and shape my attunement to the introjected mother. i imagined theresa’s introjected mother to be cold, critical, controlling, and self-centered. i assume that her marriage was loveless and that her husband had learned to shut-up and adapt in order to keep peace. in an in-depth psychotherapy with theresa’s mother i would have explored her possible envy, underlying loneliness, and early childhood attachment patterns. i like, and often use, your idea of “relational units”. theresa was bonded to her mother through the intrapsychic influence of her mother’s neglect, control, ridicule, lack of empathy, and physical mistreatment. simultaneously, theresa was also bonded to this repetitive “relational unit” by her own inexorable loyalty to her mother. this intrapsychic energy exchange of inexorable loyalty and unconscious parental influence is what maintains psychological attachment, even in the presence of painful awareness. in theresa’s situation this pain-inducing international journal of integrative psychotherapy, vol. 4, no. 1, 2013       57 “relational unit” resulted in her enduring affect-confusion and disorganized attachment. an important therapeutic task, essential in resolving such dysfunctional relational units, is to earn the client’s loyalty through a consistency, dependability, and protectiveness that provides the client with a sense that this psychotherapist is invested in my welfare. ray, although you say that the therapist’s interposition between the client and the introjected parent “may serve a protective function and is a needed part of the therapy” you also say that it is important to be “aware of the risk of idealization”. i agree because idealization is the client’s unconscious communication that he or she needs to be in the presence of someone who is attuned, capable, protective, and reparative. bowlby said that security is developed in the young child through the caretaker’s ongoing availability of emotional responsiveness, consistency, and dependability, where such caretakers are experienced as “stronger and/or wiser” (1988, p.12). the similar sense of security occurs in psychotherapy when the client comes to rely on the therapist’s competency and wisdom for protection from the intrapsychic influence of introjections. such protection can only occur if the psychotherapist also honors the client’s inexorable loyalty to the introjected parent. the “risk of idealization” occurs when the psychotherapist fails to provide a stable, protective, and reparative relationship to the troubled inner child or fails to honor the client’s intense loyalty. with such failure in therapeutic protection the client may feel abandoned by the psychotherapist and cling even more tightly to the archaic “relational unit”. the potential of theresa feeling abandoned is one of the reasons i postponed my intended psychotherapy with theresa’s introjected mother. ray, you also wondered about the significance of theresa’s urgently wanting to see me in august rather than waiting for our scheduled appointment in september. robert had received a job offer and they were moving to another city together prior to our agreed upon appointment time. i saw theresa’s plan to move and get married as a sign of success in our work together. she was fulfilling two of her aspirations: to return to school to become an attorney and to be in a loving, committed relationship. there was no time to explore what you call “a multiplicity of motivations”. perhaps a new therapist in her new city may someday investigate her motivations for getting married, moving, going to school, and terminating with me. it was time for me to celebrate her success! response to grover criswell international journal of integrative psychotherapy, vol. 4, no. 1, 2013       58 grover, you raised the question whether i considered medication for theresa. like you, i too am generally conservative in recommending medication; i am a profound believer in the healing power of an interpersonally-contactful psychotherapy. however, i briefly considered medication for theresa when she was in the midst of a great deal of emotional turmoil. metaphorically, medication may plug a psychic leak and allow the therapeutic relationship to fill an empty tank. theresa refused to even discuss the option of medication. such conversation resurrected her rage at a psychiatrist who had previously diagnosed her with having a bi-polar disorder and wanted to put her on medication. i realized that her rage at being diagnosed, “controlled”, and “not understood” were transferential reactions to her mother’s behavior. it seemed better to unfurl her transferential story rather than continue to suggest medication. i supported her, “no, i won’t do what you want me to do”, as an important statement of healthy protest – a protest that her mother never allowed. theresa’s saying “no” to me about the medication provided many opportunities for phenomenological and relational inquiries and to discuss her relational-need to make an impact. grover, i liked your statement, “resistance is more than an impediment to the therapy that must be breached. when the resistance can be identified, owned and given voice, then it’s positive and negative functions allow new options and choices. the resistance can be embraced as a part of the self.” this reminds me of what laura pearls would frequently repeat in her training group, “resistance is not against something. it is an attempt at self-support. it is the client’s expression of integrity. the therapist’s job is to support that emerging integrity”. when we validate what appears to be “resistance” and normalize the client’s integrity in saying “no”, we offer new opportunities for the client to make an impact on us and to further his or her self-definition. thank you for mentioning this important point. grover, you wondered if physically holding theresa would have facilitated her experience of parental nurturing and the working through of the childhood trauma? perhaps. and perhaps it would have been too intense and would have created further juxtaposition reactions. this was often my concern. although i frequently inquired about theresa’s physiological sensations, gestures, and body postures, my purpose in such inquiries was to facilitate her awareness, ownership, and integration of her bodily experience. we only engaged in physical touch when she initiated hugging me good-by and that was not until the end of the third year. i often encouraged theresa to ask robert to hold her in his arms when she was feeling sad, scared, and confused. international journal of integrative psychotherapy, vol. 4, no. 1, 2013       59 grover, your first long paragraph contains a succinct description of how theresa’s attachment disruptions became established: “aloof distancing of her father and the intolerant criticalness of her mother”. you go on to describe the “inadequate parenting” and how it created “early childhood affect confusion that gave her an unstable base for her personality development”. damasio (1999) reminds us how cumulative neglect of the child’s needs, repetitive criticism, disregard for the child’s level of development, and physical punishment are all recorded in the brainstem as sub-symbolic, procedural memories of self-inrelationship. in theresa’s circumstances these procedural memories were infused with contradictory and confusing physiological and affect sensations bowlby described how these unconscious procedural memories form an individual’s internal working models that provide “a sense of how acceptable or unacceptable he himself is in the eyes of attachment figures” (1973, p. 203). if you remember the work in parts 1 and 2, theresa thought of herself as “unlovable”, “a piece of shit”, and that something was profoundly wrong with her. as i worked with theresa it was evident at times that she had an avoidant attachment pattern with men. in the beginning she often expressed her internal working model and archaic self-stabilization by undervaluing and dismissing the importance of her relationship with her current boyfriend, her father, other men in her life, and me. she picked fights when robert wanted to be intimate or blamed him when she imagined a lack of attention. she frequently complained to me about him. she embraced resentment at her father and scoffed at my expressions of tenderness toward her. for most of the first three years, theresa belittled my expressions of empathy and pushed away my attempts to attune to her affect or vulnerability. in the first couple of years she was periodically angry and dismissive of me. inquiring about how she perceived me in relationship to her was a continual focal point in our work together. on occasions i had earned her anger by either miss-attuning to her affect or miss-understanding her experiences. then it was necessary that i acknowledge and take active responsibility for my errors (something her parents never did). frequently, such inquiry led to either sorrowful or angry memories about her father’s lack of intimacy and initiative or his failure to take responsibility in the family. it seems that theresa avoided emotional closeness with men because she had an implicit fear of vulnerability and intimacy. theresa’s many stories about her father revealed that she repeatedly experienced him failing to give her recognition and attention and that he was predictably unresponsive to her needs for affection and protection. in child-like attempts at self-stabilization, she denied the significance of her needs for affection, intimacy, and protection and scoffed at any suggestion that she may have such needs. international journal of integrative psychotherapy, vol. 4, no. 1, 2013       60 early in the psychotherapy it became clear that theresa had a disorganized attachment disorder in relating with women. she was disdainful of previous female therapists, in a rage with the women at work, deeply hurt by joan’s rejection, had no female friends, and hated her mother. she was disturbed and confused by all these unresolved relational conflicts with women. disorganized attachment disorders, such as theresa’s, reveal a profound psychological disorientation caused by unresolved trauma and significant loss of caring, reparative, and stabilizing interpersonal-contact. theresa experienced her mother as the only person who would act in response to her day-to-day physical needs but who, simultaneously, was the source of neglect, ridicule, rejection, and physical abuse. theresa had a profound fear of emotional and physical violation and she continually anticipated rejection. her childhood was marked by the lack of a reparative, stabilizing, or regulating relationship with her mother. as a child she prematurely attempted to self-repair the wounds of criticism and physical abuse, to stabilize herself when she was confused and disturbed, and even regulate herself at bedtime and before school because she could not depend on either parent to provide these necessary relational functions. throughout our five years of therapy i had these two destabilizing types of attachment in mind. many of my transactions with theresa were aimed at identifying and redressing her early childhood internal working models of self-inrelationship. it is in the psychotherapist’s full involvement, a commitment to being with and for the client, that healing of early affect-confusion is possible. conclusion it is both a pleasure and an arduous task to write this series of rejoinders to the commentaries on the case study trilogy. i have felt honored by the four respondents sharing their thoughts about theory and clinical practice, their dedication to developing a body of literature on relational-integrative psychotherapy, as well as providing us with a glimpse of how they would have approached the psychotherapy differently. i am highly appreciative of james allen, ray little, grover criswell, and maša žvelc and hope that each of them will realize that they have made an impact on me. no matter how much i think i am writing about a case, there is so much more that is not clearly articulated or that is left unwritten. i apologize for the significant information that may have been left out of the case study, yet the missing information has led us to a useful discourse. i am elated with the many compliments, challenged to rethink some concepts and methods, confronted with international journal of integrative psychotherapy, vol. 4, no. 1, 2013       61 other points of view, and stimulated to learn the intricacies of psychotherapy once again as though i were a young student. this professional dialogue has encouraged me to re-evaluate various theories and methods of psychotherapy and your commentaries have stretched me both personally and professionally. thank you! author: richard g. erskine, phd. is co-author with janet p. moursund on the book integrative psychotherapy: the art and science of relationship (2004, pacific grove, ca: thomson: brooks/cole) that describes in detail many of the concepts used in this article. other articles are available on the website: www.integrativepsychotherapy.com references bowlby, j. (1973). separation: anxiety and anger. volume ii of attachment and loss. ny: basic books. bowlby, j. (1988). a secure base. ny: basic books. damasio, a. (1999). the feeling of what happens: body and emotion in the making of consciousness. ny: harcourt brace. erskine, r.g. (1991). transference and transactions: critique from an intrapsychic and integrative perspective. transactional analysis journal 21:63-76. reprinted in r.g. erskine, (1997). theories and methods of an integrative transactional analysis: a volume of selected articles. san francisco: ta press. little, r. (2006). ego state relational units and resistance to change. transactional analysis journal, 36, 7-19. novellino, m. (1985). redecision analysis of transference: a ta approach to transference neurosis. transactional analysis journal.15: 202-206. stern, s. (1994). needed relationships and repeated relationships: an integrated relational perspective. psychoanalytic dialogues, 4(3), 317-345. date of publication: 17.10.2013 international journal of integrative psychotherapy, vol. 11, 2020 69 silence, withdrawal, and contact in the schizoid process marye o’reilly-knapp1 abstract silence, withdrawal, and contact as related to the schizoid condition is considered. winnicott’s theory of impingement, an understanding of the encapsulated self, and withdrawal from contact are used as the basis for therapeutic interventions. case vignettes demonstrate the impact of contact with the client who is silent and withdraws. keywords: impingement, encapsulated self, silence, withdrawal, case examples the questions one of the most important questions a psychotherapist must consider is how to listen to a client’s silence or maintain contact when the person withdraws. that became relevant to me early in my career and has continued to be of interest and relevance ever since. in an article i wrote 20 years ago (o’reilly-knapp, 2001), i considered two questions: “what is required in a therapeutic relationship so that the uncommunicable, walled-off parts can be spoken, heard, and understood? at the same time, how can the integrity and stability of the client be maintained so that self-emergence is facilitated?” (p. 44). two new questions are at the center of this current paper: how can the therapist provide the space for silence to be supported? what is needed for the therapist to maximize her or his presence when a client withdraws? case vignette: peggy as a graduate student, i could select who i worked with in my clinical rotation. i noticed peggy while talking with others on the unit. i would see her for a brief moment and then she would disappear. at the end of the morning, i decided that peggy would be my first client. i remember being excited to meet with and get to 1 e-mail: mknapp905@verizon.net international journal of integrative psychotherapy, vol. 11, 2020 70 know her and hopefully to be helpful. little did i know that my relationship with peggy would begin my lifetime search for understanding the therapeutic process and the interventions needed to work with the sequestered part of the psyche. in a journal i kept about our sessions together, i noted: the first time i spoke to peggy i told her i would be on the unit 3 days a week and i would like to meet with her and talk. she did not say anything, so i hoped this was a yes rather than a no. the first session started the next day when i sat down in the dayroom and waited for peggy to appear. i did this the same time each day i was on the unit. she did come. i greeted her and then we sat in silence for about 10 minutes. the second week she told me to leave her alone. however, she continued to come and sit beside me. i sat in silence with her with an occasional comment about my thinking about her, checking about her eating and sleeping and activities on her unit. most of the time she did not respond. over the next couple of weeks, our time together increased from 10 to 30 minutes. peggy tolerated sitting with me. in the 8 months i worked with her, peggy went from confinement on a closed unit to permission to go off the unit and onto the hospital grounds. she stopped using the bathroom floor as her escape and joined in some of the unit’s activities. i believe one of the pivotal points of our work together was in our third month. when peggy did not turn up at our appointed time, i went looking for her. i was told by one of the patients that she was in the bathroom. i found her there lying on the floor. i told her i had been looking for her. i was upset and with raised voice told her that i did not want to see her on the floor, that she was better than that. i left telling her i would be waiting outside. what worried me the most is that i could not think of any therapeutic approach that would validate my reaction. after all, i was a student, and i was concerned that my behavior might have been inappropriate and that there might be consequences. i was also concerned that peggy might experience this as a rupture in our relationship. a few minutes later, she came out of the bathroom, looked at me, and then turned away. i told her i was glad to see her. i asked her if she heard me, and she nodded her head “yes.” i asked about her retreat to the bathroom, but she did not respond. for the rest of the time of our meetings, she never returned to the bathroom floor. international journal of integrative psychotherapy, vol. 11, 2020 71 as i look back, i know my distress was appropriate and effective. as bettelheim (1976) wrote, “the infant must first become important to a human being he can influence and who therefore becomes important to him” (p. 229). this quote resonated with me because peggy certainly influenced me as she lay in the bathroom. i believe that with my response she saw me as genuinely caring about her. i became important to her. over time she responded. much of what i did with her was to be present and allow her to connect with me at her speed. we created a space relatively free of impingements, and i made contact by sitting with her in silence. although i did not have the theoretical basis i have now, i began developing a strong foundation for a therapeutic framework through reading the works by erikson (1963), bowlby (1969), perls (1969), balint (1968), piaget (1971), may (1953), and bruch (1969). in working with peggy, i believe my naiveté allowed me to be open with her and more accessible to new information. when i eventually said good-bye to her, i was sad and had tears in my eyes. i gave her a small cake with a card to celebrate her birthday. she insisted on putting the cake in the locker by her bed. i often wonder where peggy is today. case vignette: sue in my first year in private practice, i had a referral from the university where i consulted. sue had been a student and was just released from the hospital, where she had been treated for a severe schizoid state. in her first session, sue talked about her hospitalization and her fear of losing touch with reality. she was afraid that she would go so far away from reality that she would not be able to get back and would go insane. in her latest hospitalization, she tried to escape from the chaos created by her anxiety by retreating back inside, a schizoid flight to find a safe place. however, in the process she lost touch with her selfhood as well as the external world. i told her i could not ensure her that this would not occur again, but i would be there for her, whatever happened. to begin, sue recounted her life before she went to college and how she had come from a highly dysfunctional family. to help her stay together as she talked, i “held” her by asking her to slow her speech, to take deep breaths, to be aware of sensations in her body. i tried to support her in her struggles and to signal that i was there with her, that she was not alone. these steps were important as she talked about the death of her mother when sue was only 12 years old and the loss of two sisters and a brother when they departed the household. being the youngest, she was left alone with her father, who was physically abusive. the main purpose of therapy at that point was to provide sue with a reliable, secure international journal of integrative psychotherapy, vol. 11, 2020 72 relationship in which contact with her essence as a full human being could be realized. sue spent the next year encountering her childhood memories of abuse and neglect. diminishing some of the tension and conflict of her struggles helped lessen her anxiety. she began to integrate some of her thoughts and feelings and to develop a core of her personal self. after 2 years, sue left the area to live by the sea. periodically, i would receive a note from her until that stopped. some time later she called to tell me she was back in town and asked if i would see her. when she arrived for the session, sue said she had been hospitalized again and she wanted to work with me once more. i took this as her desire to have contact even though she was fearful. we made a contract to “discover more.” the next 3 years were the foundation for the work that we did. i listened to her, took her seriously, reassured her, comforted her. i was there for her in her silence and there when she returned from withdrawal. little (1990) described this state as “consummate patience” (p. 19). i valued sue’s aliveness and her unique identity as a human being. i admired her strength as she opened herself to new possibilities. this period of her therapy prompted me to recall guntrip’s personal therapy and his comment about his hidden self: “he remained alive and you have let him out” (guntrip as cited in hazell, 1994, p. 25). guntrip described that through his therapy with winnicott, he was able to reclaim the part of him that had been concealed and to come out of hiding with his therapist’s help. now, a part of sue that remained alive and hidden was beginning to come out in therapy. she continued working with me for 5 more years, and in that time she was hospitalized once. she left therapy, has been living in a retirement community, and is doing well with support from friends and her church. the encapsulated self in the schizoid position, an organizing system is constructed in an attempt to gain some control by avoiding overwhelming thoughts and feelings. within the pattern of an isolated attachment, a withdrawn, regressed part of the individual lies encapsulated, locked away in enclosed, protective fragments that serve as an armor of detachment. the mechanism of withdrawal provides the individual a place to hide, although it also inhibits activity and has a profound effect on mastery and self-efficacy. orange et al. (1977) described the experience of self-loss as an international journal of integrative psychotherapy, vol. 11, 2020 73 “intersubjective catastrophe” (p. 55). in my article “between two worlds” (o’reillyknapp, 2001), i described part of the turmoil in the loss of self as follows: basic needs and wants become lost in a massive, psychic withdrawal, and relationships are dismissed because what is most needed is also what is most feared. the person is left suspended between both internal and external encounters with no real relationship with either. the inner world consists of object relations filled with fantasies and dreams and a shell created by primitive isolation. (p. 47) i also noted that there is not only a primitive withdrawal … there is also a dissociative defensive stance used to protect the continuity of existence. the ability to separate experiences from awareness allows the individual to escape from perceived danger. withdrawal, as well as separation from internal and external experiences, becomes the shield against overpowering circumstances. (p. 45) my premise here is that in the schizoid process the person: (1) lives in a world of isolation, (2) within the matrix of unintegrated life experiences, and (3) copes as best they can in the real world. guntrip (1968/1995) wrote that there are attempts to connect that are thwarted and end up in perpetual isolation—as a “detached spectator” (p. 18). he described mental activity as disappearing into an inner world where there is absolute withdrawal from life, “into the living death of oblivion, an escape into passivity and inactivity” (p. 92). case vignette: bill bill called for an appointment out of concern that he was going into a backward spiral. he came for psychotherapy because he felt like he was going back to his “old” days, when he lived for 2 years in the woods after his return from vietnam. it reminded me of how guntrip described a part of the ego “which knows and accepts the fact that it is overwhelmed by fear and in a state of exhaustion, and that it will never be in any fit state to live unless it can, so to speak, escape into a mental convalescence where it can be quiet, protected, and given a chance to recuperate” (as cited in hazell, 1994, p. 178). i viewed bill’s time spent in the war as an important source for his present concerns. in psychotherapy, he needed a chance to recuperate. international journal of integrative psychotherapy, vol. 11, 2020 74 part of the schizoid dilemma is that the person lives within a world of isolation and unintegrated experiences and constructs a system of organizing events to avoid feelings and memories. in this position, splitting pushes out of awareness the need for contact and connection. for a client with a schizoid process, “a therapeutic relationship allows each child ego state to emerge and be met with a safe, attuned response” (erskine, 2001, p. 4). in bill’s therapy, we began with two areas that had not been dealt with in his previous therapies; only later did he examine his childhood experiences. the day before he and his friend were to leave vietnam, a grenade was thrown into their encampment, and his friend was mortally wounded. in a session, i had bill close his eyes and go back to that encampment where he held his friend in his arms as he lay dying. bill was silent, tears coming down his cheeks. to help him give words to that traumatic event, i asked bill to talk to his friend, tell him what he meant to bill, and how he felt about him. finally, i asked him to say good-bye and to tell his friend what he would remember about their friendship. we both then sat in silence. later i told bill how sad i was. i was also thankful that he was there and that his friend was not alone as he died. after the session i had a message from bill thanking me for being there for him and that he recognized how important it was for him to be there with his friend. a second area dealing with the war was raised in a weekend intensive workshop that i co-led. when bill came home from the war, his plane was greeted at the airport by antiwar protestors. they spit at his troop and called them murderers and baby killers. in the group setting, through reenactment, group members listened as bill described his return from vietnam. he talked about his arrival home and the response of protestors as he left the plane. when he finished group members talked about their feelings. then members welcomed bill with respect and love. one member in the group had been an antiwar activist. both cried as she went to him and asked for his forgiveness. this is an example of how an intensive therapy is necessary to affect difficult, unintegrated remnants of a person’s past. this group setting gave him a place to resolve a painful ordeal. most of bill’s psychotherapy focused on reorganizing his internal sense of being and emerging from isolation and historical detachment. he described how he felt alone and isolated from the world, about living his whole life alone and afraid. in one session he started to talk about his time in the woods. i encouraged him to close his eyes and go to the woods. i told him i would go with him. much of the time he was silent, and i sat with him and reminded him periodically that i was with him. in subsequent trips to the woods, he began to remember how as a young boy, around 5 or 6 years old, when his father would become violent and go after his international journal of integrative psychotherapy, vol. 11, 2020 75 mother and any of the other children who were present, bill would go into hiding, first under the kitchen table and then deep into his mind where he could not hear, see, or feel anything. according to bill, he was invisible. later, in school, he got into trouble for talking in class and fighting in the school yard. in high school he began to drink. when he joined the army, he did better because the structure helped him. over time in therapy, bill described the story of his life, including the years of isolation and withdrawal and his feelings of hopelessness and helplessness. his fear was realized, his rage and despair were heard, his excitement and joy were celebrated. bill lived for 15 years after he finished therapy. he saw his daughter graduate from college and his son finish high school. i heard from his wife that they had good times together before he became ill and died of kidney failure, which was attributed to a toxic herbicide used during the war. the between space intensive psychotherapy is necessary to affect the core of an individual who manifests a schizoid defense structure. effective therapy requires working with both the hidden, sequestered part of the psyche as well as historical events. with someone whose basic needs and desires become lost and relationships are dismissed, they are left suspended between both internal and external world encounters with no real relationship with either. the inner world consists of fantasies and dreams with a shell of primitive isolation. the external world is experienced as something with which the person is uninvolved, where they neither want nor have expectations of help from another. due to “sustained relations broken down at their most basic level,” there is self-loss and no connection to either self or others (orange, et al., 1977, p. 55) an understanding of emotional conflicts, unmet needs, and the loss of relationship are all important in dealing with loss of self. both here-and-now contact with the therapist and a return to states of fixation and dissociation provide the path for unfreezing early ego formation and unfolding of self. what was once constructed as protection and reinforced is now addressed in the therapeutic process. for both client and therapist, the process is unique to that particular relationship. theory and technique are used as a guide with continual assessment by the therapist of the therapeutic process. case vignette: sandy international journal of integrative psychotherapy, vol. 11, 2020 76 after consultation with an expert in the field of dissociative identity disorder, i agreed to work with sandy, whom i had met at one of the weekend workshops i did. over a year, she attended several more. she had been seeing another therapist in the state where she lived 400 miles away. although she had asked me to work with her, i did not want to interfere with her current therapy. however, when she became suicidal she called me. i would talk with her and then call her therapist to discuss her treatment. he told me he was going to terminate his work with her. i was conflicted and went for supervision. it was then, having the consultant’s opinion and support, that i made the decision to accept sandy as a client. after she terminated with her therapist, she and i began telephone sessions. readers may be wondering why i included sandy as a case example in this article. the reason is that i have found that several of my clients who had dissociative identity disorder also demonstrated a schizoid position. this was not evident at the beginning of therapy because the fragments that presented masked the withdrawn, regressed self. in this paper, most of the discussion will concern the schizoid condition. in addition to weekly phone sessions, sandy attended weekend workshops four times a year and a week-long residential treatment workshop in the summer. there were also occasional individual in-person sessions in my office when she was in the area. because a strong therapeutic alliance had been established in our meetings over the first year and a half, her work moved rather quickly into the memories and feelings she had repressed. during our telephone sessions, sandy was often silent, and i would be with her, telling her i was there. she started sending me drawings in the mail after a session, and this helped her to find the words as we talked about the drawing in our subsequent session. she began to allow her hidden self to show in her drawings and to talk about her vulnerability. as she started to recall the reasons she had locked herself away, she began to work with the split-off and painful memories. she dealt with her fears by drawing pictures of anger with red and black circles, fear as balls of orange and yellow, and sadness as blue and white squares. she talked about being trapped in circles of anger, balls of fear, and squares of sadness. each drawing had a feeling and a story, and i listened to them all. i sat with her as she went into the rage, terror, and despair. slowly, the drawings facilitated the emergence of her self. later, sandy began drawing pictures in which she was no longer trapped. there was a flow to the brush strokes and a lightness to the colors. the supportive, safe environment of the sessions allowed her to deal with the intense affect. time was provided for her to reenter the here and now and talk about her work with me. international journal of integrative psychotherapy, vol. 11, 2020 77 because the work was exhausting, we allowed time for her to recuperate. often a resting phase after the work helped her integrate new material. in the weekend workshops, she would go outside and sit under a tree after she had worked. she also used a journal to help her process additional information. with sandy, not only was a part of her withdrawn and hidden, she also held alter states of dissociated defensive structures. she had integrated several of her dissociated structures before coming to me, and for those that remained, i incorporated a method called “mapping” (kluft & fine, 1993). this type of recording represents a visual diagram in which dissociated parts are identified and given a voice. it was like putting the pieces of a puzzle together. in this process, sandy had a visual representation of her narrative and the fragments that needed to be unified. as she filled in her “story lines,” she was able to identify past experiences, form meaning out of events, and eventually develop an understanding of the past. this method was particularly effective for sandy because she was an artist and had a deep appreciation for graphics. being able to give meaning was an important step for her in remembering and then appreciating the assets she possessed to help her survive. the impact of impingements moving the body allows a person to shift in their surroundings as part of discovery and a “sense of real being” (clancier & kalmanovitch, 1984, p. 84). spontaneous movement is essential for exploring the environment without the sense of self being lost. winnicott described the importance of someone being present and not making demands, which allows for establishing an “internal environment” in which the self can be alone in the presence of another. when there is impingement or interruption of continuity in the body, there is “restlessness of the environment” (winnicott, 1988, p. 127). with the schizoid condition, movement is impeded. winnicott’s theory (newman, 1995) of impingements is useful in this regard, and his actual drawings illustrate the seclusion that occurs and how relationship patterns of isolation result. he used the analogy of a bubble wherein the baby is surrounded by the environment. when pressure on the outside is adapted to the pressure inside, there is a “continuity of existence” (winnicott, 1988, pp. 127–128). in a state of being , before and after birth, movement is a way for the baby to discover the environment. this move out into the surroundings is a part of discovery and the sense of existence. when pressure outside is greater, there is impingement and disruption of continuity. when impingement or encroachment is repeated, the individual returns to international journal of integrative psychotherapy, vol. 11, 2020 78 isolation. this isolation is different from loneliness in that it is a retreat from danger. in such cases, the person who withdraws from others “has experienced gross impingements from the beginning and has had to withdraw in order to preserve the core self from violation” (abram, 1996, p. 35). the state of being for the baby and even later life experiences can trigger such withdrawal. a pattern of relationship develops whereby, even without restrictions or intrusion from the outside world, the feeling of being restrained may lead to seclusion of oneself from others. in the schizoid process, isolation into what bettelheim (1976) called an “invisible fortress” severely restricts contact with others. case vignette: jane for the first month of her therapy, jane directed me to “just listen.” if i even nodded my head, she insisted that i was not listening. she told me my words got in the way. by attending to jane with my presence, i joined her without intruding. at times i broke the silence to tell her i was listening, but i think this had to do more with my own comfort than hers. most of the time i just listened. i questioned my effectiveness, even though i realized at the time my silence was vital to jane’s progress. i believe she needed what little (1990) referred to as a “settled” state, undisturbed by impingements (p. 44), and what erskine et al. (1999) described as “therapeutic presence,” a way of being there (p. 98). this attention was the entry into work about jane’s mother, who was always telling jane and her siblings what to do. jane felt like she was being smothered. she could not tolerate any reaction from me, and she later talked about how important it was for me to hear her. she reported she could now breathe. continually assessing my own responses to jane and her process helped me to safeguard our therapeutic relationship. the trauma existing in silence and withdrawal maintaining a connection with someone who is silent or who goes into hiding requires the therapist’s full attention. silences can occur when there are no words or if the words are too difficult to say, so help is needed to find the words or to say the words out loud. the client may also be silent when their experience is preverbal. it is also important to notice sounds as well as physical movement and for me to monitor my own thoughts and feelings as i sit with a client. what am i experiencing? is the connection with the client maintained? if i lose contact, what does that mean? it is important to remain calm and to tolerate silences so that a stable, settled state is created in the therapeutic setting. international journal of integrative psychotherapy, vol. 11, 2020 79 case vignette: linda when we began group sessions, linda would come into the office, sit in the corner, and remain silent most of the time. she had been referred by a colleague who thought a group setting might help linda to interact with others. after graduating from college, linda worked as a receptionist in a law firm. she was single and lived alone. her family constellation consisted of her parents, sister, brother, and aunt. she said she called periodically to talk to her parents and would learn about her siblings, and her aunt called to see how she was doing “once in a while.” it appeared most of her time was spent alone. linda seemed distant and uncomfortable when she was involved in conversations both before and during group, and she was the first to leave after the group was over. she reported she would “go away mentally” when others were talking so that she could steady herself. the problem was that she lost connection with what was going on. because she needed more time than the group could give her, i suggested she come to individual sessions to do the regressive work she needed. her individual sessions were lengthened from 50 minutes to 90 minutes to give her time to settle in and fully experience my presence. in the first individual session, linda sat on a pillow in the corner and was quiet. i listened to her silence and sensed tightness in her body. when she started to speak, she would stop midsentence and become frustrated, saying she wanted to stop and go away. when i asked her about going away, she talked about hiding herself far away where no one could see or hear her. i asked her to close her eyes and go into her quiet, and i focused on being a witness to her withdrawal. the first sessions she remained still and calm in the withdrawal for about 10 minutes. she talked later about how she frequently went to that place when she was afraid. it was a place where she felt safe. as the sessions progressed, linda began to remember being afraid and alone. she had been shivering and said that she was cold, so i covered her with a blanket. this was a source of comfort as she began to remember her mother screaming and “doing crazy things.” she started to remember the times her mother tied her to a chair because she was making too much noise or the time mother locked her out of the house for a whole night. linda’s father traveled for work and was not home most of the time. from the time she could walk until she left home to go to college, her mother continued acting out while linda took most of the abuse to protect her sisters. international journal of integrative psychotherapy, vol. 11, 2020 80 in her sessions, linda began to deal with her feelings of terror because no one was there to help her. i reminded her that i was with her now. she wept with despair as she recognized her experience of not having a caring mother. i sat beside her and held her hand as she cried and screamed for help. and when she raged, i took her anger seriously about her mother’s brutality by saying i was also angry at that behavior. one of the many times she went back to being tied up, i asked her to allow me to untie her. as she went through this she cried out “never again.” when linda opened her eyes, she reached out to me and i took her in my arms. contact in silence and withdrawal interaction with another is central to the discovery of one’s self. fairbairn (1952) highlighted the hunger for contact and connection. from in utero throughout the life span, the individual is in continual interaction with others, and these exchanges become part of the sense of self. mitchell (1988) considered the relational matrix as one in which the establishment and maintenance of relatedness is fundamental, and the mutual exchange of intense pleasure and emotional responsiveness is perhaps the most powerful medium in which emotional connection and intimacy is sought, established, lost, and regained. (p. 107) the child learns a style of connection, and these learned modes are maintained throughout life. it is in the relationship with the therapist that connection that was lost or never provided can be established and retained so that a new relational pattern can develop. guntrip (1968/1995) described the ultimate problem in psychotherapy with a schizoid process as “the rebirth and regrowth of the lost, living heart of the personality” (p. 12). as described earlier with peggy, i spent a good deal of time in silence. i arrived at the same time and waited for her. my presence was an invitation to her: i am here for you, i am waiting for you. my presence also signaled: i want to be with you. as i sat anticipating peggy’s arrival for a session, i thought about our last time together. i looked forward to spending time with her. i believed she was able to sense my desire to be with her. part of sue’s therapy involved her struggle to maintain her saneness while at the same time deal with overwhelming feelings and memories. i arranged for her to hold my hand as she began regressive work. at times i would ask her to squeeze my hand to stabilize her and to be a link to me and hopefully to reality. her clasp of my hand served as a reminder to her: you are here with me, you are not alone, i am not going away, and finally, i want you to stay with me. international journal of integrative psychotherapy, vol. 11, 2020 81 with jane, i was quieted by her, which allowed her to tell part of her story without interruption. once she had a sense of me there with her, she then moved into interchanges with me. i envisioned her process as: i know you are here, i want you to know i am here, and then we can be here together. in the work with linda, i sat with her in silence, honoring her withdrawal. she needed me to be there for her to acknowledge the existence of her withdrawal, and later, to validate and normalize her withdrawal. being present in the moment is one of the most powerful positions we have as a therapist. it takes desire and concentration to stay in contact and to provide a space in which the client’s narrative can be recounted and understood. the position of witness provides an invitation to the client: i am here with you, i see you, i hear you, i am interested in you. with bill, i waited with him when he went into his hiding places. i sat with a little boy who desperately wanted to be out in the world and be safe. he needed a place where he could explore, which he did by taking me with him, in fantasy, under the kitchen table and to the woods. there he went further into his inner sanctuary, where i sat and waited for him to come back from the hiding place we shared under the table or in the woods. along with dealing with his anguish, there were times when we played for that little boy’s benefit. sometimes there were songs, talks about baseball, laughter, and at times i even held him in my arms. my presence had the tone of “i encourage you to come out of hiding, i invite you to be in the world to explore and have fun. i know there are places in the world that are scary, and there are also wonderful places for you to be. let’s find ways for you to be safe.” in sandy’s drawings, unconscious material was brought into awareness. giving words to her sketches helped her to construct her narrative. they provided a path by which to uncover and understand her withdrawal patterns. appreciating how important graphics were to her, my remarks often included comments such as, “i see you, i picture you all alone in your hiding place, i see your struggle, i imagine you appreciating your strength.” with all the individuals described in this paper, i respected silence and withdrawal because of the importance both occupy in the schizoid process, even though it sometimes limited the exploration of other forces at work. for a more detailed account of therapeutic interventions, the reader is directed to my article “between two worlds” (o’reilly-knapp, 2001). in the therapeutic relationship, the therapist joins with the client in experiencing the affective connection needed for oneness and for the emergence of self-states. international journal of integrative psychotherapy, vol. 11, 2020 82 because of the extreme isolation and annihilation of self and others that characterize individuals with schizoid disorders, therapy needs to respectfully and consistently support the client’s unique position, deal with the need for contact, and take into account intrapsychic processes. providing a safe place for the emergence of the self and the establishment of a therapeutic bond is primary. the withdrawn space of encapsulation and the loss of relationship in the withdrawal need to be understood as attempts to survive. how the individual, with the therapist’s support and encouragement, can move from a position of avoidance of contact becomes a major portion of the therapeutic work. arieti (1974) wrote that the therapist needs perseverance in reaching such individuals. tustin (1986) identified patience, tact, and skill as requisites for the therapist in working with a withdrawn person. staying in contact takes effort for both the client and the therapist, but it is an effort well worth it in the end. conclusion i hope this detailed discussion and the case vignettes will add to our knowledge about the importance of silence and withdrawal in working with schizoid processes. the ultimate purpose of therapy for clients with a schizoid condition is to provide a place for the reorganization of an internal sense of being and emergence from isolation. in this paper, i have attempted to answer two fundamental questions: how can the therapist provide the space for silence to be supported? and what is needed for the therapist to maximize her or his presence when a client withdraws? i have shown here how i used contact to maintain connection with each client during episodes of silence and withdrawal in the schizoid process. the stability and integrity of the therapeutic relationship allowed for the integration of a split self and ultimately an emergence from seclusion. although the work was difficult, i never tired of it. in fact, i was honored by the trust given to me by these brave individuals. references abram, j. (1996). the language of winnicott: a dictionary and guide to understanding his work. jason aronson. arieti, s. (1974). interpretation of schizophrenia. basic books. balint, m. (1968). the basic fault: therapeutic aspects of regression. tavistock. international journal of integrative psychotherapy, vol. 11, 2020 83 bettelheim, b. (1976). the empty fortress: infantile autism and the birth of self. the free press. bowlby, j. 1969). attachment: vol. 1 of attachment and loss. basic books. bruch, h. (1969). psychoneurosis and schizophrenia. lippincott. clancier, a., & kalmanovitch, j. (1984). winnicott and paradox: from birth to creation. tavistock. erickson, e. (1963). childhood and society. norton. erskine, r. g. (2001). the schizoid process. transactional analysis journal ,31(1), 4–6. https://doi.org/10.1177/036215370103100102 erskine, r. g., moursund, j. p., & trautmann, r. l. (1999). beyond empathy: a theory of contact-in-relationship. brunner/mazel. fairbairn, w. r. d. (1952). psychoanalytic studies of the personality. tavistock. guntrip, h. (1995). schizoid phenomena, object relations and the self. international universities press. (original work published 1968) hazell, j. (ed.). (1994). personal relations therapy: the collected papers of h. j. s. guntrip. jason aronson. kluft, r. p., & fine, c. g. (1993). clinical perspectives on multiple personality disorder. american psychiatric press. little, m. (1990). psychotic anxieties and containment: a personal record of an analysis with winnicott. jason aronson. may, r. (1953). man’s search for himself. norton. mitchell, s. a. (1988). relational concepts in psychoanalysis: an integration. harvard university press. newman, a. (1995). non-compliance in winnicott’s words: a companion to the writings and work of d. w. winnicott. free association books. orange, d. m., atwood, g. e., & stolorow, r. d. (1977). working intersubjectively: contextualism in psychoanalytic practice. the analytic press. o’reilly-knapp, m. (2001). between two worlds: the encapsulated self. transactional analysis journal, 31(1), 44–54. https://doi.org/10.1177/036215370103100106 international journal of integrative psychotherapy, vol. 11, 2020 84 perls, f. s. (1969). ego, hunger and aggression: the gestalt therapy of sensory awakening through spontaneous personal encounter, fantasy and contemplation. vintage books. piaget, j. (1971). the construction of reality in the child. ballantine books. tustin, f. (1986). autistic barriers in neurotic patients. karnac books. winnicott, d. w. (1988). human nature. schocken books. international journal of integrative psychotherapy, vol. 11, 2020 14 relational withdrawal, attunement to silence: psychotherapy of the schizoid process richard g. erskine12 abstract this article describes the psychotherapy methods that were effective with a client who unconsciously relied on the schizoid process of splitting of the self. harry guntrip’s writings about the schizoid compromise and donald winnicott’s descriptions of the true self and the false self are discussed. alternative concepts— the vital and vulnerable self and the social self—are presented along with the methods of supported withdrawal and therapeutic description. keywords: schizoid, schizoid process, schizoid compromise, true self, false self, harry guntrip, donald winnicott, phenomenological inquiry, therapeutic description, relational psychotherapy, countertransference, withdrawal, silence, attunement, inquiry, involvement. ------------------------------------- adopt the pace of nature: her secret is patience. ralph waldo emerson (n.d.) ------------------------------------- violet was a confusing and, at times, difficult client who taught me about relational withdrawal and the importance of attunement to silence in psychotherapy. although i had previously worked with clients who were afraid of making intimate connections and struggled to talk about their inner life, i did not 1 institute for integrative psychotherapy, vancouver, canada 2 deusto university, bilbao, spain international journal of integrative psychotherapy, vol. 11, 2020 15 appreciate the significance of their urge to withdraw from relationships. prior to working with violet, i practiced psychotherapy in an active and engaging way, particularly with depressed clients. i encouraged individuals such as violet to make both internal and interpersonal contact by asking them to talk about their feelings in the first person, to look me in the eye when talking, and to engage in social activities that included participating in an ongoing therapy group. however, violet’s way of being with me challenged my therapeutic approach and stimulated me to think and transact differently. she was the first of several clients to teach me about the schizoid process. violet came to individual therapy with a variety of complaints. she was a 52-yearold professional writer who was unproductive in working on her new novel, disappointed that her previous book had received only minimal praise, and “disgusted with being fat.” she was disheartened because her husband alternated between ignoring her and controlling her. the most revealing thing she said in our first session was that she binged on sweets to ease the feelings of loneliness and hopelessness that would sweep over her. her stories included a number of selfcondemning comments. i was surprised by her remark that she was “fat” because she did not appear that way to me. violet was stylishly dressed, and her conversation was extremely polite. my first impression of her was that she was depressed. in our psychotherapy sessions, violet would go into detail about her current life, often reciting what she did day by day while avoiding talking about internal sensations or feelings. she did voice some disgruntlement about her family life and gave several examples of how she was compliant with whatever her husband or members of her extended family wanted. i was amazed that she could provide detailed information about various situations in her life but there was no revealing of herself. instead of looking at me, she looked at the carpet or over my shoulder. often i experienced that she was talking at me rather than to me. throughout the first year of our psychotherapy sessions, i responded empathetically to violet’s stories, which to me sounded both aggravating and depressing. i actively listened, even though i sometimes felt drowsy while she talked. perhaps my drowsiness was an integral part of her, as yet, untold story. i knew i was missing an emotional connection with her. it was up to me to remain attentive to my misattunements with violet’s rhythm, affect, and perhaps her developmental level of functioning and, importantly, to decipher what was occurring in our intersubjective process (stolorow et al., 1987). unlike my psychotherapy with other depressed clients, my sessions with violet tended to focus more on current events and to emphasize how violet could change her behavior. for example, i talked to her much more than i usually would about a healthy diet, maintaining a consistent schedule for her writing, and how to have an international journal of integrative psychotherapy, vol. 11, 2020 16 intimate relationship with her husband. at the same time, i tried to neutralize her continued self-criticism by pointing out her accomplishments and encouraging her to think positively. still, my interventions seemed to have limited impact. i thought it would be beneficial to include in violet’s psychotherapy some expressive methods that had been effective with other clients who were living with compliance, self-criticism, and reactive depression. on several occasions, in response to some aspect of her storytelling, i asked violet to imagine her husband sitting on a chair in front of her and to express her anger at her husband’s demands. she refused and became silent for the rest of the session. as an alternative, i asked her on a few occasions to look at me and tell me about her anger. each time she turned her head away and went silent. i was intrigued by how long she could remain silent. i questioned myself: was my use of cognitive-behavioral and expressive methods a countertransference reaction? if so, to what was i reacting? i discussed my work with violet in supervision. the supervisor only reinforced what i was already doing and addressed neither my lack of attunement to violet nor her lapsing into long silences. so, in my introspection, i searched for what was missing in our therapeutic relationship. i realized that i was not making full interpersonal contact with violet. just like her, i was not fully present. i was confused by her. i did not understand how she functioned. no wonder i periodically felt drowsy or found my mind wandering to other situations. it was evident to me that in the absence of any emotional connection between the two of us, i compensated by becoming increasingly behavioral in my interventions. eventually, i became aware of a parallel process: my focus on behavior change mirrored both her mother’s and her husband’s attempts to control her behavior. my countertransference was in my wanting something to happen … so i focused on expressive methods, cognitive understanding, and behavioral change to ward off my worry about not being an effective psychotherapist. it became clear that i was not providing the kind of psychotherapy violet needed. still, i continued to rely on therapeutic methods that had been effective with other clients. i encouraged violet to make more interpersonal contact with me, to see my face, and to speak directly to me. i talked about my feeling sad for her and irritated at her mother’s behavior toward her. i used relationally connecting words such as “we” and “us.” i wanted her to experience my listening to her and taking her seriously. however, looking me in the eye was particularly difficult for violet. the more i encouraged her to be interpersonally contactful, the more she responded with either self-criticism or silence. whenever i made any inquiry of her—whether it was phenomenological, historical, or about how she coped with a situation—she would either respond superficially or turn her head in silence. throughout the first international journal of integrative psychotherapy, vol. 11, 2020 17 year and a half of our work together, i asked violet many questions about her childhood and the nature of various interactions within her family of origin. i received abbreviated responses. our sessions continued to be filled with stories of her current life. session after session i listened intently to violet’s descriptions of what was happening to her two children, her discontent with her husband, and her difficulties with writing and food. not only did she repeat stories, but, as time went on, they became more elaborate. sometimes violet did not remember what we had previously talked about; it was as if she had not been present. i was concerned about her continued self-criticism and spent time in each session challenging how she negatively defined herself. i questioned myself as to why she continued coming to psychotherapy sessions. i told myself that she must be receiving some benefit because she never missed a session. and i wondered about violet’s unrequited relational needs and if she was unconsciously struggling to make an impact on me, or to define herself, or to find security. when i asked violet to evaluate her experience of our psychotherapy sessions, she was pleased. she said that they were much more helpful than her previous two attempts at psychotherapy. i was amazed. what was helpful? when i asked for details, she could not describe what she meant. all my attempts to make the work with her interpersonal seemed like a failure to me. i felt inadequate. yet violet continued to come to our sessions in spite of her husband’s many attempts to stop our work together. useful metaphors we continued in this same pattern for almost 2 years. at that time, i was studying psychoanalysis, particularly the british object relations perspective (greenberg & mitchell, 1983; kohon, 1986; sutherland, 1980). i was impressed by the writings of michel balint (1968), ronald fairbairn (1952), masud khan (1963, 1974), margaret little (1981), ian suttie (1988), and donald winnicott (1974). i particularly admired the writings of harry guntrip (1968, 1971) and his descriptions of working with clients who withdrew from relationship in a “schizoid compromise” (guntrip, 1962, p. 277). jeremy hazel (1994) collected several journal articles by guntrip that depicted how he developed an understanding of the schizoid phenomena and suggested a relational orientation to psychoanalysis. donald winnicott (1965, p. 17) had used the terms true self and false self to describe the fragmentations in an individual’s personality when there is an emotionally overloading disruption in the child’s internal stability and sense of self. he depicted the true self as the source of needs, feelings, and spontaneous selfinternational journal of integrative psychotherapy, vol. 11, 2020 18 expressions that become split-off, disavowed, and desensitized—“the equivalence of complete psychic annihilation” (greenberg & mitchell, 1983, p. 194). winnicott delineated the false self as someone who hides behind an emotionless façade and cannot allow themself to be either spontaneous or relaxed and quiet because they are constantly attending to the criticisms and demands of significant others. i realized that these theories were only an approximation of what happened within my clients when as a child they lived with constant misattunement, ridicule, and stress. however, the theory served as a useful metaphor in guiding my therapeutic involvement with clients. the theory was also helpful because it stimulated my thinking about early relational disruptions, intrapsychic processes, and archaic forms of self-stabilization. i was faced with a puzzle: • was violet’s polite and proper presentation her true self or her false self? • did violet have a true self? • if so, who was violet’s true self? • what sort of neglect or trauma would force the true self into hiding? • if there was a hidden true self, how could i build a healing relationship with the emotionally authentic violet? • did the so-called false self serve necessary functions or was it pathological? • what if the concept of true self and false self did not represent what was occurring inside violet? how could i then make sense of her superficial stories, the lack of interpersonal contact, and the absence of any vitality, emotions, or vulnerability? playing with this puzzle enabled me to expand my thinking. i explored the theory of the true self and the false self from a nonpathological perspective that redirected attention to the concept of self-in-relationship. who we are is always contingent on other people with whom we have been in relationship; therefore, our sense of self is always cocreated in each relationship. this concept of self-in-relationship inspired me to reexamine my attitude and way of working with violet. i was uncomfortable with the terms true self and false self because they did not depict how i experience my client(s). the words “false self” imply deceit, whereas “true self” implies something worthwhile. these terms seem to suggest that something was wrong with the person who had a false self, even though perhaps winnicott’s false self had some important homeostatic functions such as stabilization, regulation, continuity, or pseudoattachment. keeping winnicott’s ideas about splitting in mind, i thought about two aspects of violet’s sense of herself. she had a social self that achieved a semblance of relational attachment by accommodating to the requirements of significant others. she also had a vital self and vulnerable self (erskine, 1999) that subliminally international journal of integrative psychotherapy, vol. 11, 2020 19 experienced feelings, needs, and energy but remained protectively internal and isolated. i began thinking of violet (and, later, other clients like her) as someone who learned to hide her vitality and vulnerability. she created a social façade (i.e., a false self) in order to give the impression of some form of relational attachment— a persona that anxiously adapted to the expectations of others while hiding her own sensitivity and vitality. her attachment pattern was isolated and different from either an anxious or avoidant attachment pattern because she longed for a comforting relationship (ainsworth et al., 1978). violet’s isolated attachment pattern was the result of childhood attempts to self-stabilize and self-regulate her fear of being invaded and controlled (erskine, 2009; o’reilly-knapp, 2001). an essential psychotherapy were donald winnicott, harry guntrip, and the other writers mentioned earlier describing my client violet? i thought so. even though they provided some general guidelines about psychotherapy for clients who managed their life via a schizoid process, i was left without a specific therapy plan. guntrip (1968) described how a person is driven into hiding out of fear and then experiences a deep, sequestered loneliness that drives them out of hiding back into an adaptive interface with the world. such a person is constantly caught in the struggle between hiding or connecting to others, but in an adaptive way. guntrip (as cited in hazell, 1994) defined the necessary psychotherapy of the schizoid process as the provision of a reliable and understanding human relationship of a kind that makes contact with the deeply repressed traumatized child in a way that enables one to become steadily more able to live, in the security of a new, real relationship, with the traumatic legacy of the earliest formative years, as it seeps through or erupts into consciousness. … it is a process of interaction, the function of two variables, the personalities of two people working together towards free spontaneous growth. (p. 366) winnicott described the essential ingredients of an in-depth psychotherapy for clients who manifest a schizoid process as providing a respectful, understanding, reliable environment, one that the client never had and needs if they are to redevelop out of inner conflict and inhibitions. such an environment allows the person to find out for themselves what is natural for them. both guntrip and winnicott encouraged a psychotherapy that focuses on the client’s internal processes and not specifically on cognitive insight or behavioral outcome, one that provides a healing relationship to a traumatized and psychologically fragmented client (hazell, 1994; little, 1990; winnicott, 1965). international journal of integrative psychotherapy, vol. 11, 2020 20 i was impressed by the loving commitment that these psychotherapists had for their clients. i too felt a profound responsibility toward violet even though i was confused, felt drowsy, or searched for how i could help her change. what if i followed guntrip’s advice and made contact with the deeply repressed instead of focusing on interpersonal contact or change? i made a commitment to myself to respect her silences, to support her withdrawal, and to create a safe place for the deeply repressed to express herself. this required that i be consistent and dependable in providing a secure therapeutic relationship, even though i did not understand her unexpressed affect or tendency to withdraw. guntrip, winnicott, and their colleagues were defining an essential psychotherapy that focused on the client’s internal process, one that provided a healing relationship (erskine, 2021). discovering a vital self we were now near the end of our second year of psychotherapy. i had been puzzling for weeks over the questions of false self and true self that i have already mentioned. i wondered if the quality of my psychotherapy would be different if i thought of violet’s silence and withdrawal as her attempt to protect a vital and vulnerable aspect of herself and her polite, proper, and superficial presentation as a social façade that had at least two important functions: protection and attachment. i also gave considerable thought to the gestalt therapy concept of contact and interruptions to contact (perls et al., 1951). clearly, there were many contact interruptions in our relationship: i did not feel a connection to the essence of who she was, she did not express emotions, and she most likely was not in contact with her internal sensations. she told stories and i listened, but we still had almost no interpersonal contact. i wondered what would happen if i encouraged violet to focus on her internal experience instead of telling me her stories. when there was a pause in violet’s storytelling, i invited her to close her eyes and stay quiet for a few moments so that she could sense her internal experience. at first she was frightened by the prospect of doing this in front of me. encouragingly, i again asked her to close her eyes, to be quiet, to feel her internal sensations, and to not speak for a while—to concentrate on the sensations that were happening inside of her. she appeared to withdraw into herself. i was not sure if she was turning inward to feel her internal sensations or just returning to a familiar hiding place. i was concerned about the possibility that she was merely complying with my request as she had learned to do with her mother. violet remained quiet for a few minutes. she then opened her eyes to see if i was still present. i assured her that i would stay present as she went inside. we experimented with her closing her eyes and going to what she called her “quiet international journal of integrative psychotherapy, vol. 11, 2020 21 place.” at first she was able to withdraw for only a minute. then, little by little, we extended the time to several minutes. by the end of the session, she said that it was a “quieting experience.” i was not sure what her words meant, but her body seemed softer and more relaxed. the next session began with violet again telling a detailed story about her family life. after a short time, i interrupted by asking her about her experience in the previous session. she said that she was afraid to “go internal” in front of anyone because “what i have inside is private. no one can know it.” i asked her how she had experienced me in the previous session when she was in her quiet place. she said that she was “scared, but it was ok because you did not try to control me.” it was evident to me that violet’s quiet place was her attempt to self-stabilize and create a place of security. i told her that i thought it was important for her to visit her quiet place and that we explore what she was experiencing. i also said that i was willing to accompany her, and i promised that i would do my best to not invade her. i also talked about how we had been rehashing stories about her family and that in my view not much had changed in the past 2 years. she disagreed with me and said, “you listen to me. you never criticize or define me. you are gentle with me. that is why i come back.” we concluded that session by agreeing that we had seldom talked about her internal experiences and that in the previous session we had begun an important exploration. in the next session, i invited her to experiment with closing her eyes and attending to her internal sensations. i told her that i would remain physically still but that i would watch over her in a protective way. she then withdrew into her quiet place and remained silent for 15 minutes. when she opened her eyes, violet said that i had discovered her secret, “my quiet hiding place. it has been my private place, all my life.” over the next several months we often experimented with violet withdrawing from external contact and making internal contact with her feelings, needs, and body experiences. in the beginning of this experimental work, she was without any words. she had sensations in her body, but she did not know how to speak about them. violet described her quiet place as being in her childhood bed with the covers and pillow pulled over her head. in one session she said, “there are a lot of things in there that i don’t want to feel.” as she said that, i realized that i had been feeling increasingly protective of her; i could sense her intense vulnerability. i imagined myself sitting in her bedroom, vigilant, quiet, and ready. my imagination was essential in keeping me focused on violet’s vulnerability during our long periods of silence. interestingly, i never felt drowsy or distracted when violet had withdrawn into her quiet place. i was always alert and interested in her internal experience. this was very different than the sleepiness i periodically felt when she previously international journal of integrative psychotherapy, vol. 11, 2020 22 told me detailed stories about her family conflicts. whenever violet was recounting her current, day-by-day stories, i watched for little signs that she was withdrawing: averting her eyes, leaving long pauses, or jumping from one story to another. she was telling me in a coded way about the attachment disruptions in her life and her desperate attempts to feel secure. her stories were a metaphorical message about how she required my sensitivity to her unique rhythm and her need for security in our relationship. at that point, during most of our sessions, i reserved some time to invite violet into her vulnerable place. my task was to be patient, respect her silence, provide time for her to make internal contact, and encourage her to feel both the internal safety of her quiet place and the safety of our relationship. i spoke to her in a soft, reassuring voice and made comments such as “it’s important to have a quiet place,” “it’s so necessary to feel safe inside,” “there is no need to hurry,” and “i am right here watching over you.” i talked slowly and with a voice tone i might use if i were speaking to a frightened child. i provided long pauses between my statements to allow violet time to experience and process any affect related to what i was saying. as violet withdrew into her imagined bed, “covered by blankets and pillows,” i relaxed and did some deep yoga breathing to keep myself centered and fully present. i kept my eyes on her and listened to her sighs and other soft sounds while i watched her physical movements. i did not try to make something specific happen. but i wanted to create the time and place for violet to feel both the security of her quiet place and my nonintrusive, caring presence. as the months progressed, i discovered that her quiet place was not so quiet. it was also a place of fear, sadness, and profound loneliness. in some sessions, when violet withdrew to her imagined bed and covers, she was desperate to escape the memories of her mother’s control. she had many examples, at various ages, of how hurt she had felt by her mother’s criticism. from deep in her chest she would cry with spasms of heartbreak, sorrow, and loneliness. in the beginning of this therapeutically supported withdrawal, her cry was without sound, and in subsequent sessions, her cry became a full vocal cry. i remained present, listening, and periodically responding with compassionate sounds and mirroring what she had been feeling. it then became apparent to me that her highly detailed stories, her quickly jumping from one story to another at a speed that did not allow for any dialogue, was an unconscious strategy to help her not feel her loneliness. she was unconsciously looking for interpersonal connection and simultaneously fearing any human closeness. on some occasions, after a long period of what she called “going internal,” violet would make sounds that were a combination of mournful crying and disgust. these were accompanied by gestures of pushing with her hands. she was without words international journal of integrative psychotherapy, vol. 11, 2020 23 to express her diversity of feelings. she often emerged from her withdrawal in physical and emotional distress, struggling to tell me about the various incidents of neglect and the constant criticism from her mother. my task throughout all this therapeutically supported internal work—like the job of parents with young children—was to help her develop a language so that she could communicate her internal distress and needs, her vitality and vulnerability. as our psychotherapy continued in the following months, violet actively expressed an array of feelings. in some sessions she would withdraw into the vulnerability of her internal world, one in which she remembered being terrified of her mother coming physically close to her. violet described how she would try to escape both her mother’s touch and her “mean words” by imagining that she was in her bed with the covers pulled over her head. she was proud as she reported how she could “hide in bed” even when sitting at the family dinner table. violet had changed. some days she could now describe her personal experience, physical sensations, and various feelings. learning from the client when i first learned to support violet’s withdrawal into her quiet place, i often made phenomenological inquiries such as “what are you feeling?” or “what do you need?” (erskine et al., 1999; moursund & erskine, 2003). i discovered that my inquiries interrupted violet’s withdrawal. she would open her eyes and start to tell me some story about her current life rather than respond to my inquiry. phenomenological inquiry was an essential form of connection with most of my clients, and i was curious why it was not working with violet. i realized that there was an important theme in the stories violet had been telling me over the past 2 years. both her mother and her husband constantly labeled her. they both defined who she was. as a child, and now as a wife, she struggled to conform to their definitions of what she should feel and how she should think and act. violet described how the only freedom she had from their definitions was when she withdrew into her quiet place and did not have to accommodate herself to their definitions and expectations. i pointed out that the theme of being labeled and defined was present in many of her stories and that perhaps she experienced my inquiries in a similar way. she agreed, saying that she experienced them as a definition of her, sometimes as “a demand that i be different.” over the next few sessions, we made some fascinating discoveries about our relationship. when i would ask violet “what are you feeling?” she translated it to mean “what you are feeling is bad.” when i inquired about what she needed, she interpreted it to mean that something was wrong with her for having needs. when international journal of integrative psychotherapy, vol. 11, 2020 24 i inquired about her physical sensations, she tensed her body because she did not know how to act. violet was constantly accommodating, altering herself to fit what she imagined my expectations of her were, a clear example of transferring old emotional memories into our relationship. at first, understanding the transference was difficult for violet. she could not see her own accommodating reactions, although she could experience the juxtaposition between my behavior and the criticizing, controlling, and judgmental behavior of her family. she began to be more relaxed with me and more willing to spend time in her quiet place. i experimented with limiting the amount of phenomenological inquiry i used with violet. when she would withdraw into her quiet place, i was silent, observant, present, and feeling protective. at first my not inquiring provided violet with an opportunity to go deeper into her internal experience. she could feel her sadness and fear. when she was withdrawn—imagining hiding in her childhood bed—she would alternate between being frightened about making any sound and then quietly crying. but eventually she became worried that my silence meant that i had gone away. i was in a dilemma. if i inquired, i interrupted her internal experience. if i was silent, she would interrupt her withdrawal because she was worried that i was not present. in another session, i invited violet to withdraw to her safe bed. there were about 15 minutes of silence during which i watched over her in the same way that i watched over my children as i sat by their bed at night when they were sick. i watched violet’s labored breathing and the tension in her clenched hands. i said, “you must be so scared.” violet nodded her head. i was surprised because i realized that i had just defined her experience. a couple of minutes later i again said, “you must be so scared. it is important to have a safe hiding place.” she again nodded her head. after another 2 minutes of silence, i offered, “it is so important to hide in your quiet place, particularly when you are sad.” she again nodded, her breathing returned to normal, she unclenched her hands. when violet opened her eyes, she said my description of her internal experience was important because it meant that i understood her and that she was not alone. i was surprised. we discussed how my description of her internal sensations was different from her mother’s and her husband’s criticizing definitions of her. she described my voice as “tentative” and my tone soft, “not a definite, authoritarian voice” like those she was used to in her family. later, with other clients who used relational withdrawal to self-stabilize, i again discovered the effectiveness of using therapeutic description as i learned to do with violet. therapeutic description provides the client with validation of their often unspoken emotional and physical experience. it is based on attuning oneself to the client’s unverbalized sensations and experiences and helping the person form a language international journal of integrative psychotherapy, vol. 11, 2020 25 to talk about their physical and emotional sensations. it offers an understanding so that the client can further articulate their previously unspoken experiences and the profound effects of relational disruptions. it provides a vocabulary for previously unspoken experiences to be acknowledged and eventually talked about. therapeutic description also provides an interpersonal connectedness from psychotherapist to client. it is not the same as interpretations or explanations that are given to other types of clients to enhance their cognitive understanding of psychological dynamics. therapeutic description involves a sensitive attunement to the client’s way of being that includes timing, tone of voice, and carefully observing the client’s nonverbal responses to the descriptions. however, if therapeutic description is used too early, it can be experienced as defining or invasive. violet provided the best definition of therapeutic description when later in the psychotherapy she told me how she experienced my comments: “it is as though you knew my internal experience, my fear of relationship, the safety in silence, the importance of hiding, and the depth of my loneliness. you helped me find the words to talk about my inner life. now i am more alive most of the time.” in summary violet continued her psychotherapy for 4 years. we had many sessions during which she would go to her quiet place, sometimes for 20–30 minutes. during those long periods of silence, i practiced how to be therapeutically quiet: to not intervene and to tolerate my uncertainty about what was happening within violet. i periodically spoke, but only to reassure her that i was watching over her or to provide some sparse therapeutic descriptions. gradually, i acquired an intense patience, one that is so necessary in working with clients who use relational withdrawal and silence to self-stabilize and self-regulate. i was watchful of every breath, sigh, and movement she made. i listened to her silence and compassionately worried about her speechless struggle. there were often times when there would be a long silence, but she was eventually able to describe her body sensations, sob in her loneliness, and be angry at her mother while still often being scared of “getting it wrong.” in several sessions during which violet imagined being in her safe bed, she would sit up and tell me about the neglectful events in her childhood, the strict rules she lived with, and her mother’s constant demands for “perfect behavior.” i observed the tension in her arms, neck, and legs as she talked about her mother. sometimes, when i pointed out that her body tension might indicate that she was angry, she would begin by shrugging her shoulders and saying, “i don’t know.” but, international journal of integrative psychotherapy, vol. 11, 2020 26 as we focused on the language of her body, she began to recognize that she was angry. in our fourth year of working together, we were talking face-to-face. most of my transactions with violet were composed of phenomenological and historical inquiry that was designed to help her discover and put into language her emotion-filled but never-talked-about childhood experiences of parental neglect and control. during this phase of the psychotherapy, i did not use therapeutic description. that sensitive way of communicating was reserved for the times when violet was silent and withdrawn into her hiding place. the therapy was now focused on violet’s becoming aware of herself. we paid a good deal of attention to her body sensations and various emotions. i acknowledged her memories and validated her emotions. many sessions included my helping her put her untold story into words. i prompted violet in defining herself. i shared with her how she had influenced me and how i had to change the orientation of our psychotherapy. at first, she did not believe me, but eventually she said, “in the beginning you wanted me to do something different, something i didn’t know how to do, just like the other therapists. but then you changed. you got softer and quieter. that helped me be me. did you really change because of me?” in response to my various inquiries, violet told me stories about her marriage. i could hear violet’s anger at her husband’s criticism and control. she was still reluctant to do any active anger work, but she was now able to say “i don’t like it” and “i don’t want it.” she and her husband began to have arguments for the first time in their almost 30 years of marriage. she was now defining herself, refusing to comply with her husband’s demands, and expressing what she wanted in her marriage. violet’s husband became enraged at the changes she exhibited at home. he demanded that she terminate therapy. he threatened divorce. she was terrified of being alone. at the beginning of the next meeting after his threat of divorce, she shook with fear as she announced that this was her last psychotherapy session. she said that her husband had intensified his demands that she stop her therapy. a wave of sadness swept over me. violet had made some significant changes in her ability to express both her vitality and her vulnerability. at least in my presence she was neither putting on a social mask nor withdrawing. i did not know what to say to relieve her distress. i was dismayed; our ending was so abrupt. several years later i met violet on the street. she told me that she was living alone in her own apartment and that it was she who had initiated the pending divorce from her husband. he now opposed the divorce, but she was determined. she angrily said, “i’ve had it with his control. i’m now almost 60, and it’s time i live my own life. i’m coming back to see you once this is all over. i have more work to international journal of integrative psychotherapy, vol. 11, 2020 27 do.” although i never heard from violet again, i will always be grateful that she taught me about the schizoid process and the importance of the psychotherapist supporting the client in making internal contact with the vital and vulnerable self. i came to appreciate the therapeutic results that come from being attuned to my client’s silence, and i rediscovered the profound effects of relating to my clients from a nonpathological perspective. references ainsworth, m. d. s., blehar, m. c., waters, e., & wall, s. (1978). patterns of attachment: a psychological study of the strange situation. lawrence erlbaum. balint, m. (1968). the basic fault. tavistock publications. emerson, r. w. (n. d.). [quote]. retrieved from https://www.brainyquote.com/search_results?q=adopt+the+pace+of+nature %2c+emerson erskine, r. g. (1999, 20 august). the schizoid process: a transactional analysis perspective [opening address]. international transactional analysis conference, san francisco, ca. erskine, r. g. (2009). life scripts and attachment patterns: theoretical integration and therapeutic involvement. transactional analysis journal, 39(3), 207–218. https://doi.org/10.1177/036215370903900304 erskine, r. g. (2021). a healing relationship: commentary on therapeutic dialogues. phoenix publishing. erskine, r. g., moursund, j. p., & trautmann, r. l. (1999). beyond empathy: a therapy of contact-in-relationship. brunner/mazel. fairbairn, w. r. d. (1952). psychoanalytic studies of the personality. routledge. greenberg, j. r., & mitchell, s. a. (1983). object relations in psychoanalytic theory. harvard university press. guntrip, h. (1962). the schizoid compromise and psychotherapeutic stalemate. british journal of medical psychology, 34(4), 273–288. https://doi.org/10.1111/j.2044-8341.1962.tb00524.x guntrip, h. (1968). schizoid phenomena, object relations and the self. international universities press. guntrip, h. (1971). psychoanalytic theory, therapy and the self. basic books. hazell, j. (ed). (1994). personal relations therapy: the collected papers of h. j. s. guntrip. jason aronson. khan, m. m. r. (1963). the concept of cumulative trauma. the psychoanalytic study of the child, 18(1), 286–306. khan, m. m. r. (1974). the privacy of the self. hogarth press. kohon, g. (1986). the british school of psychoanalysis. yale university press. little, m. i. (1981). transference neurosis and transference psychosis. jason aronson. https://www.brainyquote.com/search_results?q=adopt+the+pace+of+nature https://www.brainyquote.com/search_results?q=adopt+the+pace+of+nature international journal of integrative psychotherapy, vol. 11, 2020 28 little, m. i. (1990). psychotic anxieties and containment: a personal record of an analysis with winnicott. jason aronson. moursund, j. p., & erskine, r. g. (2003). integrative psychotherapy: the art and science of relationship. brooks/cole-thomson. o’reilly-knapp, m. (2001). between two worlds: the encapsulated self. transactional analysis journal, 31(1), 44–54. https://doi.org/10.1177/036215370103100106 perls, f., hefferline, r., & goodman, p. (1951). gestalt therapy: excitement and growth in the human personality. julian press. stolorow, r., brandchaft, b., & atwood, g. (1987). psychoanalytic treatment: an intersubjective approach. the analytic press. sutherland, d. (1980). the british object relations theorists: balint, winnicott, fairbairn, guntrip. journal of the american psychoanalytic association, 28(4), 829–860. https://doi.org/10.1177/000306518002800404 suttie, i. d. (1988). the origins of love and hate. free association books. winnicott, d. w. (1965). the maturational processes and the facilitating environment: studies in the theory of emotional development. international universities press. winnicott, d. w. (1974). fear of breakdown. international review of psychoanalysis, 1, 103–107. relational healing of early affect-confusion international journal of integrative psychotherapy, vol. 4, no. 1, 2013   31 relational healing of early affect-confusion part 3 of a case study trilogy richard g. erskine abstract: part 3 of a case study trilogy on early affect-confusion describes the use of therapeutic dialogue, relational presence and supportive age regression in the psychotherapy of a client who lived on a “borderline” of early affect confusion. the concepts and methods of an in-depth, integrative and relational psychotherapy include a sensitivity to the client’s physiological and emotional expressions of implicit and sub-symbolic memories, therapeutic inference, an awareness of the client’s relational-needs, the effective use of a developmental image, as well the identification of an introjected other and the use of therapeutic interposition. key words: therapeutic presence, relational-needs, developmental image, subsymbolic memory, implicit memory, age regression, non-verbal enactments, supportive-regression, introjected other, therapeutic interposition, in-depth psychotherapy, aspirations, therapeutic dialogue, therapeutic inference, integrative psychotherapy, affect-confusion, phenomenological inquiry, borderline, affective attunement, developmental attunement. _________________________ our therapeutic relationship in years four and five when our psychotherapy sessions began again in september, i often had in mind an impressionistic, developmental image of theresa as a kindergarten and school age child who lived in fear of expressing her own ideas, needs, and what she liked or disliked. i felt an intense concern for the psychological safety of such a frightened and helpless child. i focused on staying attuned to her loneliness and felt a constant sense of compassion for her as a sad little girl. i often spoke in a calm way to engage that frightened and despairing child that she once was, to help her identify and talk about her feelings, needs and how she made sense of her relational experiences. international journal of integrative psychotherapy, vol. 4, no. 1, 2013   32 when theresa would lead a session into complaints about her boyfriend or concerns about work, i would return to that neglected and emotionally abused little girl by inquiring about theresa’s physiological and affective reactions in living with an angry and confrontational mother. my frequent focus on the lonely or hurt or frightened child stimulated many new memories of her mother’s disdain. now the memories were of the interactions with her mother at a younger age. session after session was filled with deep crying and a number of painful memories of how “my mother squashed my desires” and “always told me that something was wrong with me”. we were now getting to her childhood experiences of feeling helpless and worthless. one day, when she was describing her mother’s typical over-controlling behavior, theresa suddenly screamed out, “she treated me like i was a piece of shit. but i was only a little girl with needs. i needed her help. i was too little to do everything like a grown-up. i am not a piece of shit. you, mother, missed seeing the precious child that i was”. this emotional outburst marked a major step forward in theresa’s psychotherapy. we talked at length about the difference in acting helpless in life today (her crying spells and demands on her boyfriend) and actually needing to depend on her parents when she was a child. together we imagined how her life could have been if she had been treated as “precious” and contrasted it with her experience of life as “a piece of shit”. the psychotherapy had a whole different tone than in the previous three years. we were no longer talking about crises or theresa’s self-destructive behaviors; we were talking about her needs as a child and her self-worth today. it was mid-morning when theresa called me from her office. “i’m just so crazy! i do not know what to do. i’m in a rage inside. but this time i did what you told me to do; i did not scream at anyone. i cannot stand it when anyone is disrespectful. i need to talk to you”. this was again a major step forward in her psychological growth. she contained her explosive rage, used my counsel about how to manage disagreements, and called me for support. i complimented her on not raging in the office and made a lunch hour appointment that was only two hours later. when she first arrived she ranted about the disrespect from a woman at work and her boss’s lack of support. once she had aired her anger and had told me some of the details of what had occurred that morning, i asked her about what international journal of integrative psychotherapy, vol. 4, no. 1, 2013   33 “disrespect” meant to her. after several inquiries it became clear that she defined disrespect as any disagreement with her point of view. she went on to describe how she often perceives disagreement as confrontational. as i asked her to tell me more about what she associated with the word “confrontational”, she had a sudden realization that this was how her mother reacted in most situations. “i am being just like my mother” she shrieked; “i hate her for how she is so aggressive and makes even the slightest difference into a fight”. she went on to say, “i have lived with her anger all my life and now i’m shocked to think that i am being just like her”. she then began to cry and express her despair and utter hopelessness in trying to express her own ideas, likes or dislikes, wishes, and needs as a child. i now had two clear focal points for our continuing psychotherapy: first, it seemed important to address the relational–needs and survival reactions of a neglected and verbally abused child; and, second, it would eventually be beneficial to therapeutically engage with the internalized mother who was influencing theresa’s current life. in working with other clients suffering from early affect-confusion it has been extremely useful to decommission the influence of the introjected other, but only after a secure therapeutic relationship with the distraught “child” is well established. i continued to address the previously untold experiences of that little girl while also acknowledging and normalizing her aspirations. as our psychotherapy continued, her unfolding narrative ebbed and flowed with my phenomenological and historical inquiry. my consistent inquiry stimulated her to remember numerous painful and humiliating experiences that she had never talked about. and each inquiry was also a form of acknowledging what she had just said and in turn stimulating the next memory, feeling, or insight. our therapeutic dialogue included my frequent inquiry into how she coped and regulated herself when her mother was critical, aggressive or rejecting. i periodically acknowledged her intelligence and creativity in managing the deficits in the relationship with her parents and verbally applauded how she managed to get a semblance of psychological needs met outside the family. i continued to remember that she had said, “i am being just like my mother”. i started to impose myself between theresa and her internalized mother by telling theresa what i would have said to her mother if i had been visiting in their home when her mother was being so criticizing and rejecting of theresa. examples of these therapeutic interpositions included: “i would have told your mother to stop yelling at you and to sit down and listen to your feelings”; “i want to tell your mother that ‘your little girl needs your care and compassion not your criticism!’”; “you need to go to therapy, mother, and not take out your anger on your daughter.” she would sometimes cry when i would make such international journal of integrative psychotherapy, vol. 4, no. 1, 2013   34 statements. on other days she would angrily say, “that is the protection i needed from my father”. it was too soon to provide actual therapy for the introjection of her mother’s personality. my therapeutic interpositions would suffice for now since they were effective in stimulating theresa’s awareness of what she needed as a younger child and how she was creative in adjusting and coping with her mother’s critical and controlling behaviors. before i attempted any therapy with her parental introjects, more time was needed to support theresa’s self-definition, her need to make an impact and her need for security and validation. acknowledging and normalizing these relational-needs seemed to be essential to her psychological growth. she was now depending on our therapeutic relationship for her internal support. theresa described the qualities of that support as having someone in her life on whom she could “rely on and receive guidance…even protection when i am overwhelmed with feelings” verbalizing implicit memory many of theresa’s early childhood relational experiences –experiences in which she had been deprived of an opportunity to be put into language -were now coming to consciousness because we had co-created a safe place to talk about her childhood feelings, desires, needs and bodily sensations. her parents had not provided the necessary validating conversations that could have given words, concepts and meanings to theresa’s experiences; her experiences had remained without linguistic symbolization until we talked about them in our psychotherapy. my phenomenological inquiry, curiosity, concerns, and personal presence stimulated theresa’s awareness of memories that she was unable to recall on her own. she had an increasing realization that much of her current life’s conflicts were motivated by her emotional reactions to many unresolved relational conflicts with her parents. i asked theresa to describe the quality of conversations she had with her parents over breakfast or before going to school in the morning. all she could recall was her father’s absence and her mother’s insistence that she be on time, be dressed neatly, and that she stay clean. she could not remember any discussion about her excitement or fears, who she liked and who liked her, or her joys or stresses that could possibly be occurring during the school day. i asked about her returning from school and the quality of conversations with her parents at that hour. she could remember being criticized for getting dirty or being late but she was unable to recall any dialogue that acknowledged her experiences, feelings, or wishes. “my mother was only interested in my doing all my homework before i could play”, she said angrily. international journal of integrative psychotherapy, vol. 4, no. 1, 2013   35 in several sessions i continued this type of historical inquiry with the focus of my inquiry shifting to the qualities of her maternal relationship at an ever-younger age. i spent three sessions inquiring about her bedtime routine and the quality of possible conversations with her parents at that relationally crucial hour. she said that during her school years she had to be in bed by nine each night and that she could read alone for fifteen minutes. her father always watched tv and that she would sometimes give him a kiss on the cheek before going to her room alone. her mother demanded that the lights be off at 9:15; she never read to theresa or sat on the bed to discuss the day’s events or prepare for the next day. often her mother never said, “good night”; it was expected that theresa would obey the rules. there was no one to help theresa understand and manage her own world. as i focused my inquiry on bedtime for the preschool child, theresa had no memory of being cuddled, read to, or having any pre-sleep conversations with either parent. now i fully understood the cumulative neglect, over many years, that led to theresa’s conclusion: “no one is there for me”. theresa’s answers to my initial inquiries about her day-to-day life with her parents were often short and factual but each of these historical inquiries was followed by many phenomenological inquiries about her sensations, feelings, associations, thought processes and desires. this often led to an inquiry into how she survived, accommodated, and stabilized herself when no one was emotionally or conversationally there for her. my questions were not aimed at merely gathering the facts of her history; my inquiry was always focused on her inner experiences and subjective processes in response to those historical experiences. my inquiry, attunement, acknowledgement and normalization facilitated her to put her previously non-conscious body, affective, and relational experiences into words. it was slow work, yet theresa and i were now coconstructing a narrative of her young life. through our therapeutic dialogue we were acknowledging, giving meaning to and validating what she called her “unthought about” experience. i continued to focus my inquiries on a younger and then even younger child. our work often involved long silences as theresa struggled to put her physiological sensations and feeling into words. i proceeded by inquiring about her pre-school experiences and eventually asked what she knew about her infancy and toddler years. i raised questions about her play activities when she was three or four years old. during this phase of our therapy together her first answer to many of my questions was, “i don’t know”. in response to theresa’s “i don’t know” i would ask her to close her eyes and imagine herself as a pre-school child. in addition to many implicit images of “rules” and “nothingness”, she did have three explicit memories: she could remember being about three years old and climbing on her father’s lap and his international journal of integrative psychotherapy, vol. 4, no. 1, 2013   36 laughing with her; she could remember her mother “being harsh” with her when she “could not use scissors properly when i was four”; she remembered playing alone with her stuffed animals when she was between three and four years and having an overwhelming sense of deep loneliness. as we talked at length about her loneliness theresa said that all of her life, until now, she could not understand why all her “stuffed animals were lonely and scared”. much of this period of time was spent attending to theresa’s profound sense of loneliness – an early childhood loneliness that previously had no means of interpersonal expression except for her to imagine it in her stuffed animals or to deflect it into conflicts with people. she needed a consistent therapeutic presence and compassionate attunement to her loneliness and fear even though she sometimes angrily complained, “my loneliness and fears did not exist before this therapy”. were theresa’s descriptions of her pre-school years an accurate recall of actual interactions with her parents or were they her impressions? i’m not sure. however, i assumed that such impressions were created from many subsymbolic and implicit memories and therefore were an avenue for inquiring further about theresa’s subjective world. as i listened to theresa’s phenomenological experience of her early childhood, i attended to my own sensations and impressions, my own affective pull to comfort and protect her, and my knowledge of child development and what any child needs in a parental relationship in order to form a secure attachment. all of this, and all that i had learned about her in the previous four years, became the data in forming many inferences about her affective/ relational life. therapeutic inference was my most important tool when i was striving to understand and help theresa express her pre-symbolic and non-linguistic memories. her memories of early-childhood and infancy were not available to consciousness through language because her experiences were either preverbal or did not have a relationalopportunity to be put into language. although theresa lacked a coherent narrative of her life’s experiences, her sub-symbolic memories were expressed in body sensations, emotional reactions, and selfregulating patterns. her unconscious attachment patterns were disorganized, often on an oscillating borderline between avoidant and anxious. theresa lived on a “borderline” of intense neediness and rage, despair and self-reliance, impulsivity and manipulation. in observing her oscillations between avoidant, anxious, and disorganized attachment patterns, i assumed (even though i had no explicit data) that the first few years of her life were as psychologically tumultuous as her school and teenage years had been. my attunement to her affect, rhythm, and developmental levels, as well as my physiological resonance, were essential in international journal of integrative psychotherapy, vol. 4, no. 1, 2013   37 forming an involved connection that facilitated a communication of her subsymbolic experiences and implicit memories. i attended to how her pre-verbal story was expressed in nonverbal enactments, encoded in her stories and metaphors, embedded in her relational conflicts, and engendered in my emotional reactions to her. it was up to me to make use of all of this information to create a healing relationship for this distressed infant and toddler. i asked theresa to imagine being a child about sixteen or eighteen months of age, who was sitting in a high chair and being fed by her mother. i inquired about the look she imagined would have been on her mother’s face, how her mother would have reacted if she disliked the food, her mother’s tempo in feeding her, her mother’s joy or disapproval, and all the body sensations that went with each inquiry. i also asked similar questions about her emotional and physiological experience of nursing, diaper changing, bath time, toilet training, and mutual play. this whole series of inquiries lasted several months and provided both of us with a plethora of information about theresa’s early affect-confusion: her physiological sense of feeling both repulsion towards her mother and simultaneously a painful longing for an intimate connection. she remembered being frightened by the harsh looks on her mother’s face, squirming as her body sensed her mother’s rough touch, disgusted with how she was forced to eat, and the muscle contractions in her body in reaction to her mother’s rhythm. in many sessions theresa wept over what she had missed in a mothering relationship and she raged at her mother’s callous behavior. she also cried in terror as she sensed her mother’s harsh treatment of her. in our therapeutic work together theresa re-experienced the trembling body sensations of emptiness and emotional abandonment when her mother would not look at or talk to her for “hours or even days”. she now identified her “gnawing, hungry feeling” as a need for nurturing. at the same time she realized that “even as a baby i must have avoided her rough touch and mean face”. theresa had many reasons to be profoundly confused as an infant and to have formed a relationally-avoidant life pattern. i was reminded how loving and forgiving young children can be; in several sessions theresa wept and pleaded: “momma, please love me”; “momma, don’t leave me… i’ll be good”; and, “please, please, please, momma”. sometimes she would curl up on the couch and just moan the word “momma”. she feared the deep sensations of loneliness that would come when mother ignored her. she described how, as a pre-school child, she would do anything to get her mother to talk kindly to her. in another session, while experiencing herself as an older child, she screamed in anguish, “i have adapted, adjusted, accommodated and conformed my entire life just to get my mother to stop hating me”. theresa international journal of integrative psychotherapy, vol. 4, no. 1, 2013   38 became increasingly able to relate her infant and early childhood loneliness to the clinging demands she made on her boyfriend. she realized that she was demanding that robert be a “good mother” to her. dispelling early affect-confusion following these and other realizations theresa’s age regressions began to lose their thrust of urgency. in our ongoing therapeutic dialogue we reviewed these childhood experiences many times to understand their significance in her life and we also returned to these expressive early childhood emotion-filled sessions when a supportive-regression seemed to be an important form of communicating and resolving her previously non-conscious story. but theresa now had less and less of an urge to regress to earlier periods of relationalneglect. theresa was now able to make many associations and connections to her adult life behaviors and emotional reactions. she had a good understanding of her habit of pushing people away, her fear of intimacy, her rage (particularly at women), and her “tremendous longing for someone to be there for me”. as the spring of our 5th year together approached and we would again be taking a summer recess, i began to turn my attention to finding opportunities to inquire about theresa’s aspirations. what were her future plans? what did she always want to do and had never got around to doing? she said that she was tired of the subservient position of being a legal assistant and had always hoped to become an attorney. she added that she wanted to “have a loving relationship …. with robert”. this was how we ended in may of our fifth year. theresa was enthusiastic about returning in september “in order to better understand myself”. in these previous two years, while i attended almost exclusively to theresa’s experience as an infant and very young child, i kept in mind her words, “i’m just like my mother”. since i would be traveling most of the summer this was not the time to approach this issue. previously i had postponed doing any psychotherapy with her introjected mother; i would postpone it again until autumn. the therapeutic interpositions that i periodically made between the criticizing comments of an introjected mother and the natural expressions of a little girl had been effective in quieting much of theresa’s internal criticism and distress. but the psychotherapy was not complete. i considered the resolution of theresa’s introjection of her mother’s personality to be essential to our doing a comprehensive and in-depth psychotherapy. during this time my first two priorities had been to establish a greater sense of relational security for theresa and to facilitate her expression of her own relational-desires, what she liked and disliked, and her private aspirations. i was primarily focused on the child’s unrequited need for self-definition and the need international journal of integrative psychotherapy, vol. 4, no. 1, 2013   39 to make an impact-in-relationship while always keeping in mind theresa’s needs for security and validation. as a child, theresa was never effective in making an impact on her angry mother. her attempts at self-definition were met with confrontation and ridicule, an absence of validation and a lack of security-inrelationship. to avoid the unending conflicts with her mother, theresa reactively sacrificed her natural forms of self-expression. as this year came to an end, i reviewed what i had learned in my work with theresa; i had a renewed appreciation of theresa’s aggressive behavior towards people being a non-conscious expression of her unmet relational-needs for validation, self-definition, and her need to make an impact. by picking fights at home and at work she was expressing these unrequited developmental needs, never achieving satisfaction because her angry expressions were out of their original context. our psychotherapy co-created a therapeutic space that simulated memories of her original family context – a therapeutic space in which her vital needs could be expressed, validated and normalized. it was also clear to me as to why i intuitively had never used confrontation as part of my therapeutic dialogue with theresa; confrontation would have been nontherapeutic, perhaps even reinforcing of the psychological damage that she had already experienced. she seemed to thrive on my sustained affective and developmental attunement, my gentle phenomenological inquiry, and my firm and respectful involvement. when i returned from vacation in august there was an urgent phone message from theresa requesting “a special session as soon as possible”. two days later i discovered that she had been waiting a month to give me her “good news”. her boyfriend had been offered a job promotion; he had to move to a distant city. theresa had decided that since they had been having a “great relationship” for the past couple of years that she would “take the risk of moving with robert”. she talked at length about how much she had changed and how she and robert were now capable of intimate discussions instead of fighting. they had discussed their future: with her savings and his increased income, she could afford to go to law school and become an attorney. she was full of joy and excitement. she added that she had a secret: “i’ve been thinking of getting married. i am planning a big surprise for robert when he comes home this saturday night. i am going to propose that we have a wedding just before we move”. i had tears of joy in my eyes as i reflected on our five-year therapeutic relationship. i was personally enriched by what we had shared together. theresa had taught, or at least re-taught, me about the importance of patience, respect, kindness, uncertainty, priorities, parameters, and the need to attend to sub-symbolic and implicit memory in its many forms of non-verbal expression. international journal of integrative psychotherapy, vol. 4, no. 1, 2013   40 in the first couple of years it had been a difficult journey for both of us but she had grown in many ways. for the past couple of years theresa was no longer acting helpless at home by having “crying spells” or making demands on her boyfriend; she was no longer getting into conflicts at home or work; she selfregulated her affect-confusion and understood how her early relational life had influenced both her helplessness and ragging conflicts; and she now had a satisfying sense of self-worth and aspirations. theresa had changed in significant ways. my only concern was with theresa’s lingering internal criticism and the lack of opportunity to provide therapy for her introjected mother. but now it was time to say “good-bye”; theresa was no longer living on a psychological “borderline” of early affect-confusion. author: richard g. erskine, phd. is a licensed clinical psychologist, licensed psychoanalyst, certified transactional analyst, gestalt therapist, and certified group psychotherapist. since 1976 he has served as the training director of the institute for integrative psychotherapy in new york city and vancouver, bc, canada. date of publication: 17.10.2013 case study: lara international journal of integrative psychotherapy, vol. 1, no. 1, 2010 11 journey towards integration: the case of lara maruša zaletel abstract: in the following paper the author describes the integrative therapy process with a depressed client. different integrative diagnoses are presented, like self-in-relationship model, schizoid ego splitting, script system and attachment styles. the therapeutic process is described in different phases, special emphasis is given to the integrative relational methods and to the process of transference and countertransference. key words: case study, depression, schizoid ego splitting, relational methods, transference. _____________________ the aim of integrative psychotherapy is the integration of the client, which means gaining full internal and external contact (erskine & trautmann, 1997). usually it is a long process to achieve this integration. in the following case study i’m describing such a therapeutic journey, which is still not completed. on this journey i travel together with the client and we get to know each other. sometimes the journey is stormy, tiring and demanding, other times it is very pleasant and calm. this journey is enriching for both travellers (the client and the therapist) and is making permanent changes in both. the beginning of the journey when lara, a woman in her middle 30’s entered my office, my first impression was that she was depressive and had low self-esteem, because she was very pale, her body was rather bent, she was without life energy and not very talkative. at the first meeting lara indeed talked about her depression, which was the reason she came for psychotherapy. she told me that depression first appeared in her some years ago and she has suffered several recurrences since. she was taking an antidepressant; this helped her and she continued to take it along with her psychotherapy. but she didn't want to take drugs all her life so she decided to solve her problems with the help of psychotherapy. her depression manifested through tiredness, want of sleep, difficulties in concentration and memory, as slowness, pessimism, negative thinking, insomnia and stammering speech. when she came for therapy she had suicidal thoughts, but they were not strong. she mentioned she felt a bit of panic, because she could not see anything bright in the future, but she would not do anything to harm herself. at the first meeting she was neat and tidy, but as mentioned, without energy, rather quiet, international journal of integrative psychotherapy, vol. 1, no. 1, 2010 12 introverted and reserved. she made short replies to my questions and i had to ask a lot of questions. nevertheless, she had good eye contact, she was very motivated to change something in her life and immediately decided to attend the therapeutic meetings. i took this finding and the fact that she had her sense of humour preserved (we ended the session with some joking) as good resources. i also had perceived this as harbingers of her most probable establishing of a constructive therapeutic relationship with me and consequently that psychotherapy will benefit her. my assumptions were correct, since after the first couple of sessions she quickly relaxed, became more active and talkative. contact was established between the two of us. as regards psychotherapy, lara pointed out her goal was to eliminate her depression and to be able to live without antidepressants. she also wanted to reduce her self-doubts. we agreed to work on these questions and also on improving her self-image, reducing her self-criticism and working through her past. we agreed on a long-term psychotherapy, with the setting of one hour per week and concluded with an antisuicidal contract. history during her childhood lara lived in a very traumatic family situation full of psychological and physical abuse. she mentioned that everything from her childhood was connected to a bitter feeling. she lived with her mother, father and younger brother. her father was unhappy, depressive, not self-confident, but in her childhood she experienced him as a powerful and great authority. her father was addicted to alcohol and drank daily. he was very strict and required discipline from his two children, especially from lara. he set strict rules and if these were broken, he beat lara. if she opposed him and objected to what he said, he hit her. on several occasions he also harmed her, e.g. that she bled from her nose; hitting was almost a daily practice. on the one hand her mother was a warmer person but she was subordinated to lara's father. her mother did not protect her when her father beat her, at the same time she had high demands of her (at least those connected to school and society). lara could read her mother very well; she knew exactly what she felt and thought; she knew to react accordingly; she constantly took care of her mother. mother's attitude towards her was very variable. sometimes she was kind and interested in her, yet in cases when she did not like something she scolded, even hit her, which lara understood as the end of their relationship and love. but when mother showed her benevolence again, lara immediately forgave her. lara's parents often quarrelled with each other, although father was less often physically aggressive towards the mother than towards lara. lara blamed herself for being the cause of quarrels, e.g. when she wanted something, parents quarrelled, because father prohibited it while mother allowed. so lara preferred to suppress her wishes and remained quiet to avoid quarrels. according to her conclusion there would be peace at home if she was a good girl. even at her young age, lara had to assume responsibility for her younger brother. he was like her shadow and prevented her from relaxing completely. besides, she had to help him at school and play with him. parents took it for granted that lara should help him and also take care of herself. it was as if she was her brother's mother. she always protected her international journal of integrative psychotherapy, vol. 1, no. 1, 2010 13 brother and never said »no« to him. her parents divorced when she was a teenager and she lived with her mother. in her childhood lara had some friends with whom she played. but even as a small girl she was rather introvert. in the kindergarten she was reserved, she held herself back in the background, because she already had fears that her behaviour might have been wrong. she was terrified to go to the primary school, because she did not know anybody. it was hard for her to get acquainted with new schoolmates. besides, the parents greatly limited her choice of girlfriends as they kept deciding which girl she could sit together with at school and which ones she could not. they wanted her to be only in the best company. lara has lived with her husband for more than 10 years now. at the beginning of their marriage she did not dare tell her husband what bothered her. what she missed was spending more time together with him, as he often went around alone, but she did not want to make the impression that she wanted to limit him; actually she was afraid he would leave her. she was much subordinated to him, afraid of quarrelling, as the slightest quarrel seemed a catastrophe to her, again triggering her fantasy that he would leave her. she took it as an attack if her husband was of a different opinion. after she had left home she felt guilty about leaving her mother, who would not be able to confide her troubles to anyone anymore, since her brother moved away soon after her. her moving gave her a feeling that her attachment to her family was broken, that she was leaving a safe place. then her depression appeared for the first time. she did not tell anybody about her sadness; she only took refuge in bed. when sleeping she felt the safest, she forgot all her troubles. she continued this practice. lara and her husband have two children. lara loves them a lot and enjoys the time with them, but she also says that she quickly looses her temper when educating them. sometimes she notices her reactions are like her mother's. she doubts her abilities about being a good mother. she feels she does not involve herself sufficiently with her children, and she can be either too strict or too mild. lara was very successful, hard-working in primary and secondary school, but she did not finish her studies. she explained that her motivation faded away, because she was always hard-working at school when others pushed her to work, while at the university this was not the case any more. during her therapy when her depression improved she again started writing her thesis and she now wants to conclude her studies. she has a job, but her work results are average, she is not motivated. she is very sensitive to any criticism about her work, although her assumption is that they are meant just as hints of how to improve her work. she takes any comment very personally and later feels guilty. sometimes she takes her colleagues work and offers them help in order to get their attention and praise. diagnosis dsm-iv axis 1: 296.32 major depressive disorder, recurrent, moderate. axis 2: 301.82 avoidant personality disorder. axis 3: none. international journal of integrative psychotherapy, vol. 1, no. 1, 2010 14 axis 4: problems with primary support group (victim of physical and emotional abuse in childhood; disruption of family due to parents' divorce). problems related to the social environment (inadequate social support). occupational problems (job dissatisfaction). axis 5: gaf= 55 moderate symptoms and moderate difficulty in social and occupational functioning. integrative psychotherapy diagnosis in terms of integrative psychotherapy, lara’s behaviours, thoughts and affect can be viewed within a relational framework. in view of the integrative model of selfin-relationship (erskine & trautmann, 1997) it is the cognitive dimension in lara which is the most open for contact. her behavioural dimension is also well expressed, while at her emotional and body level she is more closed for contact. nor has she paid much attention to her spiritual dimension. schizoid ego splitting the so called schizoid ego splitting can be noticed in lara. in her early relationships lara did not have safe attachments. she lived through neglect and lack of attunement, the consequence of which is that children hide their feelings and relational needs. this stops or slows down the process of integration and the ego gets fragmented (klein, 1987, in little, 2001). this gives rise to the first degree of a split or withdrawal as described by fairbairn (1952, in little, 2001), where the ego splits into coping/every day self (central ego), which maintains the relation with the outer world, and the withdrawn/vulnerable self (libidinal ego), which hides itself. at an early stage of development lara could not display some parts of herself, like feelings of vulnerability, anger, playfulness, her own interests, the part connected with relaxation and enjoyment, because for all these she was punished with physical violence and emotional rejection. she hid and suppressed this part of herself and thus the withdrawn/vulnerable self formed. outwardly lara showed her coping/every day self, which listened to the parents, was good at school and at home, who did not object and had no interests of her own, while being active all the time. during the psychotherapy lara mentioned several times that she did not know at all who she was, that she did not know herself, because till then she mostly defined herself through others. this particularly describes the process of splitting into both previously mentioned selves, where the authentic self (vulnerable self) hid, while lara identified herself with the coping/every day self, which was more social self and represented her adjustments to the wishes of other people around her, like her mother, father, husband. simultaneously the splitting of external objects, i.e. people who were important for her, occurred. coping/every day self has to maintain a connection with important objects, otherwise the child could not survive on his/her own. this gives the child a sense of security (little, 2001), which represents a very important need for lara, as will be further described in the following text. for lara to be able to keep a tolerably good connection with her mother, she had to separate bad experiences and international journal of integrative psychotherapy, vol. 1, no. 1, 2010 15 internalize them, which suppressed her withdrawn/vulnerable self even more. in this way the coping/every day self is connected with the idealized object (little, 2001), which also holds true in lara's case. at the beginning of psychotherapy lara strongly idealized her mother, she spoke only of good experiences with her, not remembering disagreeable experiences, since these were split off. only with ongoing therapy was she gradually able to integrate these experiences. she was also very loyal to her mother, defending her all the time, not being angry with her, which all shows a strong tie between the coping self and the idealized object. on the other hand lara had disagreeable memories of her father from the very beginning. she mainly blamed him for her ugly childhood, so that lara probably formed a split also between both parents (father thus representing the bad object, and mother the good one). vulnerable self is in relation to the exciting/disappointing object (little, 2001) and this represents the developmentally needed relationship between mother and lara. their relationship was very changeable, i.e. mother was warm and kind to lara some of the time. lara hoped that mother would satisfy her needs, but was later disappointed and rejected by her. in my judgment lara's mother had great difficulties in getting attuned to lara. this resulted in the exciting/disappointing object to be experienced as painful and dangerous by lara, which meant that she suppressed this aspect into her unconscious as the disappointment. the withdrawn self splits further to create the internal saboteur (fairbairn, 1952, in little, 2001), which serves to keep the vulnerable self hidden and repressed. the saboteur's function is to precede criticism of other important persons and thus regulates a child's behaviour (erskine, 2007). it is namely easier to bear inner criticism than criticism by important other persons, because this would signify an end of a vital relationship. it is also too painful to incessantly repeat disappointments due to unmet needs, therefore the inner saboteur blocks these needs and even denies their existence. in lara the inner saboteur (antilibidinal ego) formed, manifesting itself in lara's excessive self-criticism. as early as kindergarten she criticised herself for her clothes, shoes, her behaviour and she worried that other children might not like her. through her inner saboteur lara constantly controlled herself, her vulnerable self, e.g., she forced herself to be strong, not to show emotions, to be constantly working, learning, to be well-behaved, and not to show her femininity. she kept convincing herself that she didn't lack anything. therefore lara created an inner saboteur to be able to survive with a violent father and mother. the inner saboteur is in relation with the rejecting/attacking object, which attacks the vulnerable self so that the latter would remain suppressed (little, 2001). rejecting/attacking object in lara was formed by aggressive reactions of mother and father, the violence (physical and verbal), daily criticism, humiliations etc. this part contains numerous contents, so the inner saboteur is very powerful. script system an important part of the diagnosis is lara's script system (erskine & moursund, 1988/1998), presented on the following figure 1. lara's script system script beliefs script displays reinforcing experiences self: i am bad, guilty, something is wrong with me. i am stupid and boring. observable behaviours: self-criticism, problems in setting limits to the others, subordination, obliging manners, always busy. withdrawal from social contacts, depression, taking refuge in her bed. introvertedness, problems in sharing personal matters with others. current events: inadequate success at work. marital problems with husband. problems with raising children. mother's rejecting, careless behaviour. depression. others: others are smarter, capable, better than me. i don't trust others. others are dangerous. reported internal experiences lack of energy, willpower. concentration and sleeping problems. pressure in chest, in throat. old emotional memories: father's and mother's criticism together with physical violence following her slightest mistake. if she could not perform at school, he father hit her on her head and said she was stupid. parents' quarrels, for which lara blamed herself. mother's contempt if she cried or displayed other feelings. her husband's sarcasm at the beginning of their relation. quality of life life and world are dangerous. one has to work hard. fantasies: fantasy that her husband will be violent towards her if they quarrel. he will leave her. about perfect life where everybody would live in perfect harmony without anger, quarrels, where she would be perfect. repressed needs & feelings anger, sadness, fear, joy almost all her relational needs figure 1. lara’s script system. the script system presents how lara turns in a vicious circle of script beliefs and reinforcing experiences which cause her depression. lara's beliefs of herself, others and the world or life correspond to the schizoid splitting and anxious-avoidant attachment styles, since they presuppose that others are dangerous, critical, while she is bad, inferior and it is consequently better for her to withdraw and hide her vulnerable self. this involves numerous suppressed emotions and needs. as for emotions, lara suppressed most of them. in her childhood lara had to suppress most of her relational needs (erskine, moursund, & trautmann, 1999). the main need which was not fulfilled was lara’s need for security, both on a physical and psychic level. in her primary family she international journal of integrative psychotherapy, vol. 1, no. 1, 2010 16 international journal of integrative psychotherapy, vol. 1, no. 1, 2010 17 could not present herself as she was. she was not allowed to share her vulnerability, as she was punished and despised in such cases. none of her relations contained safe attachments. lara fulfilled her need for safety by increasing her own control. she tried to control herself, for example by being good, quiet and obedient. in this way she assured herself safety (in order that her parents would not beat and insult her). at the same time she tried to control others, e.g. her mother, husband. she tried to influence her mother’s husband’s moods by coaxing them to improve their mood, since their bad mood meant potential danger for her (her mother usually scolded or hit her when she was angry. for lara, her control of others therefore means a substitute satisfaction of her need for security. she compensated her unfulfilled relational needs with the need for structure (more control, ego splitting, script system) and the need for stimulus (under stimulation, sleeping a lot, disavowal of affect, dissociation) (erskine, 1997). attachment styles in her childhood, i assume that lara had an avoidant attachment to her father (ainsworth, 1971, in bowlby, 1988). she avoided her father, as she was afraid to be alone with him because of his aggressive behaviour. for parents of avoidant children it is typical that they are unapproachable, indifferent to their child's needs, emotionally distant. behaviour towards the child is rejecting and uncaring, sometimes even escalating to physical and emotional violence (bowlby, 1988), which is typical of lara's father. lara's feeling was that her father rejected her, he did not love her. lara's attachment to her mother was more of an anxious resistant style (ainsworth, 1971, in bowlby, 1988). lara was attached to her, her mother gave her love at least occasionally, but she did not give her security. she was occasionally attuned to lara, but lara did not know in advance when she could rely on her. there was no constancy. sometimes her mother was over intrusive, for example she confided her marital problems to lara, she asked her intrusive questions, so that lara had to share personal matters with her even if she did not want to do this. all this is typical of an ambivalent attachment style, due to parents' not knowing how to correctly and constantly notice and meet their child's feelings and needs (bowlby, 1988). in her later life lara mainly had an avoidant attachment style (bartolomew & horowitz, 1991, in žvelc & žvelc, 2006) in her relationships and in her partnership with her husband. at the beginning of her partnership lara was distrustful, tense, easily subordinated, and only after a while managed to get attached to her husband. but she sometimes still feels doubts that her husband may leave her when he realizes she is not as she seemed to be at the beginning of their relationship. in other relations she also has problems in trusting people, because she is afraid that others may hurt her. avoiding nearness allows her to be protected from expected rejection by others, and in this way the avoidant attachment performs an important defensive function. phases of the therapeutic journey lara's psychotherapeutic process developed through various stages or phases, naturally with interlacing of these phases. during the first phase the main goal was to establish a safe environment and working alliance. to reach this i international journal of integrative psychotherapy, vol. 1, no. 1, 2010 18 used inquiry, mainly phenomenological inquiry, which is characteristic of the initial phase of therapy (erskine et al., 1999). i, as well as lara had to get acquainted with lara's inner experience and events around her, easiest to achieve through phenomenological inquiry. i also used acknowledgement (part of involvement), which is, according to the keyhole model (erskine et al., 1999), at the level of phenomenological inquiry. at this stage the existence of particular problems and patterns is just beginning to be revealed. i sometimes used normalization, as lara often felt she was not normal, as if something was wrong with her. usually lara accepted normalization very well and it helped her gradually to acquire a feeling that her experiences were completely normal. i have found attunement very important in all phases of psychotherapy. during the first phase cognitive attunement was important to me, because i wanted to understand the way lara thought, how she found meaning within and outside herself. in this way it was easier for me to adjust my explanations and questions to lara. affective attunement was also very useful to me, mainly so that i could feel lara's vulnerable part. both types of attunement helped me to better understand lara and tailor my interventions to her needs. at the same time i tried to attune myself to lara's rhythms. lara actually has had a rather slow rhythm. in therapy i then tried to allow her sufficient room for reflection, before she answered. i slowed down my rhythm too. i spoke slowly, i gave myself more time for reflection after lara's answer, so that we both had enough time for processing information. i tried to attune myself to lara's relational needs and my feeling was that during the first phase lara had a strongly expressed need for security and valuing. i noticed this through my own countertransference, i.e. i had a feeling that i wanted to protect lara. besides lara was very glad if i gave her recognition or stroked her in some other way; i noticed that this meant a lot to her. i tried to meet lara's need for security by setting clear limits of therapy, by concluding a therapeutic agreement with her, by informing her of the characteristics of the therapy and by telling her that there are no right and wrong answers. i accepted her in her wholeness, including her depressive, gloomier part. i did not condemn her when she thought i would. all this contributed to creation of a sense of safety in the therapy, she felt that she could show herself such as she was, without causing my respect towards her to diminish or without my criticizing or rejecting her. at the beginning lara and i had quite some troubles in establishing working alliance, since lara activated a strong inner saboteur who also attacked psychotherapy. also her script system was evoked. lara blamed herself for being lazy, that she must get herself in order and she worried about what i thought about her. after initial hours of therapy she felt that she just spoke nonsense, that i thought her narrative was inconsistent, that she was confused and unable to talk. at the same time she felt that she did not deserve a whole hour of therapy for herself, that her depression was not so serious to need psychotherapy, that she already felt better. my hypothesis was that already at the beginning lara activated the inner saboteur who attacked her vulnerable part, which wanted psychotherapy and wished to establish a new safe relationship. the inner saboteur was probably activated by the new relationship with me which, of course, was potentially dangerous in view of lara's past experience. all that activated lara's inner dynamics, which is very strong. moreover, lara projected the rejecting/attacking object on me, as she expected me to be critical towards her, that i would take her for a hypochondriac, a spoiled person. international journal of integrative psychotherapy, vol. 1, no. 1, 2010 19 this was a case of transference from her primary relations with her mother and father who blamed her for such matters, which she expected from me, too. my countertransference feelings which i experienced trough my attunement and involvement were those of shock over such hard self-criticism. i felt helpless against them, at the same time i felt empathy for lara, because i knew that this criticism was unfounded. i also felt her loneliness, because her inner saboteur did not allow her to let other people come near. based on these feelings i concluded that i carried lara's vulnerable part and that my psychotherapeutic task would be to try and protect it at least to some extent, because she was not capable of doing it herself. as a psychotherapeutic goal i presupposed, of course, that gradually lara would be able both to protect and express her vulnerable part and to weaken the strength of her inner saboteur. lara too agreed with this goal; she actually pointed out that she wanted to decrease her self-criticism and improve her self-image. i tried to strengthen lara's adult ego state with informing, i.e. i explained to her what psychotherapy was, the nature of my role and purpose, what were difficulties of other people who came for therapy like for characteristics of depression. this information served as a means of normalisation in terms that other people experience similar things, too, e.g. doubts at the beginning of the therapy, problems with speaking the whole hour about themselves. moreover, these explanations worked against the inner saboteur and script beliefs that she did not have serious problems, that she was only a hypochondriac, that in reality she was not depressive, but lazy. lara accepted those explanations and validations over time; she believed them and they helped her understand that she deserved psychotherapy and that her problems were serious enough to require therapy. apart from other interventions these explanations and validations managed to weaken the strength of the inner saboteur and introjections and at the same time increase the adult ego state. i found these cognitive interventions very suitable at the beginning as it was the cognitive dimension that lara had most open for contact. to strengthen the adult, beside informing i used awakening of resources, as i considered it important for lara to have at least some resources, before we started to work in depth on more traumatic events. we could go back to those resources in case the work during psychotherapy became too stressful and painful. i also assumed that these resources would help lara to improve and stabilize her moods, as this was a precondition for further, more intensive psychotherapeutic work. first i tried to motivate lara to become more active on her own behalf (behaviour intervention) so that we discussed activities which she had dropped, although she liked them, but could pick up again. i had a feeling that lara was quite open for contact in the behavioural dimension, therefore i assumed that such interventions would be effective. we practiced the »safe place« technique, techniques of diverting attention and of proper breathing. all this helped lara to improve her mood and she gained more energy and willpower. gradually all the above-mentioned interventions and methods helped establish a good working alliance between the two of us, and moreover, they boosted our contact. so we passed to the second phase of the psychotherapy which started after approximately eight sessions. lara decided to keep coming to psychotherapy and most of the time she maintained the feeling of deserving it. only on some fairly stressful occasions a feeling of guilt reappeared. gradually lara increased her trust in me; she felt well going through psychotherapy and she stated herself, that before a international journal of integrative psychotherapy, vol. 1, no. 1, 2010 20 therapeutic session she looked forward to it. during this phase of psychotherapy our therapeutic relationship slowly became deeper. lara no longer projected the rejecting/attacking object on me, but rather an idealized object, while she was more in her coping/every day self. in therapy she expected from me some magical questions and solutions, which would solve all her problems. for quite some months, whenever i asked her if anything in the therapy disturbed her, she answered “no”, that she was satisfied with everything. essentially she experienced me as omniscient and all-powerful, her idealizing transference was activated. i experienced lara as a very obliging client who wanted to find a perfect answer to each of my questions. i found psychotherapy as quite untiring for me, as lara accomplished a lot of work herself. she came most of the time to the session with some theme prepared in advance. after the session she often thought about it for some time, she looked for mistakes, what she didn't put right, what she could add. this shows that she acted mainly out of her coping/every day self which wanted to please me and to adapt to me. my feeling was that lara and i were in symbiosis during the second phase of therapy. for a while i assumed the role of an ideal object and entered into symbiosis with lara, since i felt that it would be too early for a deidealization as lara in my assessment needed to be with somebody who she felt was stronger than her to internalize more security. i took notice of that phase through my countertransference, i.e. after some strenuous session i worried if lara would be able to cope with all the burden, i had rather maternal feelings towards her, e.g. a wish to protect her from aggressive parents, anger at her parents. lara developed transference towards me out of the relation with her mother in which she wanted to take care of me and assume the responsibility for the therapeutic process. as mentioned before lara took care of her mother (reverse symbiosis), which she wanted to do in the therapy as well. when a link, symbiosis, formed between us, lara obviously activated an old memory of her symbiotic experience, that she had to take care of another person to get back at least some of the attention. in therapy we talked about this and i explained to her that in our relationship i take care of myself. i used some carefully selected self-disclosure to show her, how i take care of me. this helped lara and she could relax more in our relationship. in the second phase of psychotherapy lara and i also established a link between her present time (relation with her husband, children, mother, brother) and past. to reach this i used a lot of inquiry about her history and her decisions. the purpose of establishing linkages was to make lara aware that her past experiences were important and they influenced her current reactions. i also used validation for this purpose. in this way it was easier for lara to understand her way of reacting and she began to blame herself less. i also often used normalization, mainly when lara and i talked about the decisions she had made as a child. she attributed to herself blame for her parents’ abusive behaviour towards her. during this phase of therapy lara expressed strong loyalty to her parents. above all she idealized her mother, which coincides with our relationship. my validation and normalization helped lara to gradually gain insight into mistakes her mother made, thus to some extent diminishing her self-criticism and the power of her inner saboteur. lara and i moved in the first three phases of the keyhole model (erskine et al., 1999). the goal of this phase of therapy was for lara to gradually acquire better connection with her vulnerable self in place of her coping/every day self, while at the same time international journal of integrative psychotherapy, vol. 1, no. 1, 2010 21 increasing her contact with exciting/disappointing object instead of the idealized object. to connect better with her vulnerable part, with her needs and emotions we also did some regressive work. the working alliance with lara was mostly very good during the second phase of the therapy, although some breaks occurred. i found as important the break which occurred after a session when we worked more on regressive psychotherapy and lara came in contact with her child ego state or her vulnerable part. lara felt strong sadness, she wept, at the same time she felt her unfulfilled need for safety, understanding, warmth at home. i used developmental attunement so that lara regressed even deeper. the session seemed very successful to me, although we had to conclude quickly due to a lack of time, which did concern me. however, i had another client waiting and decided to conclude the session on time. at the next session lara was first slightly distant from me; there was not a good contact between us. i asked her to tell me in detail how she felt after the last session. through the questioning lara gradually told me that after the session she felt bad, that she had a feeling we had stopped too suddenly. after the session she still remained in trance. she felt as if i had thrown her into the world, at the same time feeling that i played with her and used some sort of trick to make her cry. i was very surprised at her statements, as i had a feeling that the session had been very efficient. yet i realised that i had been too fast for lara at the end and at the same time that it was probably the case of juxtaposition for lara (erskine et al., 1999). therefore her words did not hurt me, but i took them as valuable material for further therapy. during this session we dealt with her feelings and her protest as she was disappointed with me. i took her comments as very important, because before she used to idealize me. she denied her feelings of anger, as obviously she was not prepared to express this emotion yet. i admitted my error which was that i was not leaving her enough time to process. this helped lara and presented a new experience for her of being heard and that her opinion was taken into account. in my opinion the previously mentioned juxtaposition appeared together with my error, as lara came to feel her vulnerable part together with what she missed in her childhood and it obviously frightened her. these feelings were very powerful so that she felt that i was playing with her, that i played a trick on her. she felt two poles within herself, one which was relieved, happy, which felt positive effects of regression, and another, which warned her to be careful who to trust and that she was too naïve. probably her vulnerable part felt well, while the inner saboteur got active with the awakening of the vulnerable self and it attacked this part by warning her to take care who played with her, by saying she was naïve. simultaneously it attacked our relationship, as the therapeutic relationship threatened the stability of the inner structure. fortunately our relationship was strong enough to survive this. lara also dared to say what bothered her as otherwise her disappointment might have had an underlying influence over our relation and the effectiveness of the therapy would slowly decrease. my role changed from the idealizing object into exciting/disappointing object, since i disappointed her and was no longer perfect. still, in my opinion this event developed our relationship, because we managed to mend it. lara acquired an experience where at least in therapy she could express her feelings and needs and be responded to empathically. in the future she found it easier to tell me what bothered her. at the same time i felt that she international journal of integrative psychotherapy, vol. 1, no. 1, 2010 22 idealized me a bit less than before and started receiving me as a real person who may sometimes commit an error. as i mentioned, during the second phase of psychotherapy lara and i tried to establish a better link with her vulnerable self. because her emotions were mainly disavowed i encouraged her to connect more with her body dimension and through this with her affects and emotions. i used a lot inquiry of her bodily sensations. through the tension in her body she found out what she felt. i also attuned sometimes my breath to her breathing to understand more what she was experiencing (zaletel, 2007). then i used this information to form my interventions. when she was very aroused or her rhythm was too fast, i slowed down my breathing, so that she also slowed down. during this therapy stage lara had various relational needs, like need for safety and for valuing were still present. lara also became aware of her need for being accepted by a stable, reliable and protective other person, as she found out that this was what she wanted from her mother and father, but did not get. i tried to attune myself to this need, so that i was reliable and non-disapproving, i tried to protect her from her inner saboteur and parent ego state by accepting her idealization and lara perceived me as stronger than her introject. lara also had a need to express love as this was not allowed in her family. this need was well met at home in her new family, moreover she often expressed gratitude to me during the therapy. i accepted this, although this may have been more a part of her coping/every day self which wanted to please me. the third phase of psychotherapy involves the differentiation and separation process which lara and i reached after approximately nine months of psychotherapy. presently we are still in that phase. in this phase lara noticed that she did not know herself, that she did not know who she was, that other people defined her, mainly her husband. so lara noticed that she did not have connection with her real or vulnerable self. she expressed a wish to get to know who she was, at the same time she feared what she would be like at the end of the therapy. fear of a changed identity and her inner structure (script system) appeared. i normalized and respected these fears, because they seemed normal to me and i met them during my own psychotherapy. i also assured lara that during the therapy we would not disregard her wishes. all this helped her to be less reluctant to continue with psychotherapy. during that phase of therapy lara gradually expressed her anger better, particularly in her relation to husband. her courage in setting limits to him and her children grew. it was a great achievement also that she expressed anger to her brother to whom she previously never set limits. lara found out that each expression of anger does not necessarily provoke conflict, violence and termination of a relationship. lara still finds it hard to experience anger with parents, as feelings of guilt and self-accusation appear. in psychotherapy she has been angry with me for several times. i encouraged her to express her anger and i also enabled her to check with me after expressing her anger if our relationship still exists and if she can still come to therapy, because she was afraid that i would kick her out of therapy. so she got a new experience that relationship can also survive anger. lara developed more courage to express herself, for example in dressing and making up according to her own taste, although at the beginning she feared how others would accept it. she received positive responses and so continued with her self-definition. my encouragements of lara consisted in asking her about her wishes, international journal of integrative psychotherapy, vol. 1, no. 1, 2010 23 how she differed from her husband, how she could take care of her emotions instead of caring for herself through regulating her husband. lara was usually full of energy after sessions, she had a feeling that something began to peel off and to reshape. simultaneously she felt guilty of taking too much time for herself, but we dealt with these feelings during the therapy. most importantly, we managed to connect them with the past, so that lara could understand them better. during that phase of therapy i used a lot of validation and normalization. i asked her more about her vulnerability, although lara and i moved more in the first three phases of the keyhole model. sometimes we managed to transcend to the fourth phase of integration (erskine et al., 1999), as lara managed to change her old decision and integrate a new part of herself. a larger part of integration is still to be done. as mentioned before, attunement helped me in all phases of psychotherapy. during the present phase of therapy lara's script system started to change, mainly her script beliefs, but we are still working on this matter. lara herself is gradually beginning to recognize when the inner saboteur appears. for instance, she said: »i feel as if i'm educating myself«, which is a good description of a self-generated parent or the inner saboteur. sometimes she still gets lost in self-criticism without recognizing the saboteur, but more and more she is successful. internalizing our therapeutic relationship is of great help to her. during the week she often remembers what i would say in such a situation, thus activating the internalization of the therapy and me to protect her vulnerable self from her internal saboteur. her attachment in the therapeutic relationship changed from anxiousavoidant style into a safe type of attachment. very rarely did she project the rejecting/attacking object on me. during the therapy she no longer feels awkward talking about herself, even if she is late, she no longer fears my reaction. at the beginning of our sessions her fear was considerable. i have become more relaxed in the therapy too, without worrying so much about lara, as i trusted more that she would be able to take care of herself if problems appeared. on several occasions i shared some of my experiences with lara, as in this therapy phase she expressed her needs of both mutuality and self-definition. lara entered in contact with her real self and thus i, too, could become more of a »real« person. prognosis and concluding remarks lara continues to undergo psychotherapeutic treatment with me. as mentioned before, we are in the third phase of therapy, working on her differentiation, separation and integration. our working alliance is still very good. lara is motivated for the therapy, so i presume we will reach the goals set. up to now we have reached the goal to diminish her depression; since lara's psychic condition improved, almost all her symptoms disappeared. she has more energy, willpower, interests; there is less self-criticism, suicidal thoughts have disappeared and she is more efficient in her professional and family life. moreover, lara's inner saboteur has weakened, while her self-image has improved. lara manages to better perceive and express her emotions. she better differentiates and sets limits to other people. according to my estimation lara and i have a lot of therapeutic work to do, primarily with the integration of the parent ego state, which is still very powerful in her; i estimate that lara will need more years of psychotherapy. we have a lot to do in the area of international journal of integrative psychotherapy, vol. 1, no. 1, 2010 24 feeling and expressing her vulnerable part. i also expect our ending of psychotherapy to be difficult for lara, because we have developed a strong relational bond. but i presume that ending the therapeutic relationship with me will entail many useful growing points for lara such as having a new experience with endings, which were in her past always traumatic. so our journey towards integration will continue. psychotherapy with lara has also given me a kind of optimism in my work as well as hope for other clients. in spite of her hard childhood experiences and without safe attachment lara managed to survive, create good mutual relations in her new family and, with help of psychotherapy, also begin a satisfying life. this reaffirmed my belief that a human being is flexible and that psychotherapy works. references bowlby, j. (1988). a secure base: clinical applications of attachment theory. london: routledge. dsm-iv. diagnostic and statistical manual of mental disorders. fourth edition (2000). washington: american psychiatric association. erskine, r. g., & moursund, j. p. (1988/1998). integrative psychotherapy in action. new york: the gestalt juornal press, inc. erskine, r.g. (1997). the therapeutic relationship: integrating motivation and personality theories. in r.g. erskine (ed.), theories and methods of an integrative transactional analysis (p. 7-19). san francisco: ta press. erskine, r.g., & trautmann, r.l. (1997). the process of integrative psychotherapy. in r.g. erskine (ed.), theories and methods of an integrative transactional analysis (p. 79-95). san francisco: ta press. erskine, r. g., moursund, j. p., & trautmann, r. l. (1999). beyond empathy. a therapy of contact-in-relationship. new york: brunner-routledge. erskine, r. g. (2007). unconscious process, transference and therapeutic awareness. workshop on institute ipsa. ljubljana, slovenia. little, r. (2001). schizoid processes: working with the defences of the withdrawn child ego state. transactional analysis journal, 31 (1), 33-43. zaletel, m. (2007). the use of breathing in psychotherapy. kairos-slovenian journal for psychotherapy, 1 (3-4), p. 75-80. žvelc, m., & žvelc, g. (2006). stili navezanosti v odraslosti [adult attachment styles]. psihološka obzorja, 15, 3, 51-64. maruša zaletel is a psychologist and a certified integrative psychotherapist, working in her private practice in kranj, slovenia. her special interest is in integrating breathing and some other aspects of yoga into psychotherapy. contact information: address: gregoriceva 22, 4000 kranj, slovenia phone: 386 (0) 41 838 964 e-mail: marusa.zaletel@amis.net special thanks to my supervisors gregor žvelc and gudrun stummer, who helped me with this case study. mailto:marusa.zaletel@amis.net alcoholism is such a common condition that therapists must be exposed to clients who suffer from it, whether the therapist is ‘i have feelings, too’ the journey from avoidant to secure attachment maša žvelc abstract: in the article i describe the integrative psychotherapy of the client who showed an avoidant state of mind. i explore how in two and a half years of psychotherapeutic treatment, in a sensitive and caring therapeutic relationship, the client process of integration and development of a secure state of mind is unfolding. the client is becoming more open and accepting of her own internal states, particularly her vulnerability and the need for having a secure, warm and loving relationship with another. an increased contact with self is enabling her to make important decisions and implement changes into her life. theory of attachment is used as important guideline for diagnosis, treatment planning and understanding of the psychotherapeutic process. key words: attachment theory; integrative psychotherapy; avoidant attachment style; case study; emdr ____________________________ general information about the client when klara came into therapy with me, she was 29 years old. she came upon the recommendation of her colleague, who is a psychologist. klara is highly educated and very successful in her occupation. she is very slim and always looks impeccable. she likes to have things under control. klara came into therapy due to the problems which had occurred in the last year: • she had difficulties with driving a car (initially as a driver, later also as a passenger) – she was feeling fear, nausea and a tingling sensation all over her body. consequently, she gave up driving herself, except for driving around the town centre. international journal of integrative psychotherapy, vol. 2, no. 1, 2011 22 • klara had difficulties with her stomach, i.e. she was feeling stomach aches and nausea. soon after she had entered therapy, she was diagnosed with gastritis. she was prescribed a medication which made her feel better. • klara was working in a stressful environment and was suffering from burn-out. she was feeling tired and tense. she wished she could take a lengthy break from work. her symptoms first showed up a year before entering therapy, when klara was putting all her efforts into studying for an important, very difficult exam. this placed an immense psychological and physical pressure on her. during this time, klara was neglecting her need for rest as well as regular eating. even when she wanted to eat, she was unable to do so due to a sensation of having a lump in her throat. she also described how her former partnership relationship had presented an issue for her in the last year. her former boyfriend lived in the neighbouring country and they rarely saw each other. in a psychological sense, they were rather distant from each other. after spending one evening with her boyfriend, klara became acutely aware of the emptiness between them, which made her cry in front of him. the next morning she woke up with a tingling sensation throughout the body. from then on, klara was feeling this tingling sensation in both her legs. already on our first meeting, klara was contemplating how her lifestyle in previous years had contributed to her difficulties in the last year. after she had graduated, klara went to study abroad. she was successful in meeting the deadline for completing her studies. klara then returned to her homeland and immediately threw herself into work. in therapy, she reflected: »i had no time for myself. i was working around the clock.« when i asked her what makes her happy, she became absorbed in thought. then she replied: »well, this is a very good question… i have a feeling i am being guided by things… i do not ask myself what is it that i want.« later on, she revealed: »in the last few years, i have detached myself from my body. i have only been feeling my head, and the head has been guiding me.« at the time, klara was living with her father, mother and a younger brother. her mother was a dominant, strong and emotionally cold woman. financially, she was very successful. klara said of her father that "he is a poetry kind of guy". he likes going to the mountains, he is quiet and distant. he gives an impression that nothing interests him. several months of therapy later, i learned that he was struggling with alcoholism. in klara's family, relations were emotionally cold and distant. when her mother was dissatisfied with klara, she would ignore her for several days. klara called this "the silent treatment". she described her mother as a controlling personality. during the course of therapy, klara remembered that her mother used to beat her as a little girl. international journal of integrative psychotherapy, vol. 2, no. 1, 2011 23 certain characteristics of klara's development from her mother's narration, klara learned that the babysitter who took care of her from her 3rd to 6th months of age did not give her milk. when klara's mother found out she dismissed the babysitter. between the age of 7 and 36 months, the client was banging her head against the wall. she felt pleasure in doing so. she refused food until she was 5 years old. at school, klara was very successful, but she had no proper friends. she was troubled by the injustice and isolation which some of her socially deprivileged classmates were exposed to. in her adolescence, klara was hiding her breast development. when she was 17 years old, she was involved in a traffic accident as a passenger. the accident left her shaken, but she did not suffer any physical injuries. first impression of the client klara was talking swiftly. i sensed her anxiety, and how tense and stiff her body was. when i tried regulating her fast rhythm (e.g. with a therapeutic intervention such as: »i suggest we stop here a little… take your time to breathe in… breathe out… and simply observe what you are feeling«), tears welled up in klara's eyes. she started feeling uncomfortable. klara was ashamed of her tears and wanted to avoid them. she told me it was extremely difficult for her to seek help, because all her life she had been used to do everything on her own. she could only ever rely on herself. she viewed her coming into therapy as a defeat. despite her initial ambivalence towards psychotherapy − which klara was able to perceive and express well − she was determined and committed to psychotherapy treatment. this is what i wrote in my notes after our first meeting regarding my impression of klara and my countertransference feelings: »an agreeable woman. i feel her stiffness, tension and anxiety, and i think to myself: ‘how much pain and loneliness reside in her… how many tears that have never been cried.’ on the one hand, i feel warmth and an impulse to give her a "psychological hug", but on the other, i can perceive her upright posture and the serious expression on her face. they make me feel as if i am not to attempt to get closer, as if i am undesired in this sense.« diagnostic assessment based on the theory of attachment based on their early experiences in interpersonal relations, a child develops implicit mental schemas (siegel, 1999) including relational schemas international journal of integrative psychotherapy, vol. 2, no. 1, 2011 24 (žvelc, 2009, 2010) through which they interpret themselves and the world, as well as anticipate the future. these schemas decisively influence the way we process information. in this context, bowlby (1969) wrote about working models; main about mental representations (main, kaplan and cassidy, 1985), stern (1985) about rig’s (generalized representations of interaction) and erskine (2009) about life scripts. the manner of processing information presents one of the key criteria for classification of the client's attachment style (wallin, 2007). furthermore, the manner of processing information influences how freely a person is able to think, feel, remember and act. according to fonagy (fonagy, gergely, jurist and target, 2002), related and essential to this are mentalisation (which helps us realise how our mind mediates our experience of the world) and reflective function (which means the relation of self towards own internal experience). individuals with a secure attachment style have a reflective relationship with their own experience, which makes them more open and accepting of their own internal states. for persons with avoidant attachment style, it is typical that they diminish or deny the influence of their own internal experience. they tend to avoid their internal experience and their internal world. based on my observations, i assessed avoidant attachment style was typical for klara. klara avoided her internal world and inner experiences. she had poor awareness of her physiological sensations, her needs and feelings. consequently, she had poor contact with her body. she was neglecting the messages sent by her body, thus neglecting her physiological needs. klara was often hungry and overexhausted. in addition, she was disinterested in her emotional happenings. emotions presented a threat to her and she preferred to avoid them. she rarely allowed herself to feel them, even rarer to express them. klara hid not only her need for being emotionally close and receive support from another, but also her vulnerability and weakness. as a matter of fact, she split off this part of self from her consciousness and wasn’t in contact with it anymore. whenever this part wanted to reappear, it would have upset her and klara put all her strength into making it go away again. as a result, the client was cut off from her vulnerability and the need for being in a relationship. the above-mentioned characteristics show poor contact with internal experiences, as well as difficulties with affect regulation, both of which are important features of avoidant attachment style (erskine, 2009; schore, 1994, 2003; wallin, 2007).the client had developed a belief that she needed no one and that she could only ever rely on herself. she turned away from relationships, because she had stopped hoping that they could satisfy her basic emotional needs for being close to another, for support, love and security. the described process plays a key role in hypoactivation of the attachment system (mikulincer, 1995). international journal of integrative psychotherapy, vol. 2, no. 1, 2011 25 bartholomew and horowitz (1991) distinguished between two attachments styles which refer to avoidance in adulthood: fearful-avoidant and dismissive-avoidant. there are some fundamental differences between the two styles. although individuals with a fearful-avoidant attachment style desire to have close relationships, they are afraid of them. by contrast, people with a dismissiveavoidant attachment style appear to be self-sufficient and dismiss their need to be close to other people. for these individuals, it is very important that they feel independent and self-sufficient. they do not like to rely on other people, nor do they like to be relied upon. they rarely engage in self-disclosure, and even when they do, they do not reveal much about themselves. in terms of emotions, they appear to be more or less inexpressive. they protect themselves from disappointment by avoiding relationships which demand closeness and intimacy, and by preserving a feeling that they are independent and invulnerable. these strategies relate to defences which serve to protect an individual from being aware of their attachment needs, as well as from experiencing their weakness and vulnerability (žvelc & žvelc, m., 2006). klara's mode of functioning in life matched the characteristics of the dismissiveavoidant attachment style. in addition to the schema of "others are emotionally unapproachable", klara had also developed a schema of "the world is an unsafe place and life is a struggle". the ignorance, neglect and beatings had importantly influenced the development of these schemas. when talking about being beaten or ignored by her mother, klara assumed a tense posture, with her shoulders pushed forward. it is interesting that if one chose to observe only klara's body language, her vulnerability, insecurity and fragility would come to the fore. this would present a sharp contrast to her "decisions" and strategies of coping on a conscious level, e.g. "be strong, you do not need others, rely only on yourself". individuals with a dismissive-avoidant attachment style treat themselves and others in the same way as they were treated by significant others in their childhood or in a manner that they experienced their relationship with others (erskine, 2009; wallin, 2007). klara grew up experiencing family relations marked by emotional detachment, inapproachability and coldness, i.e. the absence of intimacy, warmth and physical expression of affection. klara's emotional needs for receiving love and being close to another had been unmet. her mother was a controlling person who had beaten klara as a child or intentionally ignored her. researchers have found that children who grow up in the same kind of family environment as klara did tend to be classified as adults with avoidant attachment style (beebe and lachman, 1988, 1994, in siegel, 1999; cugmas, 1998; ainsworth, 1978; sroufe, 1985; sroufe, cooper and dehart, 1996; both in cugmas, 1998). children of parents who fit the above description develop an internal model of attachment and they believe that their parents are useless in terms of satisfying their emotional needs. consequently, they see no sense in seeking closeness with their parent when they meet again. international journal of integrative psychotherapy, vol. 2, no. 1, 2011 26 let me sum up the ideas presented thus far. klara's life, marked by physical and emotional neglect, control and physical abuse from her primary caretakers, had influenced the development of the following working models or in other words relational schemas about herself and others: • i am helpless, vulnerable and bad. • other people are rejecting, controlling and aggressive. these contents were split off from consciousness, because they were too painful and threatening to the established psychological balance of the client. on a conscious level, klara functioned on the basis of these beliefs: • i am strong and i can rely on myself. • other people are weak, dependant and worse than me. klara's withdrawal from relationships had occurred on an emotional level, since she no longer expected from close relations to present a source of intimacy, warmth and support for her. however, klara had not completely removed herself from relationships – quite the contrary, in fact. in her family, she was playing the role of a mediator and "a merrymaker". being chatty and cheerful, klara was filling the void and masking the coldness of her family relations. she also used this strategy to avoid mother's aggression. she excelled at school, which was another attempt of hers to gain some affection. although she had had friends both as a child and as an adult, she was not particularly close to any of them. klara was not used to discussing personal matters with friends, nor did she like other people confiding in her or expressing their emotions. she did not know how to react in such situations. she had had several relationship partners. in therapy, she mostly talked about two of them. both relationships were marked by little psychological intimacy. both partners were from another country and, geographically speaking, relatively far away from her. in all likelihood, this was not a coincidence, for it allowed klara to keep a distance from them, which she wasn’t aware of. hazan and shaver (1987) similarly describe partnership relationships of adults with avoidant attachment style. the transference and countertransference characteristics further point to an individual with avoidant attachment style. for the client, i was the professional person providing therapy – and nothing more. she did not invest her needs and wishes into me. she expected nothing more than a formal, professional relationship. on one of our therapy sessions, she told me that her friend was seeing a psychotherapist who hugged her at each therapy session. klara said this would be completely unacceptable to her. with klara, i often felt the way i described our first therapy session: »on the one hand, i feel warmth and an impulse to give her a "psychological hug", but on the other, i can perceive her upright posture and serious expression on her face. they make me feel as if i am not to attempt to get closer, as if i am undesired in international journal of integrative psychotherapy, vol. 2, no. 1, 2011 27 this sense.« after our therapy sessions, i often felt inadequate and inferior. i even had a fantasy that klara only persisted in therapy with me because her friend had given her a good recommendation of me. after one therapy session, i had a strong feeling that i had done something terribly wrong. i was thinking "now she is going to be angry with me", although in reality there were no reasonable grounds for me to have such feelings. however, my internal experience was no coincidence – why did it occur exactly with this client? what was the client trying to unconsciously "communicate" to me through the process of projective identification? over time in therapy, i learned that klara was suffering from a feeling of being rejected and not being ok. when she was remembering her mother's beatings or coldness and ignorance, it became obvious how deeply ingrained her humiliation, guilt and feelings of being inappropriate had become. klara’s behaviour and attitude towards others – her colleagues occasionally called her "the ice queen" – can be understood as a way of establishing a distance between herself and others, so as to feel more secure and worthy. in an attempt to avoid experiencing how vulnerable and powerless she was, klara developed a stance of self-righteousness. as erskine (1997, p. 46) pointed out: »… self-righteousness is the protective mechanism that helps the individual to avoid the vulnerability to humiliation and the loss of contact in relationship«. at the same time, it also involves a denial of the need for a relationship (erskine, 1994). as we can see, this was the case with klara's psychological world, too. she had been using a double defence (erskine, 1997): overcompensation through self-righteousness, thus protecting herself against the feelings of shame, humiliation and abandonment, as well as gaining some control over her powerlessness. the emotions which the client had tried to avoid were similar to the ones i was experiencing when doing therapy with her. prognostic assessment the client was very motivated for therapy, and we managed to establish a good working alliance already in the first two therapy sessions. she was young, with high intellectual capacity and a well-developed observing ego. she was capable of insightful thinking and good psychological introspection. she has showed good reflective ability and was open to exploring and understanding herself. when coming to therapy, she was in big crisis, which strongly motivated her to go and stay in therapy and also helped her to loosen her defences and show more vulnerability. persistence and courage were typical of her. apart from the described difficulties, her life was stable and settled. according to my assessment of the client, the therapy had a good prognosis. international journal of integrative psychotherapy, vol. 2, no. 1, 2011 28 the psychotherapy process building a solid therapeutic relationship − in which the client feels understood and secure enough to explore and come into contact with her/his internal world, thus integrating her/his split-off parts of self − presents the fundamental principle of integrative psychotherapy (erskine, 1997; erskine & moursund, 1988; erskine, moursund & trautman, 1999; moursund & erskine, 2004; žvelc & žvelc, m., 2009; žvelc, & žvelc, m., 2011). in psychotherapy with klara, two basic process goals were important: • establishing a therapeutic relationship based on contact • exploring herself and coming into contact with the split-off parts of self, i.e. her needs, feelings, physiological sensations, thoughts, fantasies and memories. erskine (2009) emphasised that in psychotherapy of individuals with an insecure attachment style one of the most important task of the therapist is to decode the client’s infant and early childhood physiological and affective experiences, and to facilitate the client’s becoming conscious of implicit relational patterns. as a therapist, i wanted to establish such a therapeutic relationship which would allow the client to explore herself, to progress and to change. in order to do so, i employed the three basic methods of integrative psychotherapy: inquiry, attunement and involvement (erskine et al., 1988; erskine, 1997; erskine et al., 1999; moursund et al., 2004). by using these methods, i helped the client to become aware, to tolerate, to reflect on and to accept the difficult, previously unaccepted contents from her internal world. i helped her make space for these internal experiences and guided her towards understanding them and giving them meaning. the secure base, which we were successfully building in our therapeutic relationship, enabled klara (in wallin’s (2007, p.3) words) “to take the risk of feeling what she is not supposed to feel and knowing what she is not supposed to know”. through this process, klara was gradually integrating the split-off internal experiences into a more coherent and secure sense of self. the therapeutic relationship, in which we were developing trust and a feeling of being secure, enabled klara to open up and share her intimate world with me. this was a new relational experience for her, as well as a different kind of relationship from the ones she had known in the past. gradually, klara managed to transfer this new experience into relationships outside the therapeutic environment. the therapy took place for two and a half years. we agreed on having regular weekly therapy sessions, except during holidays. i divided the psychotherapeutic process into five stages, according to the themes we were working on in a particular period. international journal of integrative psychotherapy, vol. 2, no. 1, 2011 29 1. developing the therapeutic relationship, coming into contact with physiological sensations, strengthening reflective and regulatory mechanisms − 1st to 4th month of therapy the most important achievements in this period were establishing a therapeutic relationship, calming down the hyperactivated autonomic nervous system, coming into contact with physiological sensations and, consequently, recognising physiological needs and developing reflective and regulatory functions. although i continued to pursue these goals in subsequent stages of psychotherapy, as they were important for the ongoing psychotherapeutic process, the fundamental shifts in the described areas occurred in this phase of therapy. in later stages, we opened up some new areas to explore. in order to calm down her tense and hyperactivated body responses, i employed various therapeutic interventions and techniques. during the therapy sessions, i helped klara to regulate her rhythm. when she was talking fast and her body appeared to be very tense, i invited her to stop and breathe in. i would then ask her what she was feeling. this allowed klara to come into contact with her physiological sensations and affective states which she had previously been unaware of. prior to this psychotherapeutic intervention they were covered up by her disquiet and an array of thoughts and words. i noticed how klara took great care of her visual appearance. yet despite always looking impeccable, she was not in contact with her internal physiological sensations and the messages her body was sending her. by using mindfulness-based interventions, i taught klara how to become aware of her body, and how to perceive and regulate her affective states and needs. in addition, i taught her how to do progressive muscle relaxation and the "safe place" visualisation exercise, both of which would help her to relax and reduce anxiety. when we reflected on the "safe place" visualisation exercise, klara began to cry. she told me about feeling this giant gap between peace (which she had felt during the exercise) and the tension which had been constantly accompanying her. in her daily life, klara was becoming more attentive of the messages her body was sending to her (e.g. fatigue, hunger, what food suited her stomach, etc.). she started to take these messages into consideration. klara went to yoga classes and did relaxation exercises at home. due to better physiological and affective regulation, her work-related stress levels significantly decreased. klara was gradually becoming better at planning her work rhythm. she allowed herself to have more breaks and was able to cope better with the pressures of her work. it was interesting to see how, during the first few months of therapy, work-related stress presented an important issue for her to work on, but took a back seat as the therapy progressed. however, the fact that she had to seek psychotherapeutic help filled klara with shame and presented a threat to her psychological stability. the same was true international journal of integrative psychotherapy, vol. 2, no. 1, 2011 30 for crying in therapy. klara believed crying pointed out her weakness − and this was something she was terribly ashamed of. to a person with avoidant attachment style, seeking help, showing their vulnerability and weakness (e.g. crying) presents a direct conflict with their identity – i.e. "i am strong and do not need others". during this stage of therapy, we were exploring klara's protective mechanisms and beginning to understand their function. klara recognised that she wished to be strong (she did not like to feel weak), she did not want to share her feelings (she understood that as being weak) and she liked to keep people at a distance. she named her defence a suit of armour. when we discussed how the goal of our therapy was not to irrevocably take off her armour, but to help prevent the armour from automatically activating itself, she was very pleased and relieved. our goal was to make her defence more flexible, so that she could decide on her own when to activate the armour and when to take it off. klara told me that, for example, she wanted to wear this armour on business meetings, because it is unwise to show weakness in such a situation. in other, more intimate relationships (e.g. a partnership relationship) it might be better to take it off and open up. after she had seen both the positive function of her defence and the price she had had to pay for staying rigid and on guard all the time, klara became more willing to loosen her control and risk a journey into the unknown. we established a good working alliance. klara was motivated and dedicated. already on our second therapy session, she told me that starting therapy had made her want to talk at home, as well. she used to avoid discussing more personal matters with her family members, and would only talk about the weather, what was for dinner and the like. i had a feeling that my interventions “are falling on the fruitful ground” − my client was accepting them and effectively activating her powers to grow. 2. facing the unknown and accepting the split-off parts of self – 5th to 10th month of therapy on our 18th therapy session, as i inquired about her internal experiences, klara came into contact with her feeling of loneliness: »i feel somehow lonely in this world. disconnected. i think i would like to have a partner.« the emerging awareness of loneliness, the need for being close and for love opened a new chapter in our psychotherapeutic process. in that therapy session, klara reflected on her former relationship. although she had mentioned it on our first meeting, she did not talk about it up to this session. afterwards we discussed her relationships with men on several occasions, as well as her meeting a new man. in the first part of our 20th therapy session, klara was enthusiastically talking about this new male acquaintance of hers. i got a feeling that something was international journal of integrative psychotherapy, vol. 2, no. 1, 2011 31 hiding behind this. i invited her to focus on her body and inquired about what she was feeling. klara replied: »nothing special.« i invited her to feel and describe this "nothing special". at that point, she started to cry and told me how anxious she was about her father.(it is important that as therapists we do not merely follow the client's narrative, but also inquire about the things which have been left unsaid. had i merely let klara to talk, we would not − at least not in this therapy session – touch upon this important, shame and fear-inducing content. stopping and directing the client to focus on physiological sensations and emotional experiencing was strengthening her contact with self, which in turn facilitated coming into contact with other, more difficult contents.) klara started telling me about her father's alcoholism. she was worried about him, and was asking herself what she could do about it. her family was minimising this problem. the fact that klara admitted to herself − and me − that her father was having a problem with alcohol, was something new in therapy. klara realised how her father's alcoholism was connected to the question of her identity: »i have a father who drinks excessively.« klara was discovering her shame. in the next two months, she was processing the above-mentioned contents. she was working on her father's attitude towards her (he was distant and did not notice her, as if she did not exist), the relationship between her mother and her father, her mother's denial of the importance of their problems and mother's indifference. step by step, klara was making a decision that she was not going to take over the responsibility for her father's alcoholism. she thought it was her mother's task to encourage her father to go into treatment for alcoholism, because she was his wife. she discussed this with her mother, too. slowly − despite her mother's tendency to deny the problem and distance herself from it − things started moving ahead. her mother and father finally agreed to enter treatment for alcoholism. the 22nd and the following two therapy sessions, which i am going to describe in the next paragraphs, were the most difficult for klara in her entire psychotherapeutic process. during this time, her emotional turmoil markedly increased. on the one hand, she had been pondering not coming to the therapy session, but on the other, she was aware that now was particularly important for her to come. while reading t. harris' book i'm ok − you're ok, she remembered certain events from her childhood which made her realise that her family members had not been showing physical affection to each other. she missed that. she missed the warmth. (the client realised this in the 6th month of therapy; this was something completely new to her, yet at the same time so familiar. she reached a pivotal point in her therapy – a point, at which the client starts to understand what they have already known implicitly, but not explicitly, when the unconscious starts becoming conscious.) international journal of integrative psychotherapy, vol. 2, no. 1, 2011 32 moreover, she gained insight into how she had wanted to compensate the need for physical contact by excessively striving for success at work. at the therapy session, she was talking enthusiastically about this, i.e. what a remarkable discovery this was for her. when i stopped her, invited her to focus inwardly and inquired about what she was feeling, she began to sob bitterly. at first, she said that she did not know why she was crying. later on, she revealed that she felt a need for a hug (but added that with this she did not mean i had to hug her.) after this therapy session, she was feeling upset at home as well. klara cried on her next session, too. she told me that she had no one and how alone she was − and at that age! klara came into contact with her need for protection, for warmth and for being close to another. these needs had been previously split off. she came into contact with her fundamental conflict: should she open up, trust others and let them into her world – or not? on our next therapy session, klara was still reporting about being in an intense emotional turmoil and having wished not to come in the therapy. she was asking herself again why she was crying so much. we can understand her emotional turmoil as the consequence of being more fully aware of her internal conflict: »should i open up, trust others and let them into my world – or not?” and also as a juxtaposition response (erskine et al. 1999). on one hand, she has closed herself to emotional and psychological intimate sides of relationships, cutting the need for warmth and emotional support of others. on the other hand, there was a therapist, who was supporting, warm and respectfully interested in her inner needs and experiences. that facilitated her to feel the “forbidden” need for warmth and support of other (including therapist). in this therapy session, we worked on understanding what was going on, constructing the meaning of her internal experiences. i explained to klara how i saw what was going on. i told her how, in accordance with her previous experiences in relationships, she had developed the "be strong" strategy and rejected her vulnerability. klara added: »just like my mother.« by using attunement, i explain to klara how in the last two therapy sessions she had lost her balance when she realised how painful it was for her to live in such a cold family environment. she realised how she had missed care and warmth. what is more, she felt that the need for warmth, for being hugged and, consequently, for allowing herself to be vulnerable, existed in her as well. i was telling her that we had entered her sensitive area – her vulnerability and the need for other… and that these insights allowed her to come in contact with herself and with me (i put my hand on my chest). at this point tears welled up in her eyes. klara replied: »yes, i don't accept this feeling (i.e. vulnerability and the need for other), i would rather not have this feeling around. that is why it was difficult for me to come into therapy today.« international journal of integrative psychotherapy, vol. 2, no. 1, 2011 33 when a client comes in contact with their core feelings, the important (i.e. corerelated) memories begin to spontaneously appear. this is what happened in klara’s case, too. she went on to talk spontaneously about her mother and father, who were both emotionally cold and unapproachable. she remembered the events which illustrated the formation of klara's life script pretty well: »i used to spend a lot of time alone in the playpen. i would call for my mother… i would call and call... no one came by… and so one day i just stopped calling.« in such situation and similar events, klara implicitly "concluded" that there was no point in calling out for others. she could not rely on others and she had to take care of herself on her own. the following schema developed about herself: »i am not worthy of love and attention. something is wrong with me.« her next memory showed how klara had already developed a survival strategy which excluded the need for being close to someone and for receiving loving care from another. »i was sitting with my grandmother on a sofa; she wished to embrace me, but i shifted away from her. i felt unpleasant. i was not used to being hugged or caressed…« we talked about her memories and assigned them meanings. klara was making sense of how as a child she needed her mother and father; she was crying and calling for them. because nobody responded to her calls, she gradually stopped calling... and eventually stopped needing (she was no longer aware of her need for another person). she put away her emotions and needs in this relationship. klara added that even as an adult she held such attitude – not just towards her parents and other people, but also towards herself. this revealed her high level of reflective function and the depth of her insight. she put into her own words the theme which has been discussed by many authors of developmental psychology (erskine, 2009, wallin, 2007): when a person has not experienced contact in a relationship, the person has no contact with self. we talked about the function of this avoidant pattern, this hypoactivation of the attachment system which she had developed. i normalised the pattern by explaining to her that it had not developed by coincidence. it had an important function: it helped klara to survive in such relationships, preserve them and thus lessen the pain she was feeling because of them. (in integrative psychotherapy, we emphasise that each disturbing, defensive behaviour or symptom has its own function. we look for its roots in childhood or, as the case may be, in possible later life traumas. we believe that "disturbing" behaviours and symptoms represent the best possible adaptation in a given period, a "normal" response of the child to the abnormal circumstances they have found themselves in (erskine etc., 1999). with such stance we normalize the responses of the client, who in turn feels understood and accepted and paradoxically-his/her defenses begin to melt.) international journal of integrative psychotherapy, vol. 2, no. 1, 2011 34 becoming aware of how things were, hurts. klara became sad when she felt and realised how she had experienced this as a little girl. she was grieving for what she did not get in her childhood. she was giving up on her infantile hope that her parents will fulfil her needs for love and intimacy and provide her with loving care. in doing so, she was cutting off her infantile ties with her parents, which presents an important step in completing the separation and individualisation process (blos, 1967; žvelc, 2003). 3. changes show externally as well – 11th to 20th month of therapy in this period, klara implemented a lot of changes into her life: she was separating from her parents, becoming independent and building new relationships outside the family environment. she bought an apartment, moved in and began a partnership relationship. in this stage of psychotherapy, klara reflected, processed and strengthened her experiences connected with the changes she was introducing into her life. during the therapy sessions, klara's need for becoming independent from her parents and the related construction of her new identity were coming increasingly to the forefront. she began to look for an apartment and bought one in the 10th month of therapy. she moved in the following month. in therapy, she reflected on this process of becoming independent − she was looking for a new position and role within her primary family. in addition to externally visible separation − moving away from her parents − klara was also cutting off her internal infantile ties to her parents: »i used to play the role of the mediator in our family. i was artificially creating happy events and behaved like a good girl, so as to please my parents and fill the void… had i not done this, i would have risked losing them.« klara was gradually becoming aware that she no longer wished to play this role. however, she was asking herself in what way she could now relate to her parents? from the above description, we can understand how klara had split off her anger for fear of losing her parents and how she became a good girl who pleased her parents and caused them no trouble. reflecting on her new partnership relationship took a lot of space in therapy. this relationship was something completely new for klara, because her partner was bestowing her with a lot of attention, affection and tenderness. klara was not used to this − not from her relationship with her parents, not from her previous relationships with men (with whom she was involved in psychologically distant and "safe" relationships). in the beginning, she sometimes felt overwhelmed by so much tenderness. she realised that even when she wanted to receive tenderness, she appeared cold and did not know how to respond to it. she was learning new things about herself in relationship. she was recognising her feelings, wishes and needs. she allowed herself space to explore: how she felt when her partner hugged her; how she felt international journal of integrative psychotherapy, vol. 2, no. 1, 2011 35 when he wanted to have sex with her. did this suit her or not? what did she want? because of therapy, she allowed herself to explore what she was feeling and needing, and how to accept this. gradually, klara was opening up emotionally. she was able to receive and return affection and tenderness. at the same time, she realised and accepted that she needed time for herself and that she had the right to set boundaries to her partner. she was looking for her space in a partnership: how close, how far. the old way − keeping a distance − broke down, and the new way was gradually being built through processing experiences in therapy. 4. returning to "the depths" and continuing the process of integration − 21st to 26th month in this stage of psychotherapy, the client worked in depth on her relationship with her mother. in addition to the realisation that her mother was cold and unapproachable, klara learned that her mother was an aggressive and belligerent person. the central work was processing her traumatic experience for which i used the emdr method (more on the emdr method in shapiro, 2002). klara revealed how in certain situations − when wanting to protect herself and act assertively − she became paralysed. she would become silent, lost for words and would not stand up for herself. she told me she would like to work on this. i invited her to describe a recent, concrete event when a thing like that happened. she began talking about an occasion when her mother was complaining about her father: »she talked and talked… the more i was withdrawing, the more she was "towering" over me. maybe i should have reacted differently, but i cannot. i should have done something to protect myself… but i cannot. i am afraid of confrontation… and my mother does not let me go, at all. she simply fails to notice what her verbal barrage effects me. as if i was nothing. as if i was not, incidentally, her daughter. as if someone was digging inside me. i mean, i have feelings, too!!« a bit later, she added: »when i am withdrawing backwards, towards the door, i feel that i have no control. i feel anxiety, from my neck to the diaphragm. « i used the "emotional bridge" technique, inviting the client to close her eyes and think of the words "i have no control". i asked her to focus on the feeling of anxiety in her body and directed her to go back in her mind, into her childhood, and ask herself when she felt a similar feeling. i encouraged her to simply allow for any image or thought to occur to her. international journal of integrative psychotherapy, vol. 2, no. 1, 2011 36 two things came to her mind. first, there was a memory of being beaten by her mother when she was 4 or 5 years old. her second memory was of a dream: as a child, she used to have a recurring dream in which she had to eat her bicycle and had a choking sensation in her throat. by using the emdr method, i helped the client to process the traumatic experience of being beaten and its consequences. klara remembered "uttering something" which made her mother livid with rage. she began beating her. klara tried escaping the punches by lying on the floor. her mother was beating her all over, telling her: »you little brat, you think are going to talk back!« when i asked klara what she was feeling and thinking about while telling me this, she said: »i cannot go away. why do i allow this to be happening to me? why can't i react differently? i am unable to protect myself. i am unable to respond… i am helpless. it is not safe. i have no control. « i inquired what she would like to believe about herself when she was thinking about this event. she replied: »that i am ok. and that i have the right to protect myself.« by using the emdr method, we processed the event. klara returned to the event, which activated her child ego-state. she had a feeling that she was bad, not ok and not a good daughter. she felt the pain of letting her mother down for saying that to her. then she said: »go on, beat me, but you cannot reach me. i am not in pain at all. i am not here at all. i have already withdrawn. i leave my body and set myself free!« klara then commented that she reacted in the same way as rape victims do. she cried and grieved the fact that things had happened this way. how klara described and experienced this event clearly demonstrates that during the beating she used dissociation as a defence mechanism. she dissociated from her body, so as not to experience the pain and humiliation. in all likelihood, klara learned to dissociate from her body already as an infant, when she was extremely hungry due to not being fed. such events helped strengthen her pattern of dissociation and maintained it until she came into therapy. while processing these feelings, klara remembered two more events. on one occasion, she was home alone, waiting for her parents, and on the other her parents were having an argument. on both occasions, klara felt separation anxiety − she was afraid of losing them. as a child, klara interpreted these events as a consequence of her not being good enough. therefore, she resorted to becoming an even better child. we can understand this as klara repressing the anger and rage towards her parents, so as to preserve their relationship. in order to preserve a good image of her mother (and father), klara "swallowed" the bad part, which she then carried within herself and experienced herself as bad (fairbairn, 1952, little, 2001). international journal of integrative psychotherapy, vol. 2, no. 1, 2011 37 although the feeling of guilt and of being bad persisted for a few more therapy sessions, it was losing its grip on klara. in the adult ego-state, the client knew it was not her fault; however, in her child ego-state, she had a fixated feeling of being guilty and bad. it is important for the client to experience this ego-state and to tolerate it, because such mindful process facilitates further change. in order to leave a place (and all it encompasses) behind, client has to arrive there first (greenberg & paivio, 1997). when klara was processing this event, she regressed to the child ego-state. she was feeling guilty and bad. through processing this memory, empathy, self-acceptance and power sprang from this ego-state. klara said: »i am alright. and i did not deserve this to happen to me.« klara differentiated the representation of self from the object representation. we could translate this into the following words: »it is not as you have been telling me − that i am bad. i am ok and you should not have done this to me!« on our next therapy session, we continued with processing klara's experiences (with emdr) connected with the event (mother is beating her). on this session she came in touch with feelings of humiliation. she came into contact with her shame, pain and vulnerability. she went on to contemplate how as a child, and later, she was unable to ask for help. she experienced somebody offering her help as redundant… »because it makes me seem weak and vulnerable. and if i am seen as weak and vulnerable, i feel humiliated. « these words illustrate how klara connected her vulnerability not only with the expectation of rejection, but also of humiliation. (in other words, she was certain that should she show her vulnerability, she was going to be rejected or humiliated.) for a child − and for klara − this is far too painful, too much for her psychological system to cope with. moreover, klara needed to preserve a good image of her mother instead of an abuser. as a result, she had developed a defence mechanism in the form of hypoactivation of the attachment system (i.e. avoidance), wherein one can rely on themselves and be strong. klara then said: »poor child.« as a therapist, i was moved and felt a deep, profound sadness. klara then broke off contact with self and commented on the therapy session: »my, how everything was fragmented today.« it is likely that she reached the bottom in this therapy session, yet she could not, as of yet, fully tolerate the experience. this is why she withdrew herself, as illustrated by her feeling of fragmentation. in this therapy we can also see a strong juxtaposition. klara has showed her vulnerability to me and i was respectful and deeply moved by it. and this was something so far from her experiences in past relationships, so that it was hard to bear. on our next therapy session, we continued with processing these issues. klara resumed where she had stopped in the previous session. she felt the humiliation of her past… then sadness. and out of this sadness sprang her empathy and compassion towards herself. (she no longer rejected the vulnerable, weak international journal of integrative psychotherapy, vol. 2, no. 1, 2011 38 and humiliated self!) she felt pride. she felt love for herself. just as she was, with all she had: being weak and being strong. the stones comprising her wall of personality had been shifting and breaking down throughout therapy; however, now the entire wall broke down and a surge of positive self-evaluation, appreciation of self, dignity and lust for life began to flow freely. we continued the therapy with emdr by spending two more sessions on processing a "present" event − her mother complaining about her father − and a future event, for which klara imagined her mother behaving similarly. while doing so, klara's functional anger was gaining in force: »i have the right to protect myself. i feel strong enough for this! « from her feeling of being paralysed (which she had felt when we started processing these issues), klara was coming into contact with various feelings, of which i would point out the following three: her sadness about what had happened; her self-acceptance and her functional anger (i.e. the feeling that she was strong enough to set boundaries to another). if we experience ourselves as being worthy enough to be with another and strong enough to set boundaries, then there are no more reasons for withdrawing from relationships. at first, these new realisations made klara feel angry with her mother, and later grieve for the things she had not received. she gave up hoping that she was ever going to receive warmth from her mother. this enabled her to cut off her internal infantile ties to her mother, followed by a reconciliation with what was and what is. in the coming months (which overlapped with the final stage of psychotherapy), klara integrated both the good and the bad representation of her mother. in addition to recognising her bad aspects, she was now able to acknowledge and appreciate her mother's good parts. 5. the final stage − 27th to 30th month of psychotherapy the last four months of psychotherapy presented the concluding phase, where the main emphasis was reflecting on the psychotherapeutic process, on changes which had occurred during psychotherapy and on her feelings about the coming termination of therapy. in these last months, i noticed more spontaneity and a more relaxed attitude in klara's behaviour at therapy sessions. her previously tense, constricted and upright posture was becoming softer and more relaxed. klara would now often sit tailor-style, which she had never done before. it is hard to put into words, but this new sitting position reflected klara's physical relaxation, her loosening control, feeling a greater sense of security and ability to let go. she later revealed how she no longer felt the need to be constantly on guard, to constantly fight. her international journal of integrative psychotherapy, vol. 2, no. 1, 2011 39 facial features were becoming softer as well. to me, she looked truly beautiful, more than ever before. here are some of klara's thoughts on the changes that had happened to her: • »in relationships, i am able to perceive with good intuition that which "cannot be seen.« • »i have become more sensitive to what is going on in relationships. i strive to understand what is going on. i no longer avoid the things which previously i did not want to see.« • »until now, i was always on guard, always fighting. now i see that i do not need to fight all the time. i can take off my armour, too.« • »before i appeared so determined and firm, some colleagues used to call me "the ice queen". i evoked feelings of fear and respect in people. on the inside, i was scared and fragile… yet nothing in the world could make me show that. now it's different. ok, at business meetings i am still like that. but not in close relationships. i open up now.« • »before, i did not show my emotions in relationships. if anything went wrong, or if i did not like something, i just ignored it. now i tell what i think.« as a therapist, i found that important changes occurred in klara which were mutually intertwined: • the reduction and the disappearance of symptoms: symptoms connected with work-related stress (anxiety, feeling tense, fatigue, a desire to withdraw from her job, etc.) and her stomach issues markedly decreased already in the first few months of therapy. her fear of driving persisted longer, but was losing its grip on her during the course of therapy. gradually, klara was widening the geographical area in which she was willing to drive; at the end of therapy, she was able to drive anywhere in slovenia. • improved reflective function, affect regulation and regulation of her needs. • she gained important insights about herself and her relationships. • she became more open and accepting of her own internal states. she established a much better contact with herself (with physiological sensations, needs and feelings) and others (her new partner, friends and therapist). • she completed the separation and individuation process, which had previously been blocked. • in the terms of attachment theory she moved from isolation to intimacy and from avoidant to secure state of mind. • klara managed to integrate those parts of self which she had split off due to contact disturbances in previous relationships. international journal of integrative psychotherapy, vol. 2, no. 1, 2011 40 her persistent avoidance of an important part of her internal world in which memories were locked together with feelings of humiliation, vulnerability, weakness, anger and sadness − and also pride, dignity and spontaneity − gave way to awareness and acceptance. klara established contact with the split-off part of self. she realised how things were for her as a little girl. she allowed herself to feel the shame, the loneliness, the vulnerability, pain and the anger − feelings for which she used to spend so much of her energy to make them go away. through this process, she encountered her pride and healthy power. she accepted parts of herself she had been afraid of and which she had avoided. in her "dark" corner, she found not only "the dragons and the beasts", but also pride, dignity and empathy towards herself, spontaneity and a relaxed attitude. this is what we call integration. psychotherapy helped klara to make this important journey from avoidant to secure attachment. her internal world was becoming increasingly more secure − it was a world in which she could trust herself and others, where she allowed herself to be who she was, with all her positive and negative traits, with all her pain and joy. klara was satisfied with the changes that had occurred to her in therapy. when we completed our therapeutic journey, she left feeling that an important process had taken place there and came to a favourable end. she found that although life continued to serve her challenges, she had different tools now, and of better quality, to cope with the problems. she revealed that the therapy was one of the most important things that happened in her life. she was also contemplating that when she decides to have children, some new things may occur to her, and that she might need some therapy then. she wanted to hear that, should she desire so, she could come back to me and continue with psychotherapy. conclusion man is like a vast ocean, without an end… and as one is sailing through this ocean, one is discovering the ever new islands. and i imagine a person's development as a shell of a sea snail, because its shell is spirally coiled and all the spirals finally meet at one point. psychotherapy with klara was a mixture of sailing through the ocean and climbing up a spiral. together, we discovered important new lands and glided along many spirals − enough to remove important obstacles which had previously prevented a smooth cruise through her life. of course, klara continues to sail on… international journal of integrative psychotherapy, vol. 2, no. 1, 2011 41 author: maša žvelc has msc in clinical psychology and is an integrative psychotherapist, accredited by iipa and eaip. she is a supervisor approved by european centre for psychotherapeutic studies. she is a co-founder of the institute of integrative psychotherapy and counselling, ljubljana and a co-leader of integrative psychotherapy training. she also has a psychotherapy and supervision practice. she is the co-editor of the first slovenian general psychotherapy book. she can be reached at institute ipsa, stegne 7, 1000 ljubljana, slovenia. e-mail: masa.zvelc@institut-ipsa.si. homepage: www.institut-ipsa.si references ainsworth, m. d. s., blehar, m. c., waters, e., & wall, s. (1978). patterns of attachment: a psychological study of strange situation. hillsdale, nj: erlbaum. bartholomew, k., & horowitz, l. m. (1991). attachment styles among young adults: a test of a four-category model. journal of personality and social psychology, 61 (2), 226–244. bowlby, j. (1969). attachment and loss: volume 1. attachment. london: penguin books. blos, p. (1967). the second individuation process of adolescence. psychoanalytic study of the child, 22, 162–186. cugmas, z. (1998). bodi z menoj, mami. razvoj otrokove navezanosti. [be with me, mother. development of child attachment] ljubljana: produktivnost. center za psihodiagnostična sredstva. erskine, r., & moursund, j. (1988). integrative psychotherapy in action. the gestalt journal press. erskine, r. (1997). theories and methods of an integrative transactional analysis. a volume of selected articles. san francisco: ta press. erskine, r., moursund, j. p., & trautmann, r. i. (1999). beyond emphaty. a therapy of contact-in-relationship. brunner/ mazel. taylor & francis group. erskine, r. (2009). life scripts and attachment patterns: theoretical integration and therapeutic involvement. transactional analyses journal, 39, 3, 207 218. erskine, r. (1994). shame and self-righteousness: transactional analysis perspective. transactional analysis journal, 24, 2, 86-102. fairbairn, w. r. d. (1952). psychoanalytic studies of the personality. london: routledge. fonagy, p., gergely, g., jurist, l. e, & target, m. (2002). affect regulation, mentalization and the development of the self. london: karnac. international journal of integrative psychotherapy, vol. 2, no. 1, 2011 42 mailto:masa.zvelc@institut-ipsa.si http://www.institut-ipsa.si/ greenberg, l.s., & paivio, s. (1997). working with emotions in psychotherapy. ny: guilford press. hazan, c., & shaver, p. (1987). romantic love conceptualized as an attachment process. journal of personality and social psychology, 52 (3), 511–524. little, r. (2001). schizoid processes: working with the defenses of the withdrawn child ego state. transactional analysis journal, 31, 1, 33-43. main, m., kaplan, n., & cassidy, j.(1985). security in infancy, childhood, and adulthood: a move to the level of representation. monographs of the society for research in child development, 50 (1-2), 66–104. mikulincer, m. (1995). attachment style and the mental representation of the self. journal of personality and social psychology, 69 (6), 1203–1215. moursund, j. p., & erskine r. g. (2004). integrative psychotherapy: the art and science of relationship. thomson/ brooks/cole. shapiro, f. (2002). emdr as an integrative psychotherapy approach. washington, dc: american psychological association. schore, a., n. (1994). affect regulation and the origin of the self. the neurobiology of emotional development. nj: lawrence erlbaum associates. schore, a. n. (2003). affect dysregulation and disorders of the self. ny, london: w.w. norton & copmany. siegel, d., j. (1999). the developing mind. toward a neurobiology of interpersonal experience. new york: the guilford press. stern, d. (1985). the interpersonal world of the infant. a view from psychoanalysis and developmental psychology. new york: basic books. wallin, d., j. (2007). attachment in psychotherapy. ny: guilford press. žvelc, m. (2003). razvoj slikovnega testa separacije in individualizacije. magistrsko delo. [development of pictorial test of separation and individualisation] ljubljana: university of ljubljana. (unpublished msc dissertation). žvelc, m., & žvelc, g. (2006). stili navezanosti v odraslosti. [attachment styles in adulthood] psihološka obzorja, 15, 3, 51–64. žvelc, g. (2009). between self and others: relational schemas as an integrating construct in psychotherapy. transactional analysis journal, 39, 1, 22–38. žvelc, g. (2010). relational schemas theory and transactional analysis. transactional analysis journal, 40,1, 8-22. žvelc, g., & žvelc, m. (2010). integrativna psihoterapija – relacijska smer. [integrative relational psychotherapy.] in: b. lojk (ed.). psihoterapija na slovenskem : pregled psihoterapevtskih šol, udeleženk strokovnega srečanja psihoterapija na slovenskem, bled 26.–28. februar 2010. [psychotherapy in slovenia: an overview of psychotherapeutic modalities presented by participants of the professional event psychotherapy in slovenia, bled, 26-28 february 2010.] (pp. 83-93). kranj: inštitut za realitetno terapijo. international journal of integrative psychotherapy, vol. 2, no. 1, 2011 43 international journal of integrative psychotherapy, vol. 2, no. 1, 2011 44 žvelc, g., & žvelc, m. (2011). integrativna psihoterapija. [integrative psychotherapy] in m. žvelc, m. možina, & j. bohak (eds.). psihoterapija. [psychotherapy] (pp. 565-590). ljubljana: založba ipsa. date of publication: 23.9.2011 alcoholism is such a common condition that therapists must be exposed to clients who suffer from it, whether the therapist is psychotherapy with the parent ego state maruša zaletel, jana potočnik, andreja jalen abstract: in their article, the authors present the findings of the study in which they conceptualized the method of psychotherapy with the parent ego state. their aim was to explore whether this method could be divided into individual, content-wise separate chronological phases which can be observed with the majority of clients. by using a modified method of content analysis of five psychotherapy transcripts and a video recording of a psychotherapy session, nine chronological phases were identified. in order to illustrate the individual phases, excerpts from the transcripts and the video recording of psychotherapy have been included. the article proposes under what conditions can this method be used, and presents some of its limitations. key words: introject, psychotherapy with the parent ego state, phases of psychotherapy with the parent ego state ________________________ although psychoanalytic authors such as federn, freud, fairbairn and guntrip have written extensively on the psychological effects of “parental influence" or superego, also known as the internalised object, the parental influence, anti-libidinal ego, introjected other or unconscious fantasy, it was eric berne who finally developed the concept of the parent ego state within transactional analysis (erskine, 2003). berne (1961, in erskine, 2003, p. 89) defined parent ego states as “a set of feelings, attitudes, and behaviour patterns which resemble those of a parental figure”. parent ego states are an actual historical internalization of the personality of one's own parents or other significant parental figures, as perceived by the child at the time of introjection. “the historical accuracy of the portrayal is not particularly relevant. what is important is the parent-as-experienced by the client. a person introjects not so much what his or her parents “actually” thought and felt and did, as what he or international journal of integrative psychotherapy, vol. 3, no. 1, 2012 15 she experienced them thinking and feeling and believing about the child, about themselves, and about the world” (erskine, 2003, p.105). the internalization of the personality of one's own parent(s) occurs in early childhood and, to a lesser extent, throughout one’s life. introjection is an unconscious defense mechanism which is frequently used by the child when there is a lack of contact between the child and the caretakers who are responsible for satisfying his or her needs. the child's primary need is the need for contact with other people, which stems from the fact that he or she cannot survive on its own. when the child's relational needs are not met, he or she becomes anxious. the child resolves this external conflict by unconsciously identifying with the parent (i.e. by internalizing the parent) which, in effect, denies the child's needs. the internalization of the parent's personality serves to lessen the external conflict between the child and the parent, on whom the child depends. the relationship with the parent is seemingly maintained – the child preserves an illusion that he or she is accepted and loved. however, the price of the internalization of the conflict is a loss of valuable aspects of self – a loss of spontaneity, flexibility and intimacy (erskine, 2003; erskine, 2004). the introjected parent ego state manifests in two ways: as an active ego state which communicates with the outside world, or as an intrapsychic influence. berne described the active parent ego state as a reproduction of feelings, attitudes and behaviour of the introjected parent or other significant persons in actual transactions with people. by contrast, the intrapsychic influence manifests in clients as a phenomenological experience of self-doubt, a constant sense of being controlled, the loss of knowing what one desires, and/or chronic anxiety, and/or depression. other clients may be aware of the presence of an influencing introjection or psychic presence of another person; they hear another voice that is criticizing, warning, or rule-making (erskine, 2003). psychotherapy with the parent ego state by identifying the parent ego state, berne created a theoretical framework for therapeutic work with the different manifestations of anxiety, depression or low self-esteem, all of them stemming from the intrapsychic conflict (erskine, 2003). in spite of this, most of the clinical transactional analysis literature has either focused on therapy of the child or adult ego states; very little has been written on the treatment of parent ego states and the resolution of intrapsychic conflict (erskine, 2003). psychotherapy with the parent ego state has been researched by mcneel (1976), dashiell (1978), mellor and andrewarth (1980), and erskine (2003). working with introjects holds an important position within relational integrative psychotherapy. the method of psychotherapy with the parent ego state was described in detail by richard erskine in his article titled introjection, psychic presence and parent ego states: considerations for psychotherapy (2003). international journal of integrative psychotherapy, vol. 3, no. 1, 2012 16 it is important to take note that psychotherapy with a parent ego state can only be performed after much therapeutic work has been done on the child ego states. effective psychotherapy of child ego states and parent ego states produces a reorganization of psychological processes and both phenomenological and behavioural change (erskine, 2003). before using the method of psychotherapy with a parent ego state, several guidelines ought to be taken into consideration. due to the child's biological need for contact, the client’s child ego states are often loyal to a parent ego state. therefore, it is essential for the client to experience the therapeutic relationship as being good and solid. if we deprive the client's parent ego state of power without having first established a good therapeutic relationship with the client, the client's child ego states will be left without a significant other to whom he or she feels a sense of protection and attachment. consequently, the client will feel psychologically worse. what is more, the intrapsychic relationship between a child ego state and a parent ego state which has been disrupted by a premature intervention may result in increased clinging to an intrapsychically influencing parent ego state (erskine, 1999; erskine, 2003). before proceeding with the parent ego state therapy, it is important to set a differential diagnosis, so as to determine to whom the client's internal voice belongs. it may belong to the introject, or to a fantasy of a parental figure which erskine and moursund (1988/1998) refer to as a self-generated parent ego state which is similar to what fairbairn (1952) and little (2001) call the "internal saboteur". this self-generated parent, fantasy figure or the internal saboteur is frequently even more critical than the actual parent, since it was designed to distract from both the internal influence and memory of the introjected other person. in addition, the introjected parent ego state has a proper life story that can be elicitated in the psychotherapy. the fearful or criticizing messages of the self-generated parent, which were developed by a small child, are often much harsher and more controlling while also appearing to be fragmented and disconnected (erskine, 2003; erskine, 2007). in the process of treating the parent ego state, the conflict with that significant person is acknowledged, verified, and resolved. after a successful psychotherapy process, the client generally experiences a combination of feelings such as sadness, compassion, relief or freedom. people usually need plenty of time to process the experience, express any residual feelings, and talk about the meaning they have derived from it. the result of psychotherapy with the parent ego state is that the client regains the self that was lost due to the introjection. clients are less likely to act out their parent ego states towards others and, without the internal influence, are less likely to be in child ego states. in addition, as the content of the parent ego state becomes integrated with the adult ego, the client now has the possibility of dealing with the real person of the parent differently. therapists may also find that previously unresolved transference issues with the therapist are now non-existant or more easily resolved (erskine, 2003). international journal of integrative psychotherapy, vol. 3, no. 1, 2012 17 method of study the goal of our study was to conceptualise a psychotherapeutic method – psychotherapy of the parent ego state. we explored whether this method could be divided into individual, content-wise separate chronological phases which can be observed with the majority of clients. structuring the method into phases would facilitate easier learning for therapists; at the same time, it would provide the basis for further research and enable monitoring of the method’s efficiency in resolving the intrapsychic conflict of the client. in our analysis, we focused on chronological sequences of transcripts, based on the therapist’s interventions. we employed the following steps to conduct our study: 1. based on the existing literature, we selected five psychotherapy transcripts in which the method of psychotherapy with the parent ego state was used. we chose two transcripts from beyond empathy. a therapy of contact-inrelationship (erskine, moursund and trautmann, 1999); two transcripts from integrative psychotherapy in action (erskine and moursund, 1998/1988) and a transcript from a chapter resolving intrapsychic conflict: psychotherapy of parent ego states (erskine and trautmann, 2003). in addition, we analysed a videotape of psychotherapy with the parent ego state (erskine, 2007). 2. we determined which transcript was to be analyzed first. 3. each member of the study team performed the analyzing, structured into chronological sequences (phases), on her own. 4. we compared and harmonized the individual chronological phases, their titles and contents. 5. we repeated the same procedure with the remaining four transcripts. 6. we analyzed the video recording of the psychotherapy together. 7. joint analysis of all six transcripts were then compared; we redetermined the chronological phases which had been observed with the majority of transcripts. phases of psychotherapy with the parent ego state when analyzing transcripts and the video recording of psychotherapy of the parent ego state, we identified the following content-wise separate chronological phases: 1. identification of the introject; 2. agreement on psychotherapy of the parent ego state with the client; 3. stepping into the parent ego state; 4. establishing a therapeutic relationship with the parent ego state; 5. psychotherapy for the benefit of the parent ego state; international journal of integrative psychotherapy, vol. 3, no. 1, 2012 18 6. psychotherapy of the relationship between the parent and child ego states; 6.1 exploring the relationship between the parent and child ego states; 6.2 dialogue between the parent and the child ego states – the “empty chair” technique; 7. conclusion of psychotherapy with the parent ego state; 8. dialogue between the child and the parent ego states – the “empty chair” technique; 9. returning to the adult ego. the individual phases do not necessarily follow chronologically (i.e. as written in this article); they interweave with each other. furthermore, not all of the phases we identified may occur in a psychotherapy. psychotherapy with the parent ego state may take place in one, or several, therapeutic sessions. erskine (2007) recommends taking 90 minutes for a psychotherapy with the parent ego state. 1. identifying the introject in this phase, the therapist uses a phenomenological and historical inquiry. the therapist inquires about the client's past and his or her parents; the therapist identifies the script, self-criticisms, etc. if the therapist identifies the introject, he or she may decide to proceed with psychotherapy with the parent ego state. in this phase, the therapist invites the client to talk in detail about how he or she experiences the introject. such exploration includes all dimensions – emotional, mental, physical and behavioural. when the client experiences self-criticism, it is recommended for the therapist to establish whether it stems from the internal saboteur (the self-generated parent) or from the introject (the introjected parent). one of the ways for the therapist to separate the internal saboteur from the introject is encouraging the client to step into the shoes of the self-critical voice, so as to recognize to whom does the voice belong. transcript: therapist: so, you said you weren’t allowed to be happy. what does “not allowed” mean? client: to smile at inappropriate moments. this was not good. therapist: how did you know that? client: because i was punished. therapist: punished for smiling? client: they were criticizing my behaviour. don’t you know when to act appropriately? therapist: so just close your eyes and say it again. just talk to the little kid out there and say it to her. international journal of integrative psychotherapy, vol. 3, no. 1, 2012 19 client: don’t you know when is the time to act like an adult, appropriately to the environment you are in? therapist: keep going, voice. i want to hear it in the tone you used to have. client: you are not able to think. therapist: keep going, voice. client: are you really that stupid? therapist: keep going, voice. you are telling her she is stupid, you are telling her she can’t think. client: can’t you see that you are not so important. therapist: keep going, voice. i want to hear your tone. i think right now you are covering up your tone. please, let me hear it. client: if you don’t know how to react, stay out of here. therapist: keep going. stay out of here. you tell her that she is stupid; she doesn’t know how to react, to stay out of here. you have some important reason for picking on the kid. client: i don’t want you here. therapist: who are you? client: that is my mother. therapist: keep going. close your eyes and stay with it. so you don’t want her, mother. client: yes. (erskine, 2007). 2. agreement on psychotherapy with the parent ego state with the client the therapist presents this technique to the client by explaining that the client is to assume the role of one of his or her parents; the therapist is going to communicate with this parent, and not with the client (i.e. this is not the “empty chair” technique). although the therapist primarily supports the client, the therapist is simultaneously aware of the client’s intrapsychic dynamics, e.g. the loyalty of the client’s child ego states to the parent ego states. a client whose child ego state is very loyal to his or her parent ego state may need reassurance that the psychotherapy which is about to begin will be for the benefit of both (i.e. the client and the parent), and that the therapist will show respect for the parent ego state. transcript: therapist: would you like me to talk to her1 about the anger? loraine: you could; you don’t know her. you could … therapist: that’s never stopped me before. international journal of integrative psychotherapy, vol. 3, no. 1, 2012 1 “her” refers to the client's mother. 20 loraine: oh, yeah … i need practice talking to her about her anger. i don’t know if i really want to talk to her for real about it. but i could talk to her for pretend. therapist: loraine. i’ll talk to her for real. then maybe, for the first time, you won’t have to be forced to take charge. loraine: okay. i won’t have to keep having the, all those, i work hard at those boundaries. … therapist: well, how about if i take over the boundaries, and you get a little vacation. what do you think of that? (erskine et al., 1999, p. 266-267) the second part of the therapeutic agreement presents the client's consent to participate in psychotherapy with the parent ego state. the therapist explains to the client that the work can be stopped at any point should he or she feel too much discomfort. they may agree on a particular sign which informs the therapist that the client wishes to stop with the method. 3. stepping into the parent ego state the therapist guides the client and invites him or her to deepen the internal contact with the parent ego state by repeating the name of the parent several times, thus activating multiple dimensions of experiencing – mental, emotional and physical. it is important to deepen the contact with the parent ego state, because in the initial stage of such psychotherapy or when the client experiences painful emotional memories, there exists a danger for the client to step out of the parent ego state (erskine and trautmann, 2003). transcript: therapist: sit the same way your mom would sit … just close your eyes. let your body get right into her posture. see if you can put the same expression on your face that reflects what mom feels. (pause) what is your name, mom? (erskine & trautmann, 2003, p. 113). 4. establishing a therapeutic alliance with the parent ego state in this stage of psychotherapy with the parent ego state, the therapist sets the foundation for psychotherapeutic work by establishing a therapeutic relationship with the client. this is not to say that the therapist's care for maintaining a good therapeutic relationship is less important in other phases of psychotherapy quite the contrary. with this type of psychotherapy, a triangular working agreement is established between the therapist, the client and his or her international journal of integrative psychotherapy, vol. 3, no. 1, 2012 21 parent ego state. the primary goal of the psychotherapy, however, is directed towards the benefit of the client, of which the parent ego state is informed prior to concluding the agreement with the therapist. "the therapist must be able to suspend his or her own knowledge of “reality” and allow the client to truly become the other. the therapist's ability to respond to that other with full contact and authenticity makes it possible for the client, in turn, to fully take on the persona of the introject. without this suspension of “reality” the deliberate choice to believe the unbelievable, therapy with an introjected other would be mere playacting; it might possibly lead to some intellectual insights, but it could not have the profound intrapsychic and behavioural influence" (erskine et. al., 1999, p. 312). the therapist presents himself or herself, inquiries how the parent ego state feels in psychotherapy and explains its purpose to him or her. transcript: therapist: debra. you can call me rebecca … (pause) what do you think about being here, debra? anna (as her mother debra): i don’t like it. therapist: you don’t like it? why, debra? anna (as debra): why do i need to be here? therapist: well, mostly so that i can get to know you debra… ultimately, it’s to help anna. and for anna to understand how important you are in her life. (erskine & trautmann, 2003, p. 113). the goal of this phase of psychotherapy is to invite the client to deeply experience his or her parent ego state, as well as to establish and deepen the trust between the therapist and the parent ego state. the therapist should not rush the therapy process; its pace ought to be leisurely and comfortable for the client, so as to enable him or her to step into the shoes of this new identity as thoroughly as possible. moreover, such rhythm provides enough time to all the participants for getting to know each other. in this phase, the therapist and the parent ego state acquaint with each other mostly through chatting. however, “it is not quite the same as a casual conversation, for the questions are more pointed and the direction more one-sided; yet it is different from an initial therapy session in that this “parent” has not requested any kind of help for himself. the therapists are interested, respectful and alert to the possibility that this ego state may become open to a new a new kind of experiencing. at this point, the parent interview becomes parent therapy” (erskine & moursound, 1988/1998, p. 94). international journal of integrative psychotherapy, vol. 3, no. 1, 2012 22 the therapist for example says: “i’d like to know a little bit about you. will you tell me, like where you come from?” (erskine & moursund, 1988/1998, p. 92). similar questions from the therapist can be: “what was your family like?”, “what business was your dad in?” (erskine & moursund, 1988/1998, p. 94), “what kind of family do you come from?” (erskine & moursund, 1988/1998, p. 265). if the parent ego state refuses to cooperate, is rude, dismissive, distant or fails to see any meaning in psychotherapy, the therapist goes on to explain to the parent ego state why their conversation is necessary for the benefit of the child ego state. if the parent ego state remains uncooperative even after this explanation, the therapist stops psychotherapy with the parent ego state. transcript: therapist: have you ever had a conversation like this with anybody who could understand your deep inner process, like i’m trying to do? jon (as his father herbert): no. therapist: well, to answer your question of a few minutes ago, then maybe that’s one of the reasons we should talk. that finally somebody’s going to take time to understand your process. and what it’s like. jon (as herbert): i still don’t know what it has to do with my son. therapist: how about if i make a deal with you? before we stop this interview, when the time is up, i’ll detail how it affects your son. and then you can decide if you want to come back again for a second session … (erskine & moursund, 1988/1998, p. 268–269). 5. psychotherapy for the benefit of the parent ego state the primary focus of such psychotherapy is the parent ego state. in this phase, the therapist poses numerous phenomenological questions, so as to increase the client's identification with his or her parent ego state. the therapist validates the parent ego state, and avoids direct confrontation and interpretation in order to deepen the therapeutic relationship. the therapist uses the information obtained from the client, and inquires the parent ego state on his or her primary family, and on memories of painful experiences. an in-depth investigation of the parent's primary family should not be pursued if the parent's ego state does not want it, or if enough content for therapeutic work has been obtained in relation to the actual client’s family. the therapist may inquire on experiences from different life stages of the parent ego state (e.g. kindergarten, school, first employment, wedding, birth of children, etc.) in order to search for script decisions in each life stage. once a script decision is discovered, it is explored in detail and normalised. transcript: international journal of integrative psychotherapy, vol. 3, no. 1, 2012 23 therapist: tell me about yourself, when you were a little girl in that family. client (as her mother): i was born by mistake. therapist: you were? client (as her mother): yes. therapist: what is a mistake? client (as her mother): my mother was a widow. that was her second marriage. and my father was a very wealthy man, also a widower. and by the rules of society, he needed to have another wife. because he had his own children from the first marriage. and because my mother had been married and didn’t have any children, they thought she was never going to have them. but accidents happen. so first my sister came and then me. therapist: you were an accident or were you planned? client (as her mother): no, we were not planned. therapist: but many kids are born in that way and they are still loved. client (as her mother): yes, but not in that time. therapist: oh yes, many kids were born in that way, so lets go back to your story. what made it so significant that you felt unloved and unwanted? client (as her mother): i don’t know exactly. i was raised by my stepsister. my mother was not able to do that. therapist: not able? client (as her mother): no. therapist: what is not able? client (as her mother): because she was so scared. she was so unhappy to have us. and she was ashamed. therapist: ashamed? client (as her mother): yes? therapist: what do you mean? client (as her mother): she was not proud of us. she felt guilty. therapist: were you and your sister supposed to be boys? client (as her mother): no, we were not supposed to exist. (erskine, 2007). the therapist encourages expressing forbidden feelings by validating and normalising them. in addition, the therapist explores the parent's unmet relational needs. transcript: therapist: i sure see your tears. client (as her mother): i don’t feel at home anywhere i go. therapist: so no matter where you go … client (as her mother): yes. therapist: … that feeling, that uncomfortableness that you said it is all over your body, it goes with you. client (as her mother): yes. international journal of integrative psychotherapy, vol. 3, no. 1, 2012 24 therapist: do you have a name for that uncomfortableness, mom? client (as her mother): terror. therapist: terror. and i see the tears that go with you. … therapist: mom, can we assume that at least the first 18 years you were always sad and depressed? client (as her mother): yes, i was. therapist: so, no modern material things could ever make you happy? client (as her mother): yes. therapist: cause i think your unhappiness is telling a big important story about your life. just like all those tears that want to come out. they are telling the story. in fact, you were probably much more unhappy than you were even able to tell. but you can't go on showing it all the time, can you? client (as her mother): no. therapist: how did you cover that? client (as her mother): i showed others my perfect, strong side of me. (erskine, 2007). in this phase, we use the same methods as with the usual psychotherapy: inquiry, attunement, involvement, regression techniques, the "empty chair" technique (talking to a partner, with the parents who are represented by the parent ego state, etc.), and inquiry regarding feelings towards the therapist, positive resources and pleasant experiences of the parent ego state, defences and so on. 6. psychotherapy of the relationship between the parent and child ego states 6.1 exploring the relationship between the parent and child ego states the essential feature of this phase is that, by acting more confrontational towards the parent ego state, the therapist works for the benefit of the child ego state. notwithstanding, the therapist ought to incorporate a balance between validation and confrontation into the psychotherapy. sometimes a confrontation is necessary in order to protect the child ego state. what is more, such intervention can serve to correct distortions and possible script beliefs in the parent ego state which, in effect, initiates the deconfusion of the child ego state (erskine & trautmann, 2003). at the forefront of the psychotherapy is the search for the yet unknown script beliefs which the parent has transferred to the child. the therapist inquires for example how the parent ego state experienced the child, what the child was like and what expectations did the parent have towards the child. furthermore, international journal of integrative psychotherapy, vol. 3, no. 1, 2012 25 the therapist explores how the parent's script influenced his or her feelings and behaviours towards the child, the child's development and their relationship. transcript: client (as her mother): my husband took our daughter with him to ljubljana sometimes, because he studied there. she was three years old. and i’m sad because he never took me. therapist: just like your mom never took you. client (as her mother): yes. therapist: and did you get jealous? client (as her mother): yeah, very much. therapist: what do you mean? client (as her mother): i’m not good enough. she is, but not me. therapist: i’m not good enough. so once again no one is there for you. client (as her mother): yes. therapist: i’m not good enough. so did you soon get more and more depressed again? client (as her mother): aha. therapist: so, when the little girl does come home, what kind of things do you say to her? client (as her mother): (with a cold voice) how was it? what was she doing? where was she? what did she see? therapist: and when she responds with her excitement and joy, what do you say? client (as her mother): oh, really. therapist: oh, really. what does “oh, really” mean? client (as her mother): i don’t know. therapist: we started this conversation by you saying some pretty nasty things to her. you were telling her that she was stupid, that she didn’t have the right to be happy, and that you didn’t want her. client (as her mother): yeah. my feelings were stronger than… therapist: tell me about your feelings. … therapist: what do you communicate to that little girl when you are with her? client (as her mother): i think we start competing with each other. therapist: can i argue with you? client (as her mother): i don’t know. therapist: you start competing with each other or do you start competing with her? client (as her mother): in fact, i did. therapist: yes, so let’s get out of this together. client (as her mother): yes. therapist: so, you compete with her. how? international journal of integrative psychotherapy, vol. 3, no. 1, 2012 26 client (as her mother): whatever she does, i always have remarks to that. therapist: like? i want to hear it. client (as her mother): you can be better. therapist: which really means you are not good enough. client (as her mother): yes. therapist: ok, keep going. client (as her mother): why did you do it this way? therapist: which really means? what’s the real sentence? client (as her mother): she did it wrong. therapist: what else do you say? client (as her mother): why are you asking so many questions? therapist: which really means? client (as her mother): (is quiet) therapist: shut up and don’t bother me. is that what it really means? client (as her mother): yes. therapist: how would you say it in your words? client (as her mother): (is still quiet) therapist: why are you asking so many questions? looks like an innocent question, but it’s really an embedded statement. what is your statement? because i gave my interpretation, which really means shut up. what’s your statement to that question? client (as her mother): i don’t want to answer your questions, because i don’t even want you to ask me. therapist: mmm, thank you. that’s even more informative than my interpretation. mine was simply shut up, but you say even more. i don’t want your questions, because i don’t want to be bothered to answer them. so part of your message to her is that she is a bother. (erskine, 2007). the therapist is more direct now, providing more interpretations and confronting the parent ego state in order to work for the benefit of the child ego state. even though the parent ego state received more empathy from the therapist in the previous phase, the therapist now takes sides with the child ego state. the therapist encourages the parent ego state to assume responsibility for inappropriate behaviours and attitudes towards the child ego state. as the parent ego state looks for excuses for his or her inappropriate behaviours, the therapist confronts the parent ego state more and more. transcript: client (as her mother): at first i had a housemaid in her early stage for few months. i went back to work when she had 4 or 5 months. and then she gets ill and then i take her to my mothers place. because they advice me. therapist: your mother doesn’t know how to raise children. international journal of integrative psychotherapy, vol. 3, no. 1, 2012 27 client (as her mother): no, but doctors advised that she could use the change of environment, air and i had no other solution. therapist: why would a doctor advice you that a child needs a change of environment? client (as her mother): i don’t know. therapist: yes, you do. client (as her mother): because of her illness. therapist: stop mom, stop. i believed every single word you said until that last one – that i don’t know. i thought you were entirely truthful till that word. why would the doctor suggest that the child changing environment and be separated from her mother. what does that doctor know that you are not telling me? client (as her mother): i don't have a slightest idea. fact is that my girl gets ill in short time after her last vaccination. therapist: what kind of illness? client (as her mother): whooping cough. therapist: a respiratory illness. so they send the baby to be with someone else. client (as her mother): yeah therapist: so this doctor knows that your child has a psychosomatic illness. client (as her mother): yes. therapist: so what’s wrong between you and the baby that this baby can not breath fluent. client (as her mother): we were never close enough. therapist: i believe you. because i think that is the only procedure you ever know. client (as her mother): yes. therapist: so you give her away in the same way that you mother abandoned you. for medical advice of course, more socially appropriate. client (as her mother): yes. (erskine, 2007). at the same time, the therapist endeavours to normalize the feelings, behaviours and thoughts of the parent ego state towards the child ego state which are the consequence of the parent's script decisions and/or traumatic experiences. the therapist may also choose to validate positive elements of this particular parenthood. should the parent ego state show resistance at this point, this is usually a sign that the therapist is approaching the script; regardless, it is recommended to slow down the therapeutic process and to use more validation and normalisation. international journal of integrative psychotherapy, vol. 3, no. 1, 2012 28 transcript 1: therapist: we began by you jumping into this work, mom. i was talking to your daughter and you just jumped right in. and you told me that she was not allowed to be happy. so, here she is, she is going out with her father, she is having a happy time.it sounds like your words were designed to destroy her happiness. and you must inside your head have some important reason for doing that. (erskine, 2007). transcript 2: therapist: tell me about the importance of taking good care of everything. loraine (as her mother alice): i never had a doll. (pause) if i had had a doll i would have taken care of it. therapist: and she (your daughter) probably just plays with the doll, takes its clothes off, throws it around, and doesn’t brush the hair, right? loraine (as alice): yes…but i’m not so worried about the toys, i let them play, make messes; i let them, they dug in the backyard; we had, called it the dirt pile, they were always out there covered with mud, and… therapist: sound like you were a great mother! loraine (as alice): well, thank you. therapist: giving all the opportunities that any child should have. loraine (as alice): that’s what i wanted to be. (erskine et al., 1999, p. 283). the therapist is now inviting the parent ego state to show empathy towards the child ego state and to explore which relational needs of the child he or she failed to meet. additionally, the parent ego state is encouraged to gain insight into how his or her script was transferred to the child ego state, and what role the child ego state played in this process. transcript: therapist: i can understand you. jon (as his father herbert): if you do, you’re the first one. therapist: i’m sorry that’s true. and yes, i guess it’s got to start sometime…i think your son struggled to understand you. and you know what he did? jon (as herbert): it’s hard telling what he’s done. therapist: i can tell you. it’s not hard. jon (as herbert): i’m listening. therapist: in order to get the same thing that you’ve always wanted from your dad, real support and encouragement for existing; in order to hear “i love you”but more than to hear it, herbert, in order really to feel it that he belongs, rather than being an outcast in his own relationship with you international journal of integrative psychotherapy, vol. 3, no. 1, 2012 29 he’s carried your sadness. he’s carried your belief that “i can’t get what i want out of life.” that “life’s the shits,” and “what’s the use.” but mostly he’s carried your pain. in the hopes that if he carried your pain, and stayed depressed for you, you’d be relieved enough that you could be there for him. your son is very loyal. (erskine & moursund, 1988/1998, p. 286-287). it is desired for the parent ego state to express regret for the mistakes he or she has done with the child ego state, and to show a willingness to make amends. transcript: ben (as his father max): yeah, i was angry with ben. i was angry cause he couldn’t play ball. therapist: that’s the social excuse. ben (as max): i was angry because, because i was jealous. therapist: max, i have a good respect for you. that takes a lot of balls to say that. ben (as max): wish i’d done it sooner. (he weeps) therapist: what would you do differently, max? if you would turn the clock back? ben (as max): i could love my wife, and i could love ben too. (erskine & moursund, 1988/1998, p. 105). if, despite the psychotherapy, the parent's ego state remains very critical or destructive towards the child ego state, the therapist's persistence may occasionally contribute at least to some cognitive insight that the parent did not want to behave as he or she did towards the child ego state (i.e. it may provide a cognitive explanation of the parent's conduct and what needs did the child meet for him). in an ideal outcome of psychotherapy, the parent ego state gains insight into his or her mistakes with the child ego state, expresses his or her regret, and gives permission to the child ego state to change his or her script decisions. when the parent ego state behaves destructively towards the child ego state, shows resistance to psychotherapy and refuses to cooperate with the therapist, the goal of the psychotherapy is for the therapist to remove or diminish the parent ego state's authority and the power to interfere with the client's dealings. the therapist may encourage the child ego state to resist to the parent ego state; furthermore, the therapist may give permission to the child ego state to change his or her script decision, thus making a stand against the parent ego state. in the latter case, a good therapeutic relationship between the therapist and the child ego state is crucial, since the child ego state needs a lot of support from the therapist. international journal of integrative psychotherapy, vol. 3, no. 1, 2012 30 6.2 dialogue between the parent and the child ego states – the empty chair technique the therapist is directing the parent ego state to imagine the child in front of him or her. transcript: therapist: would you try something brave? client (as her mother): yes. therapist: just imagine that little girl, mom, right in front here. that little girl you were so envious of, that little girl you gave those destructive messages to. and see if you can take a few minutes to speak to her honestly and maybe, if possible, tell her about those tears coming down your face. (erskine, 2007). the therapist encourages the parent ego state to use the insights gained in the previous phase of therapy in order to talk to the child ego state about his or her own childhood, life and primary family; what he or she missed in that family; about his or her script decisions and what he or she was doing wrong. furthermore, the parent ego state is encouraged to discover what message he or she conveyed to the child ego state, and how did his or her own past experiences, and the resulting script beliefs, influence the child ego state. the parent ego state ought to tell the child ego state what task the child had to perform for him or her. the therapist encourages the parent ego state to talk about his deep feelings; in order to increase the intensity of feelings, the parent ego state may repeat several times what he or she feels towards the child ego state. another important thing to consider is the exploration and acknowledgement of ambivalent feelings which the parent ego state may feel towards the child ego state, e.g. envy or anger. only after this split has been felt and discussed, can a new integration occur. additionally, the parent ego state may tell the child ego state what he or she appreciates about the child. transcript 1: client (as her mother): i wasn’t aware of doing this to you till now. therapist: name “this” so she knows what you are talking about. client (as her mother): that i competed with you, that i rejected you, that i taught you things that weren’t good for you. i have never meant to do that. therapist: keep going. client (as her mother): i am feeling so sad now because i know you couldn’t love me. in fact, you showed me so much attention every time i rejected you. and you are working so hard just to please me. therapist: and my message to you was … international journal of integrative psychotherapy, vol. 3, no. 1, 2012 31 client (as her mother): i don’t want you to succeed. therapist: keep going mom. it’s time to be really honest with her, because she’s been so confused. she has not known what is true and what is not true. client (as her mother): i really want you to be happy, to be successful, and to be accepted by others. therapist: but the truth is … client (as her mother): that i do everything to destroy that. it was so selfish from me. i was so blind. therapist: blinded by … client (as her mother): my own fears, my expectations. therapist: tell her the truth. client (as her mother): can i? therapist: yes. tell her what you know right this moment. client (as her mother) (hesitates) therapist: you can, but i don’t know if you are willing to. client (as her mother): yes, i am willing to. therapist: so tell her. client (as her mother): i admire all your strength and effort for the things i put you through and you didn’t go away. you have courage to stay with me, to love me. therapist: and instead what i communicated to you was … client (as her mother): a rejection. (erskine, 2007). transcript 2: jon (as his father herbert): i hated you, but i loved you! therapist: tell him, elaborate on each one. jon (as herbert): (still sobbing) i love you because…you were the only thing i ever really made, and you were good. and i had so many dreams for you. i wanted you to have the things i never had… therapist: tell him…about hating him. jon (as herbert): and i hated you, because you took from me what i did have. therapist: tell him more about that. jon (as herbert): i wanted someone to take care of me… (each phrase is punctuated by sobs) and who’d be there for me…and only for me…but that changed when you came… therapist: let it come out of your heart, so it doesn’t have to fail you. jon (as herbert): i wanted you to be close to me. and i was so scared of being close to you. therapist: yeah, say that confession again. jon (as herbert): i wanted to be close to you, but i was so afraid of getting close to you. therapist: cause you tell him what you believed would happen if you got real close. international journal of integrative psychotherapy, vol. 3, no. 1, 2012 32 (erskine & moursund, 1988/1998, p. 291-292). the therapist encourages the parent ego state to regret his or her conduct towards the child ego state, to apologise and to show willingness to make amends. finally, the parent ego state is to say what he or she wishes for the child ego state in the future. transcript 3: jon (as herbert): i want him to have the things i never had. therapist: tell him that. jon (as herbert): jonny, i want you to have the things that i never had. i want you to have a name that you can be proud of. and i want you to be happy. i want you…to be… therapist: just put the period there. “i want you.” jon (as herbert): i want you. (he cries softly) therapist: now go on. i want you… jon (as herbert): i want you to be happy…and i want you to have the things i never had…i want you to be successful in life…i want you to be trusting. (erskine & moursund, 1988/1998, p. 294). it is desirable for the parent ego state to give permission to the child ego state to change his or her script decisions. transcript 4: therapist: and you told me 15 minutes ago »i trained my daughter to do like me«. client (as her mother): yes. therapist: you could give her a permission to do it differently. client (as her mother): yes, i am going to. therapist: then go ahead. client (as her mother): daughter, grab all the happy moments that you can. and enjoy them no matter what anybody has told you. i really want you to be happy. therapist: for your sake or for hers? client (as her mother): for her sake. therapist: tell her. tell her some more. client (as her mother): i really want you to be happy for yourself because you deserve it and you need that. (erskine, 2007). the therapeutic work is more directional and, instead of questions, the therapist now uses many unfinished sentences, interpretations and confrontations. however, the content is still coming from the parent ego state. international journal of integrative psychotherapy, vol. 3, no. 1, 2012 33 7. conclusion of psychotherapy with the parent ego state the therapist asks the parent ego state whether he or she agrees to stop the therapeutic work at this point; the therapist thanks the parent ego state for cooperation. before terminating the session, the therapist asks the parent state whether he or she has anything to add, and explains that he or she may return to psychotherapy at any time. the therapist then tells the parent ego state that he or she will now talk to the child ego state, and asks the parent ego state to respect this, i.e. not interfere with the psychotherapeutic process. transcript 1: therapist: yeah. yeah. (pause) well, debra, i really appreciate your coming and talking. and being as honest as you were able to be. now we need to listen to anna. okay? let her talk, and not get in the way, okay? (pause) when you’re ready you can come back another time (long pause) (erskine & trautmann, 2003, p. 128). transcript 2: therapist: anything more you want to say to her before we stop, mom? client (as her mother): i am glad i have you. therapist: mhm. well, maybe before we completely stop, you could listen to your daughter. would you be willing to listen to her? client (as her mother): yes. (erskine, 2007). 8. dialogue between the child and the parent ego states – the “empty chair” technique during the psychotherapy, the child ego states observe the interactions between the therapist and the parent ego state. since the therapist is often empathic and understanding towards the parent ego state, the child ego state may experience that the therapist is taking the parent’s side and has abandoned the child. for this reason it is imperative that the therapist come back to both child and the adult ego states of the client before the work is completed in order to re-establish the relationship. after the therapeutic work with a parent ego state, it is important that the child ego state has an opportunity to respond to the parent ego state. in doing so, the therapist meets two fundamental relational needs of the client the need for self-definition within the relationship and the need to make an impact (influence the other); often both of these relational needs have been restricted or prohibited in the primary relationship with the parents (erskine 2003; erskine & trautmann, 2003). international journal of integrative psychotherapy, vol. 3, no. 1, 2012 34 at the beginning of this phase, the client changes seats and steps out of the parent ego state role. the therapist encourages him or her to respond to the story told by his or her parent ego state. transcript 1: therapist: okay. you stay there, alice (mother); we're gonna bring loraine (the client) over here (moves loraine back to her original seat, facing “alice’s” chair). just get out of alice’s skin… (erskine et al., 1999, p. 307). transcript 2: therapist: (the client moves to another seat) just close your eyes and look at your mom, at the way she looked when you were a young woman, and a little girl… and just respond to her. (erskine, 2007). the client expresses his or her feelings to the parent ego state about what he or she has heard during the psychotherapy, and reveals what it was like to live with such a parent. the client also shares what new information or insight he or she has gained during this therapeutic session. the therapist directs the client to pay more attention to his or her own emotions, and to focus less on understanding the emotions of the parent ego state. transcript 1: therapist: tell her what it’s like, living with that kind of burning anger. loraine: it’s really scary; it’s really confusing. it’s really…it’s really sickening, it’s really nauseating. it really nauseates me. therapist: yeah. loraine: it’s like when hair burns. ugh. smells. i never knew who you were mad at. i knew you were mad all the time, and you never… (her voice trails off into silence) therapist: and tell her what you know now. loraine: i know you were mad all the time. i know your burning anger, and i know it’s not about me, and i know it’s probably not even about dadand all the sarcastic little remarks you make and all that, that was just …little safety valves all the time, a little steam. and that’s kinda exhausting. (erskine et al., 1999, p. 308-309). transcript 2: therapist: tell her about those things she has just said to you. client: mom, i know all those things, even if you didn’t speak about them. most of the time i was angry with you. i feel sorry for myself. but i was happy that i had you and the father. therapist: so tell her what she did to destroy your happiness? international journal of integrative psychotherapy, vol. 3, no. 1, 2012 35 client: on several occasions you spoiled my happy moments. i was tired of proving myself to you and i didn’t show anything. to make it pass as quickly as possible. what you really did to me was that i didn’t allow myself to be happy, to be satisfied. (erskine, 2007). this phase of therapy includes setting boundaries to the parent ego state. the child ego state responds to the parent ego state by rejecting the burden which he or she is no longer willing to carry from the parent ego state. the therapist encourages the child ego state to express what he or she did not like in the parent ego state, what he or she did not want to do, and what he or she needed instead. as a result, the client gains insight that he or she is not responsible for the behaviour of the actual parent. the client then decides what he or she appreciates in the parent ego state and tells this to him or her. this enables the client to form a more realistic image of his or her parent ego state, and to integrate his or her positive features (i.e. the ones he or she might like to preserve). it is important to first emphasize the positive aspects of the parent ego state, as this helps the client to minimize feelings of guilt and validates his or her loyalty to the parent ego state. the client can thus realise that he or she cannot help the parent ego state, and that what he or she has tried to accomplish (i.e. caring for the parent ego state) was an impossible task. transcript: jon: yes, dad. i’ll still love you. therapist: tell him what you love about him. jon: in so many ways. you’re such a kind and compassionate person. and you’ve got a neat sense of humour. therapist: just let yourself see his face now, jon. just as though he’s right here. tell him about that humour. that kindness. jon: (beginning to cry) in the midst of all your crossness, and harshness, you could sill have time for a funny story, or a joke. and we could laugh a lot together. (sobs loudly) therapist: tell him what you appreciate about laughing with him. … therapist: and tell him what you also resent about him. jon: (crying again) that you never, that you gave me very little chance to get close to you in a fun way. therapist: yeah, and tell him what else you resent. jon: and i always had to be your caretaker, and i always had to listen to you, and you wouldn’t listen, you took very little time to listen to me. you never had time for me. only it was always, i had to meet you on your terms. you were very critical of me, dad. therapist: say it again, and tell him how much you resent that. jon: you were very critical of me. therapist: tell him what goes on inside… international journal of integrative psychotherapy, vol. 3, no. 1, 2012 36 jon: i tried so hard to be a good little boy, and i was never good enough for you. (crying) i’m still a good little boy! (erskine & moursund, 1988/1998, p. 296-298). therapist: tell her (your mother) about the part of her anger that you resent. loraine: ahhh…well i resent thinking it was my problem. i resent you not clearing that up for me. i resent you not owning that. uhhh, i resent you letting me think that it was my job. i resent the anger in that house. i don’t want to eat that anymore. i don’t want it: the anger in the creases, in the towels. i don’t want that anymore. all the work, work all day, work, work, work, work, work, to make it okay. it is okay. it’s been okay. i’m okay… therapist: what are you feeling, loraine? (long pause) you feel like you are holding-to me it feels as if you are holding something down. loraine: i guess i’m just sad. feel caved-in, sad. therapist: sad about…will you say more about that? loraine: i’m sad i can’t fix it. ‘cause i love you. therapist: yeah, tell her about being sad that you can’t fix it. loraine: i’m sad that you’re sad. i’m sad that… therapist: tell her about the job she assigned you. the impossible task. loraine: oh, yeah. make mom’s life okay. therapist: did you want to do that job? loraine: i think i wanted to, originally. yeah. it was…gave me a way to be with her. therapist: tell her. loraine: i thought the only way i could be with you was to take care of you, to carry your shit. therapist: yeah, say that sentence again. loraine: to carry your shit. i don’t want to carry your shit. i can’t do it anymore. (erskine et al., 1999, p. 309-310). the client returns the responsibility to the parent ego state and makes a new decision. he or she describes in detail how this decision is going to change his or her internal and external life in the future. if the client is not willing to change the script decision, the therapist may ask him or her to envision how he or she might live out the old script decision in 5, 10, 25 or 50 years if the script decision remains unchanged. such predictive envisioning often provides a powerful internal impetus to make a new decision (erskine, 1974). transcript 1: loraine: to carry your shit. i don’t want to carry your shit. i can’t do it anymore. therapist: so return it to her. international journal of integrative psychotherapy, vol. 3, no. 1, 2012 37 loraine: well i am grateful to you. you gave me a lot. but i’m not grateful for that. you can have it. i feel like i filled up your buckets all the time, and you just dumped them out. you said, “here, this is empty again.” and i can’t, uh, i can’t do that anymore. therapist: “so what i’m gonna do is…” loraine: what i’m gonna do is…take care of myself. and i’m gonna tell you when, you’re coming in on me, when your expectations are not real. when i can’t meet your expectations. i don’t know if you’re gonna get it. i don’t care if you only did have an eight grade education; i think you are smart as hell. (erskine et al., 1999, p. 310-311). if the child ego state shuts down during this conversation and is attacked from the parent ego state, the therapist may reconnect with the parent ego state, asking him or her to allow the child ego state to express himself or herself, so that both of them have equal opportunity for self-expression. in doing so, the therapist encourages the child ego state to express the forbidden feelings and needs by providing him or her the necessary security (i.e. reassurance that the parent ego state will not attack him or her again). transcript 2: therapist 2: that movement of your arm is saying something. (silence) anna, mom’s right there. she told you some important things, and now it’s your turn. tell her what your arm is saying (long pause). ... therapist 1: debra, just because you couldn’t talk about it doesn’t mean anna can’t either. therapist 2: tell her, anna, what you mean when you say “i needed you to protect me.” therapist 1: debra, let anna do what you needed to do – to say what she thinks and to be angry. you also needed to make an impact. anna: i couldn’t talk to you, mom (sigh). you weren’t even around; you didn’t want to listen. therapist 2: talk to her now, anna. anna: (pause) she’ll get angry at me. therapist 1: debra, you said you were going to let anna do what she needed to do. anna: she’ll blame me, she’ll get mad at me, and she’ll only hate me more. therapist 1: not anymore, anna. i’m keeping her out of the way. you’re not going to get any more from her by holding back. you know that not speaking up is a dead end. go ahead and do what you need to do. (erskine & trautmann, 2003, p. 130-131). international journal of integrative psychotherapy, vol. 3, no. 1, 2012 38 at the end of this phase, the therapist asks the child ego state whether he or she has anything else to say to the parent ego state. transcript: therapist: so tell her what you have gained from this conversation with her today. client: i am really glad that you told me those things. and i really would like to forgive you, but it’s hard. therapist: even if it is hard, at least you don’t have to be confused anymore about joy. client: no, i am not. therapist: well maybe it is too soon to fully forgive her. just tell her that you would like to be able to forgive her. that is sufficient for today. client: yeah, i guess. it is sufficient. therapist: anything more you want to say to her before we stop? client: i am glad that she taught me so many things, useful things. the most important thing which she gave me was a permission to be alive. that i have always had for myself. therapist: and today she gave you another permission. client: to be happy. (the client smiles) (erskine, 2007). 9. returning to the adult ego in this final phase, the therapist helps the client to return into the adult ego (the client returns to his or her own chair). the therapist inquires the client how did he or she experience this psychotherapeutic method, whether it provided any benefits to him or her, and how does he or she imagine applying the new insights into practice. it is essential to include this phase, even if the therapist skipped some of the preceding phases. it is vitally important for the client to return to the adult ego at the end of a psychotherapeutic session. if the therapist fails to take this into consideration, serious ruptures may occur in the therapeutic relationship. the client's feeling of self as separate from the introject may weaken, which can sometimes result in headaches or a sense of confusion and disorientation (erskine, 2003). often, the client will spontaneously switch from the parent ego state to another ego state at the end of a psychotherapy session. for the therapist, this is a signal that the client feels a need to process, assess and integrate the experience (erskine & moursund, 1988/1998). international journal of integrative psychotherapy, vol. 3, no. 1, 2012 39 conclusion by means of study and analysis, we determined nine chronological phases of psychotherapy with the parent ego state. the use of this method is not possible when the client's parent ego state refuses it despite the therapist's sensible explanation. because clients are so different from each other, certain deviations were observed in the determined phases of psychotherapy with the parent ego state. therefore, the therapist may choose to use numerous psychotherapeutic techniques such as the "empty chair" technique, regression techniques, and finding resources. however, the success of such psychotherapy also depends on the character of the parent ego state, e.g. will he or she regret his or her inappropriate behaviour, will he or she subsequently apologize to the client and/or give the client permission to change his or her script decisions. the weakness of our study lies in the fact that transcripts of only two therapists were included. it would be sensible to study sessions of psychotherapy with the parent ego state from several psychotherapists, so as to determine whether they differ in some key characteristics. in addition, it would be valuable to analyze more psychotherapy transcripts. this would enable us to empirically explore the efficiency of psychotherapy with the parent ego state by following the nine chronological phases on a larger sample of clients. authors: maruša zaletel is a graduate psychologist at university of ljubljana and a certified integrative psychotherapist with the international integrative psychotherapy association and european association for integrative psychotherapy. she is working in her private practice in kranj, slovenia and is supervising and training students at the institute for integrative psychotherapy and counseling in ljubljana. she is also a certified integrative supervisor with the institute eurocps in france. please sent reprint request to her at maruša zaletel, gregoričeva 22, 4000 kranj, slovenia; e-mail: info@psihoterapija-mz.si jana potočnik is a bachelor of communication sciences at university of ljubljana, faculty of social sciences and has a clinical training in integrative psychotherapy from institute for integrative psychotherapy and counselling in ljubljana. she is trainee psychotherapist in private practice in ljubljana and is preparing to be certified as integrative psychotherapist. please sent reprint request to her at jana potočnik, na jami 9, 1000 ljubljana, slovenia; e-mail: psihoterapija@janapotocnik.si andreja jalen is a graduate psychologist at university of ljubljana. she has a clinical training in integrative psychotherapy from institute for integrative psychotherapy and counseling in ljubljana. she is working in a primary school international journal of integrative psychotherapy, vol. 3, no. 1, 2012 40 mailto:info@psihoterapija-mz.si mailto:psihoterapija@janapotocnik.si international journal of integrative psychotherapy, vol. 3, no. 1, 2012 41 as a counselor. she is mainly engaged in work with children who have behavioral and emotional problems. please sent reprint request to her at andreja jalen, staneta žagarja 30, 4240 radovljica, slovenia; e-mail: andrejajalen@gmail.com special thanks to richard g. erskine whose work made our study possible, for his support and valuable suggestions. the authors also wish to acknowledge gregor žvelc for his help and vital contributions. references: dashiell, s. r. (1978). the parent resolution process: reprogramming psychic incorporations in the parent. transactional analysis journal, 8, 289-294. erskine, r. g. (1974). therapeutic intervention: disconnecting rubberbands. transactional analysis journal, 4(1), 7-8. erskine, r. g. & moursund, j. p. (1988/1998). integrative psychotherapy in action. new york: the gestalt journal press, inc. erskine, r. g., moursund, j. p., & trautmann, r. l. (1999). beyond empathy. a therapy of contact-in-relationship. new york: brunner-routledge. erskine, r. g. (2003). introjection, psychic presence and parent ego states: considerations for psychotherapy. in c. sills & h. hargaden (eds.), ego states: key concepts in transactional analysis, contemporary views (p. 83-108). london: worth publishing. erskine, r. g. & trautmann, r. l. (2003). resolving intrapsychic conflict: psychotherapy of parent ego states. in c. sills & h. hargaden (eds.), ego states: key concepts in transactional analysis, contemporary views (p. 109-134). london: worth publishing. erskine, r. g. (2007). unconscious process, transference and therapeutic awareness. workshop on institute ipsa. ljubljana, slovenia. little, r. (2001). schizoid processes: working with the defences of the withdrawn child ego state. transactional analysis journal, 31 (1), 33-43. mcneel, j. r. (1976). the parent interview. transactional analysis journal, 6 (1), 61-68. moursund, j. p. & erskine, r. g. (2004). integrative psychotherapy. the art and science of relationship. pacific grove: brooks/cole thomas learning. date of publication: 25.6.2012 mailto:andrejajalen@gmail.com psychotherapy with the parent ego state method of study phases of psychotherapy with the parent ego state 1. identifying the introject 2. agreement on psychotherapy with the parent ego state with the client 3. stepping into the parent ego state 4. establishing a therapeutic alliance with the parent ego state 5. psychotherapy for the benefit of the parent ego state 6. psychotherapy of the relationship between the parent and child ego states 6.1 exploring the relationship between the parent and child ego states 6.2 dialogue between the parent and the child ego states – the empty chair technique 7. conclusion of psychotherapy with the parent ego state 8. dialogue between the child and the parent ego states – the “empty chair” technique 9. returning to the adult ego conclusion international journal of integrative psychotherapy, vol. 7, 2016 60 nurturing an integrating ‘adult’ in integrative psychotherapy linda finlay abstract: a goal of transactional analytic psychotherapy is to ‘strengthen the adult’: to develop a thinking, analytical part of self that can manage overwhelming, problematic emotions. however, this understanding misses the layered complexity of what the adult ego state offers and can also promote an unhelpful dissociation in the client which counters the essence and intention of integrative psychotherapy. in this article, i offer a way of conceptualising work with the adult ego state as nurturing a client’s integrating adult – the cohesive, ‘grown-up’ part of our thinking-feeling-experiencing self in the here-and-now, free of contaminations from old parent and child scripts. the article opens with an explicitly theoretical exploration of the ta concept of ‘adult.’ in the second, applied section, i explore how we might work with the adult ego state in our integrative psychotherapy work via three processes: decontaminating the adult from parent prejudices; deconfusing the child; and nourishing the integrating adult. the final section offers a case study illustration focused on nurturing a client’s integrating adult. key words: integrative psychotherapy; transactional analysis; ‘integrating adult’; relational psychotherapy ______________________ introduction in integrative psychotherapy, we sometimes aim to develop a client’s analytical abilities to help them manage overwhelming, problematic emotions. integrative therapists who draw on transactional analysis (ta), may conceptualise this process as ‘strengthening the adult’. (therapists oriented more towards cognitive international journal of integrative psychotherapy, vol. 7, 2016 61 behavioural therapy may similarly works with engaging the ‘thinking’ of clients though explain it differently). however, this understanding, which arises from the functional ta model (joines, 1976; oller-vallejo, 1997), represents how the ta field moved into taking more of a reductionist cognitive-behavioural approach rather than an in-depth response to developmental trauma and neglect. focusing unduly on the client’s ‘thinking’ misses the layered complexity of what the adult ego state potentially offers. namely, it misses the idea of a feeling-thinkingexperiencing adult. it also seems to enshrine and promote the growing of a self that is disconnected and dissociated – the precise opposite of what we are trying to achieve as integrative psychotherapists. in this paper, i would like to argue that a better way of conceptualising our integrative therapy work with the adult ego state is to see ourselves as nurturing a client’s integrating adult. here i follow erskine (1988, 1991) and support conceptual and structural ta models which consider the adult to be the part of us in contact with present reality while parent and child are in contact with the past. in integrative psychotherapy, we aim to bring about a client’s integration by working with them holistically, thereby enabling them to hold polarities and make meaningful connections with previously disowned parts of self (erskine & moursund, 1988; erskine, 2015). we facilitate self-awareness, self-compassion and insight towards helping the client to feel more comfortable with their own self (or parts thereof) and with others. we can understand this process as one where an integrating adult ego state is nurtured towards greater integration. with the (continually evolving) integrating adult more to the fore in the executive, clients are better able to problem-solve in the here-and-now, respond to life situations more effectively and access greater choice when making decisions. the first part of this article is explicitly theoretical. it clarifies the ta concept of ‘adult’ following berne’s (1961/1986) original conceptual model where he posited the notion of the adult ego state as coming from a more autonomous, integrated place involving feeling, attitudes and behaviour. here the person is shown to have a growing capacity for awareness, spontaneity and intimacy. more than simply being a theoretical concept, the adult (like the other ego states) is accepted as a ‘phenomenological reality’. in the second, applied section, i explore the nature of our integrative psychotherapy process when we work with a client’s adult via decommissioning the parent, deconfusing the child ego states and nourishing the integrating adult (erskine, 2015). the third section offers a case study illustration of therapy based on strengthening the client’s integrating adult. throughout this paper, i follow the ta convention of capitalizing the first letter of the ego states to distinguish these from the usual use of the terms parent, adult, child (berne, 1961/1986). international journal of integrative psychotherapy, vol. 7, 2016 62 clarifying what is meant by ‘adult’ transactional analysis (ta) theory is frequently reduced to simplistic soundbites, with the adult ego state is caricatured as a logically minded, rational controller who, devoid of feelings, acts like spock in star trek. a better way to conceptualise the ideal adult ego state might be as a cohesive, ‘grown-up’ part of our thinkingfeeling-experiencing self, free of contaminations from old parent and child scripts (stewart & joines, 1987). in berne’s (1961/1986) original terms, the parent ego state is seen to include the feelings, attitudes and behaviours resembling past parental/authority figures; the child ego state is made up of relics of the individual’s own childhood. in contrast, the adult ego state arises in a biologically mature person who functions as an adult intellectually and in emotional responsivity. in adult, we are able to act on our values and moderate our ability to draw on resources available in the environment. the ideal adult ego state comes from an integrated, freed-up place that holds awareness of different parts of our selves/ego states. here, the feelings/thoughts/behaviours of the parent, adult and child are taken into account (berne, 1961/1986; 1964). this adult works out how to ‘be’ in the here-and-now while remaining aware of how the child ego state might attempt to satisfy its needs and/or acknowledging that the parent says what ‘should’ be done. importantly, this adult ego – along with child and parent gets continually updated moment by moment (clarkson, 1992). in other words, the ta adult includes our grown-up thoughts and feelings. it consists of age-related cognitive and emotional elements along with behaviours, moral reasoning, attitudes, curiosity, ability to be creative or productive, being in loving contact with others, and so forth. our adult symbolises that part which offers us grown up resources to think-feel, analyse, evaluate, make decisions and systematically work through problems. head and heart are connected; the adult is not a dissociated, data-processing ‘computer,’ as portrayed in other variations of ta theory (e.g. in simpler behavioural versions of the functional model in contrast to the conceptual and subsequent structural models which are more phenomenological in focus). another common misunderstanding is to see emotional reactions as located solely in parent or child. arguing against this idea, lapworth, sills and fish (1993) give the example of how an adult response to the death of a friend involves despair, sadness, anger, existential questioning – all possibly adult responses to the international journal of integrative psychotherapy, vol. 7, 2016 63 present reality of bereavement (though they may also involve regression to child responses or activation of parent responses). as another example, consider the sexual/intimate feelings and behaviour we experience as adults. these are necessary, normal, wholesome feelings, attitudes and ways of being that have evolved throughout our lifespan and can now be found in the adult ego (though again sometimes they may be contaminated by negative, defensive aspects of fixated child or introjected parent injunctions from the past). ideally, with the integrating adult to the fore, a playful, curious, joyous, childlike way of being can emerge that is not engaging in game-playing and is unafraid of earlier restrictive socialising processes (harris, 1970). to show the working of this adult ego state, consider how as children we may have thrown a tantrum when things didn’t go our way. as we grew up, we learned to negotiate, assert ourselves and/or accept provoking situations more gracefully. the adult in us might now see the humour in the possibility of having the longedfor tantrum while recognising that other options are likely to be more productive. here, the child and parent ego states are, in a sense, updated (‘redecided’) towards determining what is a safe way of expressing feelings. the old information and reactions are stored away and decontaminated, allowing new choices to be made as the need to throw a tantrum diminishes in intensity. in the integrative psychotherapy field, erkskine (1988, 1991, 2015) has explored the concept of an integrating adult, building on berne’s (1961/1986) original conceptual model and definition of the adult ego state as “autonomous” (i.e. uncontaminated by child and parent ego states but clearly aware of one’s history). erskine explains the integrating adult as one who has assimilated both archeopsychic (experiencing child) and extereopsychic (introjected parent) experiences and is not controlled by relics and defence mechanisms of the past. in other words, the adult ego is in contact with current reality while parent and child are in contact with the past. in summers’ & tudor’s (2005) co-creative model of ta, the ‘integrative’ adult is described as a way of being that is in contact with self and others. it is seen as resourceful, creative, curious, and responsive, with awareness of how less helpful choices and responses arise from compulsive parent or child ways of being. the integrative adult is able to prevent the replaying of negative self-dialogues and automatic scripts replacing them with more positive, choiceful alternatives. extending these ideas, žvelc (2010) suggests the term ‘healthy relational schemas’ (cognitive structures we use to organize meaning) to describe this internal regulation and feeling of safety and calm. he acknowledges that the concept of integrating adult is much broader than this but notes that our experience international journal of integrative psychotherapy, vol. 7, 2016 64 of the present moment depends on relational schemas. for him, the integrating adult involves a continuing process of restructuring of relational schemas which themselves are based on – if not controlled by experiences with others from both the past and present. one critical debate at stake is whether or not parent and child are viewed as having positive potential and are open to being changed such that these ego states could be considered in contact with the present reality (like the adult). different theorists take different views. even berne himself offered contradictory messages (oller-vallejo, 1997). i follow erskine’s (1988, 1991, 2015) view that it is the positive aspects of parent and child that get incorporated into the adult as part of the integrative process. in other words, when internal conflicts and problematic, defensive aspects of introjected parent and fixated child are resolved, they can be integrated into adult. other authors (e.g. novey et al, 1993; gouldings, 1979) would argue more for the positive as well as negative use of parent and child ego states. the aim with their various models is not to subsume the parent and child ego states into one (adult) ego. child and parent ego states are preserved as distinct parts with specific adaptive functions. summers (2011, p.64) has since added a further level of complexity by arguing for a dynamic adult with integrating, disintegrating and non-integrating capacities: i think it is important to account for experiences, relational or otherwise, that we hold as some unintegrated fragments but are not defensively organized. in the ongoing process of lifelong learning we hold many fragments of experience (ideas, feelings, images) at different levels (conscious/preconscious/nonconscious) that we may or not be able to integrate but we are nonetheless able to tolerate the fragmentation, not-knowing, and uncertainty. in summary, the application of this theory, as delineated by the authors and theorists noted thus far, suggests that a core aim of therapy is to enable the development of a stronger, less contaminated, more autonomous, integrating adult. the integrative function displayed by this ego state is to mindfully ‘own’ the disparate parts of self and to mediate between their contradictory needs and values. the three different sources of experiential information are integrated: 1) what is occurring in the present moment, both within the self and outside (interpersonally in a particular context); 2) past experiences and subsequent learning about behaviour, effects and consequences; 3) the values and influences from significant others (parents, spouse, friends, therapists and so on). in short, the processing of the adult ego (as with the child and parent ego states) involves temporally layered, multidirectional awareness and responsiveness. international journal of integrative psychotherapy, vol. 7, 2016 65 in the next section, i emphasise the practice of bringing parts of self explicitly to the fore and suggest ways in which therapists might nurture a client’s integrating adult: the ‘grown-up’ part of the thinking-feeling-experiencing self that is in the here and now, relatively free from contamination by parent and/or child. ‘strengthening the adult’ in therapy sometimes a client’s child or parent ego state can dominate or overwhelm that person’s way of being. for instance, fuelled by their child ego state, the client might be emotionally overly reactive, with little capacity to analyse a situation before responding. in extreme cases, it can be hard to detect the presence of any adult thinking and/or feeling. alternatively, a client might be overly repressed/oppressed and oppressive to others, indicating in turn, dominant critical injunctions from the parent ego state. this parent ego may also represent the actual parent’s own vulnerability where their adult is similarly driven by parent or child needs – a dynamic that may be replicated in a trans-generational field. (this historical focus which considers personality development over time is explicated by what is known as a second-order structural model of ta stewart & joines, 1987). at a less extreme level, we may find child or parent ways of being leaking into the client’s adult ego. if, out of the client’s awareness, unhelpful child neediness and/or parent judgements creep into adult reasoning, we say the adult is ‘contaminated’ by child or parent (berne, 1986; clarkson, 1992). for instance, the view that “i can’t write academic essays” may be spoken from child or parent shame, while “we’ll be happy once we have a baby” could be said to indicate child ‘magical thinking.’ similarly, it is possible that apparently ‘rational’ statements such as “immigrants can’t be trusted” or “i have to support the islamic state as i believe in islam” may contain some parent prejudice and child fear. as the client grew up, perhaps with little experience to go by, they may have believed these various social (and perhaps inter-generational) messages, which they now see as ‘fact.’ in these ways, childhood situations are mistaken for grown-up reality (stewart & joines, 1987). given the way the adult mediates between child needs and parent demands, reinforcing and strengthening the client’s adult ego is useful as a central therapeutic strategy for integrative psychotherapists. here the boundaries between the ego states are clarified, including separating the adult from introjected parent and/or archaic child ego states. the goal is to facilitate and empower the international journal of integrative psychotherapy, vol. 7, 2016 66 person to engage their adult ego state mindfully, in the here and now, so that the person can choose to employ the positive aspects of whatever way of being is most appropriate to any given situation. but how exactly do we help clients achieve this? following berne (1961/1986) and others, i find it useful to think of a three-pronged (often sequential) approach: 1) decontaminating the adult from parent prejudices; 2) deconfusing the child ego state; and 3) nourishing the integrating adult. (see figure 1). in his integrative approach to ta, erskine (1991; 2015) presents a similar threepronged strategy: i. amending or decommissioning the extereopsychic (i.e. parent) ego states to resolve internal conflicts; ii. deconfusing the archaeopsychic (i.e. child) ego states and relaxing fixed archaic defenses; iii. facilitating the integration of life experience into a neopsychic (i.e. adult) ego. taking a more psychodynamic line, hargaden and sills (2002) build on menaker’s (1995) work by presenting three categories of transference: projective, introjective and transformational. in contrast to erskine’s work, the latter transference relates more to working with projective identifications than with those of the neopsyche. figure 1. three ways to work with the adult ego state deconfusing the child nourishing the integrating adult decontaminating the adult from parent prejudices international journal of integrative psychotherapy, vol. 7, 2016 67 decontaminating the adult from parent prejudices the process of ‘decontaminating’ the adult involves awareness-raising designed to minimise intrusion by critical injunctions and restraining parental scripts. therapists often play a significant role in cleaning up and strengthening any indistinct or fragile boundaries, for instance when giving clients permission to think, feel and behave in ways that counter archaic messages. when decontaminating the adult, the therapist’s own adult probes and challenges the client’s so-called adult beliefs, helping the client to be reflexive (i.e. critically self-aware) and recognise any distorted thinking. a valuable opportunity for some decontaminating arises when a client expresses that they are “sorry about crying” or that “therapy is self-indulgent.” in response, the therapist could explore where such views come from (perhaps the client’s parent modelled never crying or they belittled vulnerability) and probe what meanings are carried (e.g. the client considers themselves “weak” or “selfish”). further exploration may even expose a ‘double contamination’ (stewart & joines, 1987) where the client re-plays a parental slogan (e.g. “boys don’t cry”) confirming it with a child belief (“i’m weak to cry”). therapists often highlight those more negative or persecutory parent messages apparent in clients who habitually put themselves down in shame and self-loathing. for instance, i talk with clients about “turning down the volume” of those critical voices or “getting a distance” from them. this invites their adult to take action towards decommissioning toxic components. it’s also an implicit invitation to adopt a more compassionate attitude towards self (and others) an attitude likely to move the client out of defensive versions of parent or child and into a here-andnow mindful adult more quickly. beyond critical injunctions, the parent can over-dominate in other ways which reveals further complexities of the parent ego state such as acknowledging the role of the ‘parent in the child’ or the ‘child in the parent’ (stewart & joines, 1987). for instance, when discussing a client’s interactions with her baby, it may become apparent that the client is parenting from the ‘parent in her child’ (e.g. treating the baby like a doll, alternating between showering it with love and damaging it in frustration). as a different example, the ‘child in the parent’ might come out in learned (childlike) beliefs such as “alcohol helps; i need it to dull my pain.” this way of living might have been introjected by the child who may, without awareness, follow the script of the parent by drinking to excess when faced with emotionally difficult times in their life. international journal of integrative psychotherapy, vol. 7, 2016 68 in their integrative version of therapy taking a relational psychodynamic approach to ta, hargaden & sills (2002) see the decontamination of archaic messages occurring transferentially. while social level transactions between client and therapist (as described above) take place from adult to adult, ulterior levels of transactions also take place between the therapist’s adult and the client’s child. through ‘empathic explanations’, the therapist helps the client’s adult understand connections between the client’s ego states. at the same time, a nourishing relationship is being developed, one in which (for example) a client may learn that deepest child wants/needs can be met in relationship, rendering obsolete repetitions of the client’s parent or child ‘self-management’ process. this view of the therapy process is also supported by the integrative psychotherapy work of erskine & moursund (1988). tudor (2003, 2011) places less emphasis on the unconscious and transference, arguing that it is not necessary to work in the client’s past. instead he sees the therapist’s role is to help the client expand their neo-psyche (integrating adult) functioning. he recommends doing this relationally, through adult-adult transactions in the present (where, phenomenologically speaking, past and future also reside). where ruptures occur, perhaps inevitably, both therapist and client have an opportunity to reflexively process how parent/child dynamics have been co-created. the focus is not so much on specific ego states but on how “relational possibilities are being co-created on a moment to moment basis” (2011, p.329). deconfusion of the child ego state in ‘transactional analysis in psychotherapy’, berne stated that “the ultimate aim of transactional analysis is structural readjustment and reorganization … reorganization generally features reclamation of the child, with emendation or replacement of the parent. following this dynamic phase of reorganization, there is a secondary analytic phase which is an attempt to deconfuse the child” (1961, p. 224). most of berne’s descriptions of psychotherapy emphasise his first phase, the decontamination of the adult ego from child or parent ego states to develop a thinking/analytical part of self that can manage problematic emotions. the second stage of deconfusion is usually engaged in longer-term relational work. deconfusion involves working through the contaminations emotionally as well as cognitively. it takes a more explicitly developmental focus, where therapy involves clarifying and exploring the unmet needs and longings of the child, along with some ‘re-parenting’ (clarkson, 1992). during this process, the therapist attunes to international journal of integrative psychotherapy, vol. 7, 2016 69 the developmental level of the child by acknowledging, mirroring, validating and normalising. it’s about witnessing the child’s experience and helping to find the child’s voice. deconfusion facilitates the adult ego’s integration of physiology, affect, and cognition such that behaviour is by choice (given the current context) rather than being stimulated by archaic fear or compulsion (erskine, 2015). while decontamination work with the adult is largely cognitive, work on child deconfusion is fundamentally relational and transferential (hargaden & sills, 2002). with deconfusion work the transferential dynamic is just often more figural and explicit. (this is not to deny that transferential dynamics are also likely to be present when working with the client’s adult or parent ego states. with decontamination work, transference may still present – for instance, when a client projects onto the therapist that they think the client is “mad”). during deconfusion, unsatisfied child needs may be projected onto the therapist. this occurs when the therapist is experienced by the client as the source of possible satisfaction of the need (positive transference) and also its frustration (negative transference) (erskine, 1991). through this transferential ‘re-parenting’ relationship, the client can be supported to regress, allowing both therapist and client to re-examine old patterns and access old wounds towards the goal of healing them. hargaden & sills (2002) discuss the value of ‘holding’ the client’s child when 1) the client is regressed to being totally dependent; 2) anything other than affirming empathic mirroring would be experienced as persecutory; and 3) the client connects with their critical parent in rage and hatred, against either themselves or the therapist. trautmann (1985, p.190) describes the process with reference to the level of childhood fixation and quality of attachment to parental figures: therapy is effective when the internal parental influence or dialogue is externalized (transferred), allowing for the resolution of childhood impasses and traumas, and the emergence of a stronger, uncontaminated, more integrated adult. the specific approach used to effect this resolution depends on the level of childhood fixation: the more symbiotic the child, the more actively the therapist needs to take on the transference relationship. an implicit goal of the deconfusion process is to receive care and compassion from another person in a way that is therapeutic and also to enhance the client’s adult so they can give themselves the care and compassion their confused child part yearns for. this enables a nurturing, self-compassionate way of being to emerge which engages a positive self-parenting process (differentiated from dysfunctional international journal of integrative psychotherapy, vol. 7, 2016 70 self-parenting which children evolve in the absence of adequate parenting). healing is achieved over time partly as the client internalises the therapist’s empathy and compassion and as they perhaps grow a new more nurturing adult (as opposed to an archaic nurturing parent) modelled on the therapist’s nurturing. hargaden and sills (2002) call this internalising of the healing relationship ‘introjective transference’. they argue that it is only when the therapist is willing to enter into, and be impacted by, the transferential relationship with the client that deconfusion can take place. in the introjective countertransference, the therapist is called to enter a symbiosis with the client in order to meet their archaic child needs. here, the therapist is somewhat objectified and used towards meeting the client’s narcissistic needs; they are there to listen, attune, soothe and contain, rather than intrusively insert their own presence (which would be child to child competition or parent to child demand). such an approach draws on kohut’s (1971) self-object theory and highlights how the child’s psychological strivings for mirroring, idealization and twinship are met by the therapist’s counter-transferential response which evolves from soothing/attuning to handling grandiose expectations and then finally to allowing exploration of sameness and individuation. the complication in this therapy process comes when the therapist employs their own ‘nurturing parent’ (which involves parental introjects and possibly unmet child needs) rather than parenting healthily from an integrating adult. here for example, the therapist might overwhelm or smother the client with care reinforcing therapist parent interactions which may promote unhelpful power dimensions and dependency. if a therapist sees a client needs reassurance, a more helpful adult response might be to encourage the client to find their own self-compassion and nurturing, i.e. encouraging the development of the client’s own internal resources. here the therapist strives to be present with and for the client, respecting, supporting and loving them for who they are and celebrating their personal development from an integrating adult ego (erskine, 2013). there is room to be creative in the therapeutic process engaging a therapist’s nurturing side or childlike spontaneity but the adult needs to take the lead. utilising a parent ego state when working with a client without adult monitoring may mean the therapist is under influence of their own needs and/or non-integrated ‘borrowed’ ego states originating from their past (clarkson, 1992). nourishing the integrating adult international journal of integrative psychotherapy, vol. 7, 2016 71 the process of nourishing the integrating adult aims to strengthen and expand the client’s adult capacity to experience and manage feelings/needs in the present moment in a cohesive, balanced way. in this more connected place, previously repressed or disowned feelings, needs or desires are reduced, along with the compulsion to use parent and child defenses at times of stress. contact with the adult is important to clarify the client’s life choices/goals. such contact also serves as an observing ally when working with the child or parent (erskine, 1991). in integrative psychotherapy, we can facilitate this growth in four main ways. the first is through raising awareness. secondly, we have a role to play in helping the client explore and enjoy their adult. on this basis, we can then encourage the client to engage relationally (and compassionately) with the different parts of themselves. the final layer of healing comes when, with our support, our client can reconnect more positively with their parents, wider family and cultural heritage. awareness-raising in therapy, perhaps the most important thing we offer beyond the therapeutic relationship is space for the client to cultivate self-awareness. here, sharing basic ta theory (which is relatively accessible) with clients can be particularly helpful, enabling them to notice and understand their responses and perhaps choose to act differently. the key to raising a client’s self-awareness is helping them recognise those times when they may be responding compulsively, from parent or child, in damaging or limiting ways. reflexively knowing from which ego state a feeling/behaviour may be coming may be sufficient for the client to interrupt their more defensive parent or child response. this decontamination work then allows more mindful choices about how to handle the situation from adult. for instance, a person might be helped to become more aware of their retroflected anger and how they are protectively loyal to an abusive parent (adapted child response). moving into adult allows them to see more of the ‘reality’ of their situation. to this end, summers & tudor (2005) – drawing directly on berne’s (1961/1986) original work on diagnosing ego states recommend offering the client four clues to help them identify which ego state they (or others) may be using at any particular time: • behavioural – are you behaving in a parental or child-like way? for example, are you “telling someone off“ (parent) or “sulking” (child)? international journal of integrative psychotherapy, vol. 7, 2016 72 • social – are others around you behaving in a complementary fashion? if others are being child-like, this might indicate that you are operating from a parent ego state. • historical – does your attitude or behaviour remind you of one of your parent figures, or yourself when you were younger? • felt sense – do you “feel” as if you are one of your parent figures, or as if you are younger than you actually are? (2005, p.4) good therapy questions tap into here and now experiencing and awareness: “what part of you is talking now?” or “how are you experiencing this in your body?” or “what does that mean to you?” with this kind of phenomenological inquiry (erskine, 1993) the therapist shows a genuine interest in the client’s subjective experience and meanings. such interventions help the client recognise the current and arachaic feelings, thoughts, and behavioural impulses arising from different subjectivities and ego positions. they can then begin to make sense of their needs and relational patterns, and will find themselves better placed to be less impulsively reactive and more choice-full. taking a linked but different line, žvelc (2010) ties ta to mindfulness and schema theory. he proposes a ‘mindful adult ego state’ to describe a state of presence and self-acceptance in the here and now present moment. such a mindful state, he argues, provides a helpful third person perspective on experiencing. in the mindful adult, the person accepts whatever experience arises without judgment enabling them to dis-embed from enacting relational schemas. thoughts and feelings simply become passing objects and in a ‘being’ rather than ‘doing’ (i.e. problem-solving) adult mode. this is the attitude he recommends towards our integrative project. exploring and enjoying the adult in practice, we invite the client’s adult to be present by being ‘in adult’ ourselves. if we want to nurture a client’s adult, we need to be aware of (and try to resist) invitations to respond from our own parent or child place. if we respond to the child of a hurt, vulnerable client from an overly controlling or nurturing parent position, then we shouldn’t be surprised if their child gets activated. if nurturing or containment is needed by a traumatised or acting out client then the therapist’s loving, attuned, present integrating adult needs to take the lead. revelling in adult to adult transactions can prove nourishing for both client and therapist. here both might have stimulating intellectual debate or humorous international journal of integrative psychotherapy, vol. 7, 2016 73 exchanges – perhaps about the games we play when dealing with recalcitrant children, difficult partners or uncooperative computer technology. affirming when adult to adult interactions are happening between therapist and client can help both parties savour the satisfaction of this growth. this then might encourage adult transactions to be repeated by the client in other areas of their life. of course, it is important for the therapist not to flee into a disconnected way of being by holding onto theory and knowingness in defence against vulnerability. our adult-adult use of thinking and meaning-making with our client needs to be done as a tentative, emergent, relational exploration (rowland, 2016). as summers & tudor helpfully note, it is possible to be in adult while behaving in a parent or child-like (rather than in parent/child) way because it is appropriate and/or simply fun. alternatively, drawing on more relational psychoanalytic versions of ta, we might note a simultaneous ulterior transaction between the therapist’s nurturing adult and client’s child in an idealising transference or between therapist’s playful adult and client’s child in twinship transference. the point is for the client to recognise they have choices. can they be curious about themselves, others and life in general? can they celebrate, and be excited by, the different possibilities that being in adult opens up? when in adult “flow” we will naturally explore and expand our range of being and relating because we are curious about ourselves, others and life. we will invent and test new possibilities, expanding our relational, emotional, intellectual or technical capacities. (summers & tudor, 2005, p.5) engaging relationally with different parts of self perhaps the most important step in integrative psychotherapy is to work strategically with parts of self to help the client come into contact with their different parts, rather than denying or disowning them (erskine, 2015). facilitating the person to be in relationship with their different parts helps to strengthen their sense of identity. the process of learning to attend mindfully and reflexively to child needs can also be healing. it involves the emergence of self-love and compassion, realised in part by internalising the therapist’s love and compassion. at a theoretical level, we might see this as the strengthening the nurturing aspects of the adult in the here and now (rather than reinforcing a nurturing parent ego state based on international journal of integrative psychotherapy, vol. 7, 2016 74 introjections from the past). the significant shift is the move into a growing (and growth-full) integrating adult who reflexively understands the needs of different parts (and of the whole) and then finds ways to handle these. in the following passage a client (steven) talks about his growth in therapy, in a letter written to his therapist, by showing how his emerging ‘adult me’ cares for ‘little me’: little by little i feel a bit more grown-up, the person opposite me is talking to me as if i am capable, intelligent and as if i have a future. this is music to little me’s ears, and little me decides to sit still for short periods of time and trust that things are being taken care of. there is an adult in the room that i can trust and the adult is me. my thinking is more rational, forgiving and strong; part of me is able to recognise that little me is afraid of that thing over there in the shadows and offers the little me some comfort in kind words, hugs and compassion. the uninvited guest starts to feel less like a terrifying stranger and its presence is acknowledged…i tell myself that i’m safe and try sleeping with the light off. i deserve a good night’s sleep – and i get one ☺. i trust adult me to take care of little me. i recognise, through the eyes of the person sitting opposite me, that my circumstances were not normal and in witnessing this i am able to forgive and understand the little me. i am responsible but i am not to blame. i am not inferior or unlovable – it is not me that is lacking but my environment. i know this intellectually and emotionally (finlay, 2016, p.133). helping the client reclaim their heritage elsewhere (finlay, 2016), i discuss the multi-dimensional nature of our therapeutic focus related to integration at intra-psychic, body-mind, relational-social and transpersonal levels. the two latter arenas of integration are specifically addressed when working with clients who are seeking to reclaim their heritage. with the integrative project being to encourage the owning of unknown and disowned parts, our broader family, community and cultural heritage must be a part of that process, beyond any intrapsychic awareness-raising. is there space for the client to claim any positive aspects – both of their legacy and current social location? hargaden and sills (2002) suggest that another dynamic is involved in the latter stage of therapy work, particularly where deep transferential deconfusion work has international journal of integrative psychotherapy, vol. 7, 2016 75 been engaged. this involves the therapist grasping the opportunity to give the client’s ‘parent’ back to the client, enabling the latter to re-engage with their parents in more realistic, appreciative or – if possible compassionate ways. more than this, the process also allows them to re-claim their heritage, whether in the form of community, culture, or intergenerational linkages. hargaden and sills (2002, p.162) explain it thus: the therapist has allowed herself to be used, to help build the client’s self and self-esteem, to help him free himself from the bonds of stale patterns of relating. in some cases, she has allowed herself to become central to the client, to be idealized, negated, twinned with. at a certain point, however, she needs to become ordinary again and step back in order to encourage the client to rebond with the familiar and cultural identity that is his rightful inheritance. they contrast survivors of abuse who have been too hurt by a crazy parent to allow themselves to forgive with those who have come to proudly own their rich cultural and inter-generational heritage. even where the client ends up in acceptance that reconciliation with an abusive parent is impossible, there may be other familial gifts that can be appreciated and claimed. to give some examples, a client might acknowledge that their love of books or their musicality or their healthy constitution comes from a problematic parent. therapists play a part in enabling wider integrative linkage when they show some respect and/or compassion for the specific parents involved. i have witnessed the extraordinarily healing and transformative results achieved by the use of a parent interview (mcneel, 1976; erskine & moursund, 1988; zaletel, potočnik & jalen, 2012; finlay & evans, 2016). here the therapist offers therapy to the internalised parent (parent) to help decommission toxic components of the ‘child in the parent’ or the ‘parent in the child’. the aim is to help the client externalise their internal family experience and see this as separate from themselves. to give an example, a client might become aware of carrying a parent’s shame – shame that perhaps they don’t need to carry themselves. whichever way the process is understood, clients who have been on the receiving end of therapy with their parent ego state often recognise and talk about the increased compassion they feel for their parent. the broader integrative linkage can also occur through the therapist showing a genuine interest in the client’s background and cultural history. games/scripts and ways of being can be passed down through the generations and it can help to recognise these in the client’s historical-cultural matrix (berne, 1964). beyond intrapsychic function, it’s also about making links between the influence of a person’s history/culture and their ever-changing present. the challenge for us as international journal of integrative psychotherapy, vol. 7, 2016 76 therapists is to remember that the integrating adult may look very different for someone from a different background and culture to ourselves. awareness of inter-generational trauma, as well as the richness of cultural heritage, can also enable new perspectives and renewed healing. here active roleplay, enactments or ritual ceremonies (as seen in the fields of gestalt and drama therapy) offer the opportunity to symbolically complete unfinished business. as the trauma is being worked through, adult observation skills are called upon to mark the here-and-now: to distinguish today from traumatic times in the past when clients weren’t safe. clients come to view traumatic past experiences as something that happened to them (or to previous generations) then and as not representing who they are now. there are many different forms of therapy which tap these areas of intergenerational trauma. focusing-oriented therapy (fot) for complex trauma, pioneered by shirley turcotte, is one example. drawing on her own canadian aboriginal heritage, turcotte has evolved ways of using the phenomenological approach of focusing on bodily felt sense to engage: intergenerational/vicarious trauma; reclaim identity; and do de-colonization work (see: http://www.focusing.org/newsletter/sep2009/sep_2009_newsletter.pdf) another route is the field of therapy known as family constellations, which seeks to reveal underlying familial bonds and forces carried unconsciously over generations. also called systemic constellations, this approach aims to uncover systemic dynamics that span generations while still working at an individual level. when a family constellation is set up, the facilitator invites a client to select different representatives from the group for their family. these representatives are then placed by the client (silently and intuitively) in particular positions reflecting a living family tree. then the work of new positioning and dialoguing begins, for instance, the faciliator might ask constellation members what they are feeling. new insights and a more complete picture of the family system begins to emerge and can be worked through (manne 2009). case illustration when she first came into therapy, marnie was in her mid-40s. she held a responsible position in the legal department of a successful commercial firm and presented as highly professional if somewhat cold, controlled and dissociated – an exterior which masked much inner turmoil. international journal of integrative psychotherapy, vol. 7, 2016 77 the fact that she never qualified as a solicitor had left marnie feeling she was a “failure.” she gave up her promising law degree when she became pregnant and her husband “insisted” she give up work. when her son was 14, she left her husband (and their problematic marriage) to move to a different part of the country and pursue her career. her son chose to stay with his father (and the extended family) and to be near his school friends. marnie’s childhood was scarred by her toxic, mentally unstable, violent father who routinely found fault with her. marnie’s mother – a kinder, gentler woman – died when she was six years old, leaving her to deal alone with her persecutory and aggressive father. to survive, marnie learned to be confluent with her father’s views; she accepted she was a “bad” child who failed at everything and always did things the wrong way. when she first came into therapy she was racked with guilt about being a “rubbish” mother for leaving her son to pursue her own “selfish” ends. shame was her constant companion and she would frequently beat herself up for being “hopeless” and “unworthy.” decontaminating the adult ego state in the early stages of our therapy, i experienced receiving numerous projections. marnie seemed to expect a judging, critical eye while she simultaneously hungered for positive validation and a loving gaze. at one point, we had a little rupture when i clumsily stated my view that marnie had been physically and emotionally “abused” by her father. marnie immediately denied this saying she had had a “normal” father and childhood and that she was the problem. she then accused me of “making” her feel shame. this was the first of several mini-ruptures where i had to own my part in objectifying marnie. frustrated with her compulsive shame/guilt responses, as well as angry with this vicious father, i was feeling stuck as a therapist. shame was in the room for both of us. i realised belatedly that i had betrayed marnie, just like her father had done, by not staying with her experience. our work needed to go much more slowly. rather than being defensive or blaming marnie for our mutual helplessness (which would be working from child or parent), i took the opportunity to apologise to marnie (in adult) and confirm that she was right. that moment of acknowledging the sequence of injury, my remorse and her forgiveness allowed her to contact her felt sense of betrayal in life and brought us closer in our relationship. it also helped us be more present and authentic in future challenges to one another. i tried to stay with my compassion for ‘little marnie’ rather than my frustration with marnie’s parent ego state which is filled with criticism of marnie. in other words, i had to turn international journal of integrative psychotherapy, vol. 7, 2016 78 down the volume of my own critical thoughts (being mindful of my own tendency to criticise) and marshal my nurturing adult therapist side. engaging both our adult ego states, i regularly challenged (both subtly and directly) marnie’s self-defeating expressions. for example, i’d say “i think you are being really hard on yourself” or “are you really a complete failure? have you not succeeded at some things? can you think of something that you have done well?” i faced regular invitations to criticise marnie and tried steadfastly to refuse them, defeating her expectations. i feared that anything remotely disapproving or objectifying would only reinforce marnie’s own crippling self-view. deconfusion of child in addition to working more cognitively, through my powerfully-felt maternal countertransference, i offered marnie loving compassion. “i don’t like to think of little marnie being hurt like that” or “i’m feeling like i want to give little marnie a hug” or “what does little marnie want?” transferentially, i became the ‘good mother’, explicitly championing and caring for little marnie. i fought to give ‘little marnie’ space to exist; i strove to hear her voice. through my compassion, i tried to model something of how to care for little marnie. at times my efforts were clumsy, or i risked moving to ‘rescue’ marnie (an impulse probably originating in my child ego state): for example, when i felt driven to minimise the damage caused by marnie’s toxic contact with her father and her own self-flagellation, i was perhaps seeking to give the protection and care my own child self had longed for and didn’t always get. given marnie’s own history of being locked into drama triangle dynamics with her father, the pull at me to jump into the triangle as rescuer was perhaps unsurprising – particularly so if we factor in my own history of compulsive rescuing. (the drama triangle – karpman, 1968 plots behavioral moves (transactions) between people where roles of persecutor, victim and rescuer are played out as familiar favoured positions out of awareness. often replicating less healthy childhood dynamics, these positions are a psychological attempt to meet unmet needs.) for marnie, part of the challenge was to accept the love she had so longed for. my loving compassion invoked a ‘juxtaposition’ response (moursund & erskine, 2004). here the nourishment provided by our therapeutic relationship contrasted with the toxicity of her relationship with her father. she now confronted two contradictory ideas: her archaic sense that father didn’t love her because she was unlovable; and the notion that in reality she was lovable, which could only mean she had an unloving father. beyond the cognitive dissonance invoked by this juxtaposition, international journal of integrative psychotherapy, vol. 7, 2016 79 considerable relational threats were lurking. by going into contact-full relationship with me, she risked getting hurt -and replaying the experience of being abused. now face-to-face with the reality of having been ‘unloved’ by her father, marnie also confronted the profound grief of having lost the mother who might have loved her – something she had previously kept at bay. over a three-year period of weekly therapy, we explored her guilt, shame, grief, rage and the reality of the existential decisions she had taken in her life. much use was made of chair-work where different parts of marnie’s self were placed on different chairs. together, marnie and i were able to become aware of, witness and validate the varied and contradictory experiences of her different ‘selves.’ i also did a parent ego state interview in which we enacted a dialogue with her introjected mother. this allowed marnie to connect with a special source of love and support she began to realise she still carried within her; she hadn’t lost her mother completely. the emergence of a more integrating adult marnie began to trust me more fully and blossomed with my nurturing. she grew in her self-understanding and became more accepting (even valuing) of her self, needs and life. she learned that some of her relationships and interactions (specifically at work and with her father) required her to be in adult and that she had a role to play in protecting her own little marnie. it was challenging for her but, over time, she learned to say “no” from her adult ego and became more adept at putting up self-protective boundaries when necessary. this way of being was in contrast to her previous use of protective mechanisms involving withdrawal and dissociation. on one occasion, marnie was required to visit with her father (from whom she had learned to keep a good distance) for a family funeral. marnie expressed her understandable anxiety about this upcoming visit and we explored the terror arising in marnie’s child ego. together we came up with a strategy (adult-adult problemsolving) whereby she would leave ‘little marnie’ with me for a “holiday” while ‘adult marnie’ went to stay with her father and attend the funeral alone. the thought that i was continuing to protect and hold her in mind felt enormously powerful and nurturing to her and proved something of an epiphany. that ‘little marnie’ was safely cared for elsewhere felt freeing to marnie, allowing a more capable, balanced, resourceful ‘adult marnie’ to ‘take over’ when relating to her father. importantly she learned to view her father less with terror and rage and more with compassion. when in adult, she could see a sad, ill, old, alcoholic father shaped international journal of integrative psychotherapy, vol. 7, 2016 80 by his own toxic, traumatic childhood. this bile-full, aggressive man was her father – one who was never going to give the love and appreciation she craved. thereafter marnie was more able to actively care for her own child part. by doing so, she understood that she was growing a new choice-full, balanced, compassionate and nurturing adult side. she saw that she had begun to internalise a version of both her mother and myself, which offered a counterbalance to her internalised father. the latter stage of therapy focused on reinforcing this new integration. “new marnie” was now much more aware of her damaging critical introjects and resultant shame. she knew those shamed and shaming parts of herself, while never likely to completely disappear, were mostly contained and could be managed better. she was more mindful of her choices and about what she could do to keep herself safe and stay open to positive messages. she embraced life with a healthy new zest, forming fresh friendships, adopting new hobbies and surrounding herself with emotionally nourishing people. more significantly she learned to put a boundary between herself and those whom she felt were toxic for her while she made new connections with an estranged aunt and brother. i saw ‘little marnie’ less often and rarely felt any pull to nurture. much of our latter work involved enjoying adultto-adult transactions (while recognising there was still perhaps a trace of childadult in her idealising and twinship transference – i.e. ulterior transactions). there was less need to mother little marnie now as new marnie seemed to have this calmly in hand. instead, our work focused on being curious about, and celebrating, the emergence of, “new marnie”. we took another year to end. marnie had moved from detachment, and then dependence, to self-supporting autonomy. the process involved a slow letting go for both us. as we celebrated her growth, i know that our sharing has also had a part in the healing and growth of my own integrating adult. specifically, i learned a valuable lesson of nurturing from my adult ego and not parent; and not rescuing from my child. witnessing her journey was also affirming of my own as i was able to share some of the resources i developed to counteract shame. conclusion in the case illustration and the theory preceding it, i have emphasised the practice of bringing parts of self explicitly to the fore and have suggested ways in which therapists might nurture a client’s integrating adult: the ‘grown-up’ part of the thinking-feeling-experiencing self that is in the here and now, relatively free from international journal of integrative psychotherapy, vol. 7, 2016 81 contamination by parent and/or child. importantly, the emergence of this integrating adult is viewed as a dynamic, on-going process engaged in throughout adult life, leading us constantly towards integration. three therapeutic processes or strategies have been highlighted: decontaminating the adult, deconfusing the child, and explicitly working with the integrating adult. awareness raising; exploring and enjoying the adult; engaging relationally with different parts of self; and helping the client reclaim their heritage offer four ways of fostering the process of engaging the adult. through these processes, the therapeutic relationship can offer a transition space – a threshold – between old protective script-led patterns of being and new ways of relating (erskine, moursund & trautmann, 1999). several caveats are warranted here. while the metaphorical use of ‘selves' can be powerful, i do not want to give the impression that this is the only way of working or that interventions drawing on parts of self are the only way forward in integrative psychotherapy. some clients and therapists do wonderful integrative work without this metaphorical focus. some might even argue there are times when forcing symbolic fragmentation of the self into parts or ‘selves’ is contraindicated or when forced integration is unnecessary. i do not recommend applying this approach automatically or mechanically. it’s better to wait until we strongly sense the presence of different parts of selves who seem to want their own voice. (when working with the multiple personalities appearing when a person has a dissociative identity disorder, a similar approach might well apply, as i would try to be equally be attentive to whoever emerged and was present in the therapy space). that said, this way of working seems to figure regularly in my own practice. perhaps i find it helpful for my own therapeutic journey and relationship with my self. it makes sense to me and helps me attune to the parts in others. working with parts of self also seems to help clients develop reflexive awareness of internal and external disconnection; at times, it can call forth an integrative energy. at a practical level, i find that metaphorically working with the relationship between big and little selves offers a useful way of giving voice to a person’s ambivalent, divided, dissociated, and fragmented self-experience while also highlighting the relevance of having a positive, validating relationship with oneself. that one part may be vulnerable and in pain also allows the possibility of having some containing distance from it, something particularly useful when working with rage or shame. i agree with deyoung (2015) when she says working with parts of selves allows the “light and air” to get at a person’s chronic shame: international journal of integrative psychotherapy, vol. 7, 2016 82 bringing shame to light often illuminates a needy part of self who is despised by a tough, independent part of self. listening respectfully to both parts and helping each to find compassion for what drives the other brings better balance and harmony to the whole self system…parts of self can find space to speak the unspeakable about need, longing, and humiliation, and in their speaking and being heard, integration happens. often a time of working with “parts” comes and goes in therapy, and later clients look back with fond nostalgia on parts they once encountered as “other” but that are not just everyday aspects of the self they know (pp.132-133). such integrative work has been shown to involve a layered awareness and responsiveness in the therapist. our attention here requires a dual focus: on the client’s awareness of, and relationship, with parts of themselves, and on the client’s wider relationship with their social world. i would argue that such a shift away from clients’ inner worlds towards the interpersonal-social life world of work, relationships, community and cultural heritage is essential if fuller integration is to be truly owned. with our therapeutic project of integration through relationship, a key goal must surely be reflexive awareness and compassionate acceptance of the many different parts of us which lurk or emerge in our transactions. these parts need to be worked through (through decontamination and deconfusion processes) and then brought together offering new ways of being. growing a client’s integrating adult will help them be more fully present when interacting with others and so in fuller contact with the social world. engaging fuller relationships with self and other, they will be en route to some healing (finlay, 2016). author: linda finlay, phd, is a practicing integrative psychotherapist (ukcp registered) in york, north yorkshire, uk. she also teaches psychology and counselling at the open university, uk. she has published widely. her two most recent books, published by wiley, are: “phenomenology for therapists: researching the lived world” and “relational integrative psychotherapy: engaging process and theory in practice.” acknowledgments: i am grateful to sarah greening (cta, ukcp reg psych) who first drew my attention to this concept of the ‘integrated adult’ and in subsequent discussions inspired me to continue to explore it more deeply. i am also indebted to richard international journal of integrative psychotherapy, vol. 7, 2016 83 erskine who generously offered invaluable comments and teaching on an earlier draft. of course, any errors within this article are my responsibility. references berne, e. (1964). games people play: the psychology of human relationships. harmondsworth, middlesex, england: penguin. berne, e. (1986). transactional analysis in psychotherapy: a systematic individual and social psychiatry, london: souvenir press. (first published in 1961, new york: grove press.) clarkson, p. (1992). transactional analysis psychotherapy: an integrated approach. london:tavistock/routledge. deyoung, p.a. (2015). understanding and treating chronic shame: a relational/neurobiological approach. new york: routledge. erskine, r.g. (1988). ego structure, intrapsychic functioning, and defense mechanisms: a commentary on eric berne’s original theoretical concepts. transactional analysis journal, 18(1): 15-19. erskine, r.g. (1991). transference and transactions: critique from an intrapsychic and integrative perspective. transactional analysis journal, 21(2), 63-76. erskine, r. g. (1993). inquiry, attunement, and involvement in the psychotherapy of dissociation. transactional analysis journal, 23, 184-190. erskine, r.g. (2013). phenomenological inquiry and self-functions in the transference-countertransference milieu. international journal of integrative psychotherapy, 4(1): 19-27. erskine, r. g. (2015) relational patterns, therapeutic presence. london: karnac. erskine, r.g. and moursund, j. (1988). integrative psychotherapy in action. newbury park, ca: sage. finlay, l. (2016). relational integrative psychotherapy: engaging process and theory in practice. chichester, west sussex: wiley blackwell. finlay, l. and evans, k. (2016). an invitation to engage in relational-centred phenomenological research. in: j.roubal (ed.) towards a research tradition in gestalt therapy, newcastle upon tyne: cambridge scholars publishing. hargaden, h. and sills, c. (2002). transactional analysis: a relational perspective, london: routledge. harris, t.a. (1970). i’m ok – you’re ok, london: pan books. karpman, s. (1968). fairy tales and script drama analysis. transactional analysis bulletin, 7(26), 39-43. kohut, h. (1977). the restoration of the self, new york: international universities press. lapworth, p., sills, c. and fish, s. (1993). transactional analysis counselling, bicester, oxon, england: winslow press. international journal of integrative psychotherapy, vol. 7, 2016 84 manne, j. (2009). family constellations: a practical guide to uncovering the origins of family conflict, berkeley, ca: north atlantic books. menaker, e. (1995). the freedom to inquire, new jersey: jason aronson. moursund, j.p. & erskine, r.g. (2004). integrative psychotherapy: the art and science of relationship. southbank, victoria, australia: thomson/brooks cole. perls, f.s. (1971). gestalt therapy verbatim (j.o.stevens, comp. & ed.). new york, ny: bantam. (original work published 1969) rowland, h. (2016). on vulnerability: personal reflections on knowing, knowingness, and meaning making in psychotherapy, transactional analysis journal, 46(4), 277-287. stewart, i. and joines, v. (1987). ta today: a new introduction to transactional analysis. nottingham, england: lifespace publishing. summers, g. (2011). "dynamic ego states". in: h. fowlie, & c. sills (eds.), relational transactional analysis: principles in practice (pp. 59– 67). london: karnac. summers, g. and k. tudor (2000). cocreative transactional analysis, transactional analysis journal 30(1): 23-40. summers, g. and k. tudor (2005). introducing co-creative ta, accessed august 2016 from www.co-creativity.com. trautmann, l. (1985). letter from editor, transactional analysis journal, 15: 188-191. tudor, k. (2003). the neopsyche: the integrating adult ego state. in c. sills & h. hargaden (eds.), ego states (key concepts in transactional analysis: contemporary views) (pp.201-231). london: worth publishing. tudor, k. (2011). empathy: a co-creative perspective, transactional analysis journal, vol. 41(4), 322-335. zaletel, m., potočnik, p. and jalen, a. (2012). psychotherapy with the parent ego state, international journal of integrative psychotherapy, vol. 3, no. 1, 15-41. žvelc, g. (2010). relational schemas theory and transactional analysis, transactional analysis journal, vol. 40, 8-22. date of publication: 29.7.2017 http://www.co-creativecoaching.co.uk/dynamicegostates.pdf http://www.co-creativecoaching.co.uk/admin/uploads/cocreative%2520transactional%2520analysis.pdf http://www.co-creativecoaching.co.uk/admin/uploads/introducing%2520co-creative%2520ta.pdf http://www.co-creativity.com/ international journal of integrative psychotherapy, vol. 12, 2021 89 schizoid phenomena and relational needs dan eastop abstract this article describes schizoid phenomena and how the concept of relational needs is used in integrative psychotherapy. drawing from client work, the author explores some of the unique qualities involved in offering a contact-oriented, relational form of therapy with an individual who uses the schizoid process of a social façade to protect the vital and vulnerable self. relational needs are discussed in terms of transference, countertransference, and schizoid phenomena. keywords schizoid, schizoid process, social façade, relational needs, schizoid phenomena, transference, countertransference, relational psychotherapy, integrative psychotherapy was fairbairn (1952) being provocative when he wrote that “according to my way of thinking, everybody without exception must be regarded as a schizoid”? (p. 7). there appears to be a sense of mischief in his words, but it remains a wonderful starting point for a discussion on the schizoid process: the idea that on some level we all share the psychological ability to split off experiences, compartmentalize the self, and use withdrawal into inner reality as a means of organizing our relating and how we regulate being in contact with others. it also serves as a beginning to a discussion about how, as therapists, we might use our own experiences of schizoid phenomena to help our work with clients who rely on relational withdrawal to stabilize and regulate their affect. it may help us to remain present and in contact with such individuals, appreciating the creative, adaptive ways a schizoid person will regulate and control relational contact. international journal of integrative psychotherapy, vol. 12, 2021 90 when we are with a schizoid individual and there seems to be little emotional contact, as therapists we need to find ways to maintain contact within ourselves, that is, to remain solid and present and at the same time to facilitate the client’s reestablishing contact with their affect and physical sensations. when someone is “talking at me, rather than to me” (erskine, 2020, p. 15), therapy becomes a performance, an acted-out interaction rather than an experience of authentic contact. exploring how relational needs (erskine et al., 1999) are experienced moment to moment, and how they are expressed by the client, offers structure to the therapeutic work. we cannot know what is happening in the inner world of a client. we are always reaching for understanding: assimilating, noticing, and developing ideas and clues to a person’s internal experience. our experience of this reaching for (or waiting for) can often hold crucial information about how to be in contact with certain clients. we have to indwell, to put ourselves into the internal experience of the client who uses a schizoid process. in fact, i find it necessary to go searching for the person in their schizoid withdrawal. i search for a connection with the fragmented, split off, or hidden parts of my client. when i sense that i do not know what my client may need from me, when i feel there is something lacking in our interpersonal contact, or when i do not know what we are doing, it is essential that i attend to these internal experiences and use them as guides. in attending to my countertransference, i am building a collection of impressionistic images, developmental and relational pictures, and a sense of what relational experiences were missing in my client’s early life. in this article, when discussing the schizoid process or a client who engages in schizoid phenomena, i am not referring to a person diagnosed with schizoid personality disorder. johnson (1994) viewed character structure as existing on a continuum. at one end is the personality disorder and at the other is a higher level of functioning that he called a “character style” (p. 11). an individual with a schizoid personality is at the disorder end, and someone with an avoidant personality is at the style end (little, 1999, p. 3). in defining an integrative psychotherapy perspective, erskine (2011, p. 3) used a three-part continuum—schizoid style, schizoid pattern, and schizoid disorder—to distinguish the frequency, duration, and severity of the client’s internal splitting and their use of archaic self-protective procedures. using the idea of a continuum, i experienced the client discussed here as having a unique way of relating that i describe as a schizoid pattern. we often speak of working with schizoid phenomena or with a schizoid process, but i think it is also helpful to talk about the psychotherapy we do as working within the schizoid international journal of integrative psychotherapy, vol. 12, 2021 91 process. this involves being prepared to work within the therapeutic transference (little, 2011) alongside the theoretical belief that “the sense of self and self-esteem emerge out of contact-in-relationship” (erskine &trautmann, 1996/1997, p. 317). in making the concept of relational needs a cornerstone of the psychotherapy, i can remain within the client’s unique process: relational-needs are the component parts of a universal human desire for intimate relationship and secure attachment. they include 1) the need for security, 2) validation, affirmation, and significance within a relationship, 3) acceptance by a stable, dependable, and protective other person, 4) the confirmation of personal experience, 5) self-definition, 6) having an impact on the other person, 7) having the other initiate, and 8) expressing love. (erskine, 2011, para 17) working closely with relational needs provides a way to understand and track the client’s attachment style, relationship history of needs met and not met, and patterns of accommodation and coping while also providing a here-and-now guide to the client’s current needs in the therapeutic relationship. i am attentive to these various expressions of transference, including various ways of relating to me, expressed and unexpressed emotions, and the qualities of our intersubjective dialogue. each of these provides me with a unique lens to view what is happening within the person. as erskine (2001) described, “transference is the active means whereby the client can communicate his or her past. this includes the neglects, traumas, and needs that were thwarted in the process of growing up, as well as the defenses that were created to compensate for the lack of need fulfillment” (p. 4). in working with clients who exhibit a schizoid style or pattern, i find it crucial to find ways to anchor myself in the relating so i can remain fully present. working closely with relational needs, i can better understand my clients’ histories, the story being enacted in their transference, my own countertransference, and what they require from me in order to have a healing relationship. the concept of relational needs creates an anchoring in the relating and a structure to my understanding of which needs are emerging in the foreground of the relating and which are in the background, either disavowed or waiting to emerge. many clients who have either a schizoid style or schizoid pattern will enter therapy with little or no appreciation of their current or historical relational needs. international journal of integrative psychotherapy, vol. 12, 2021 92 a psychotherapy that is relationally focused involves creating an interpersonal environment in which the person’s relational needs can freely emerge, be felt and known, and be responded to in active, contactful relating. case study: helen i will use a case study of psychotherapy with “helen” to illustrate the concept of relational needs. i will show how different relational needs moved in and out of the foreground of our relating, including which needs were out of the client’s awareness, yet to emerge. i will highlight the quality and nature of how relational needs were expressed or not expressed and describe how i used my countertransference to discover and attune to the relational needs of this withdrawn, hard to reach client. it is possible to see a cluster of relational needs unique to clients who have either a schizoid style or pattern, and this awareness can guide our work. relational needs are often out of the client’s awareness and may be disavowed, inverted, or blended together. in my experience, working with relational needs within the schizoid process facilitates the emergence of the true self (winnicott, 1965), that is, an intrinsic sense of self that is “vital and vulnerable” (erskine, 2020, p. 18). helen entered therapy with no awareness of her relational needs and appeared unconscious of having any needs at all in relation to others. therapy involved her gradually seeing herself as having unique relational needs, understanding how these were neglected by significant others, and discovering how she created ways of coping. her primary way of coping and adapting involved being a hard-working student and disavowing her feelings and needs. this continued into higher education, where she achieved several degrees in mathematics and science. in helen’s early childhood, her mother focused her attention on helen’s two brothers. significant memories for helen included her father dying when she was 17 and her leaving home for university. she took pride in being the “trailblazer” of the family and described how she went it alone as a “self-sufficient unit.” when her mother moved the family to a new house, helen no longer had a bedroom and so seldom returned home. she said, “i’m like a bad penny” to describe how she always seemed unwanted. in our psychotherapy sessions, helen behaved as a “good client,” always arriving on time and rarely missing a session. she was the same way at work, a good international journal of integrative psychotherapy, vol. 12, 2021 93 employee who worked hard and waited for praise. as a result, she performed at a consistently high level in her work but was always exhausted and lonely. her husband worked in the same company, and they had two children. helen described herself as having a “breakdown” in which she felt emotionally and physically incapacitated. her doctor diagnosed a major depression. i understood her breakdown to mean that helen’s sense of self, her internal structure, became so emotionally overwhelmed that it no longer provided the psychological functions of stabilization and regulation. as i pieced together a picture of helen’s script system (erskine, 2015a, 2015b), it became clear how her early experiences, her relationships with others, and her ways of coping matched the isolated attachment style (erskine, 2011) people like her use to organize their relating with others. her core script beliefs had shaped her career and approach to life. these included: “i am alone in the world,” “other people are scary,” and “i must work hard for others.” these and other behavioral patterns reinforced the necessity of finding ways to fit into the world. eventually, helen’s script system exerted such overwhelming pressure on her work persona that she was unable to interact and perform in the workplace. under the pressure of her script beliefs, she could no longer integrate her affect, physiology, and cognition. the result was a breakdown in her sense of self—the capacity to integrate physiological sensations, various affects, and thought processes—and a retreat to a less demanding internal world. deciding to come to therapy was difficult for helen because it was an admission to herself that she could not cope and needed the support of a psychotherapist to reestablish a secure sense of self and to be able to work again. her initial struggle in therapy was about the polarity between her childhood patterns of self-reliance and self-containment and the therapeutic opportunity to be vulnerable and receive support from someone else. prior to her breakdown, helen’s role at work had changed. previously her tasks had been solitary, and the isolation from other people had become her “comfort zone.” however, she had been made a project manager, which required her to interact with numerous workers as well as to rely on others. helen described herself in this breakdown as if she were in a “mixing bowl with no ingredients, with an emptiness and loss of purpose.” she told me she felt like a “jigsaw puzzle broken up and swept off the table” and described how her depressive phase felt as if the world had been turned on its head. her usual ability to rationalize and order things had been taken away, and she felt stripped of her normal self. helen experienced a great deal of shame in going through the breakdown and being off international journal of integrative psychotherapy, vol. 12, 2021 94 work. she talked about losing her role and purpose and being embarrassed about what others would think of her on her return. in the beginning of our work together, i frequently asked helen what she needed from her session that day in an attempt to give her a sense of choice and bring us into contact with what she needed. over time, i discovered that my questions were misattuned to her patterns of being in relationship. the inquiry was too confusing and opaque for her; she was not in a place to communicate her needs or even to access what her needs were in the moment. i began to see her confusion as an important communication in itself. the “i don’t know” to the question of “what do you need?” was an expression of her unmet relational needs, needs that were unknown to her. i wondered if her “i don’t know” meant “i don’t know who i am.” in those early days, helen was unable to define herself, particularly in relation to the “authority” of a psychotherapist. instead, our work centered on helen finding her own needs in relation to me rather than my explicitly inquiring about them. however, both helen and i became increasingly aware of her relational needs as they emerged both in our person-to-person relating and through the transference. security in the beginning, i did not yet know of helen’s rich, creative fantasies and ideas. i was preoccupied with the rigidness of how she presented herself, her routinized behaviors, and how she related to me. the more i tried to make contact, the more she pushed me away. i began to appreciate helen’s overwhelming need for safety in the therapy. this was not initially obvious because of the way she presented herself: she was not nervously quiet or shut down nor did she show a clear need for protection. as moursund and erskine (2003/2004) described, “the need for relational security is most likely to be foreground at the outset of treatment” (p. 109). helen strove to uphold a narrowed perspective on her life that discounted and avoided other aspects of who she was, particularly her relationships with others. her life had involved carefully structured, controlled relations with people; she remarked that she was experienced by others as a loner, superior at times, not easy to interact with. my experience of her relational need for safety in the therapy emerged in my countertransference. i felt controlled; the space, interactions, and rhythm of our work felt stifling. early on i felt fixed, positioned, and unable to feel involved. i experienced helen as needing to direct the dialogue. she ignored my questions international journal of integrative psychotherapy, vol. 12, 2021 95 and changed the subject so that our conversation remained superficial. she kept me at a distance, avoided interpersonal contact, and declined my invitations to explore her affect. she needed to feel safe: safe in herself, safe in relating with me, and safe in the parameters of what our psychotherapy was for her. helen’s relational need for security in relationship was masked by her various attempts to control the process of the therapy sessions. she was often highly descriptive in her language, using words or intellectualization to fill the space. it was as though she were saying: “if we stay over here talking about this stuff, we won’t get near to the vulnerable me inside.” it eventually became apparent that helen was withdrawing from interpersonal contact in the midst of our sessions. i suspected that she used this form of withdrawal in all her relationships. she appeared to have developed a carefully constructed social self, a part of her that was able to interact with others but in a rigid and narrowly prescribed way. she had a well-rehearsed social façade. guntrip (as cited in hazell, 1994) described this social self: “this fundamental detachment is often masked and hidden under a façade of compulsive sociability, incessant talking and hectic activity. one gets the feeling that such people are acting a somewhat exhausting part” (p. 168). the beginning phase of therapy with helen could be seen almost entirely as a demonstration of the importance of the relational need for security in relationship. she observed me from the safety of emotional withdrawal and revealed little of her inner experience. i was unsettled and distracted by her repetitive, prepared, and superficial stories, which kept us in “safe” areas of discussion. i was perplexed: “where am i going with this?”; “how come i can’t seem to feel a relational connection with this person?”; and “how come i am left confused and cold, out of touch?” as with many clients, helen’s relational need for safety in relationship was crucial for any psychotherapeutic work to take place. however, this need is often not conscious because the person, like helen, may have prematurely, and without awareness, assumed the function of stabilizing and regulating themselves: a pseudo sense of security. reliance on a social façade as a protective way of relating and maintaining control with others can mask the underlying need for a profound physical and emotional sense of security. o’reilly-knapp (2012) compassionately depicted this attempt at pseudosecurity, describing how “a social façade masks the pain and loneliness of an isolated existence” (p. 3). many individuals who rely on schizoid processes had early childhood caretakers who repeatedly overlooked and neglected the person’s physical and relational needs while also being invasive and/or controlling. such neglect or international journal of integrative psychotherapy, vol. 12, 2021 96 invasion/controlling resulted in the person accumulating physical and affective memories that are often disavowed and unconscious. this can result in them placing their personal needs secondary to the needs or even demands of their caregivers. they learned to hide what they needed—to split off from their own awareness—and to attend instead to the needs of their caretaker. this relational pattern is often reenacted in the therapeutic relationship, which is what helen was doing by reenacting with me an early childhood pattern she had learned in order to cope with emotional neglect. the schizoid individual may be extremely attuned to the therapist’s needs, often appearing to be kind, thoughtful, compliant, and/or passive. as clinicians, we need to keep in mind the early experiences of the accommodating child, the adapted self that is skilled at meeting the needs of others and disavowing, splitting off, and/or detaching from their own. stewart (2010) highlighted this: “if a therapist brings his/her archaic needs for security into session, then there’s a likelihood he/she will communicate in covert ways messages such as ‘i need to be taken care of’ or ‘i am overwhelmed by your needs’ ” (p. 43). the client’s accommodating to the therapist is a form of withdrawal: “i sense you need caring for so i will go away” or “i sense you can see my vulnerability and i am scared.” the behaviors that emerge from a person’s social self are centered around conforming and accommodating to others. it is as though the client were saying, “i need you to accept me in my adaptation”; “please accept this version of me”; or “i will be ok for you.” they are displaying a social self that struggles to maintain a façade that provides an artificial sense of acceptance, validation, and security. with many schizoid individuals, there may be periods of therapy in which the person needs to maintain a sense of safety by repeating a familiar story. when helen told me the same stories, i was initially frustrated. there was no real contact between us, no emotional connection, and i did not know how to be involved with her. my reactions reflected part of helen’s story. i was often emotionally distant and uninvolved. eventually, i learned the importance of patience and staying present. initially, i became another person to whom helen accommodated. i felt that she was not interested or, more importantly, did not want to see me as a relatable other. but she also needed me to be there every week, to be reliable and consistent, to be a mirror to her rigid and repetitive style of relating. it was a long time before she could allow herself to see me as a person separate from my professional status. it was a revelation for both of us when she began to allow herself to see that the psychotherapy offered much more than support for her job performance. international journal of integrative psychotherapy, vol. 12, 2021 97 as our work shifted into a new phase, helen needed to idealize me in order to create a new sense of safety, much like a child needs a stable adult who is predictable, consistent, dependable, and responsive to their emerging needs. with helen’s increased idealization of me, she perceived a new quality of safety in our therapeutic relationship. she described needing a safe space to speak her thoughts to a sensitive listener who would not criticize, overwhelm, or make demands of her. this new phase allowed helen to become aware of needing safety in the relationship with me. she needed a therapist who was involved in her life, whom she could trust with her ideas, and who would foster her changing sense of herself. impact in supervision i shared how i believed i was not making an impact on helen’s life and how uninvolved i felt i was in our work together. i was in deep countertransference, feeling i had so little influence and so little emotional connection with her. there was something happening between us that i needed to understand and resolve. i wondered if i was mirroring her experience of me. did helen sense that she had no impact on me or on anyone in her life? was she living without any emotional connections? her relational need to make an impact became apparent to me through my experience of how hard i was trying to relate to her. helen was skillful at making as little impact on others as possible. she painted a picture of herself as being on the outskirts of social groups all her life, fearful of others, wanting to fit in but not knowing how. she described “floating around cliques at school” and “nabbing people for chats.” her adolescent experience of being an outsider and finding social interaction scary had continued into her work life and was an ongoing source of anxiety. she described feeling “invisible” to others, “not having a place,” and “not having an impact.” i imagined how lonely she must have been, and yet the sadness i felt did not match the matter-of-fact way she spoke. helen’s interactions with others were mainly through maintaining a social façade characterized by passive accommodation and adherence to social rules and etiquette. manfield (1992) suggested that there is often a “careful screening” going on with schizoid individuals that helps protect them from “anything that might expose them to attack or rejection or may be later used to pressure or coerce them” (p. 208). this seemed to be the case with helen. international journal of integrative psychotherapy, vol. 12, 2021 98 clients who rely on a schizoid process to manage the affect inherent in relationships often experience an emptiness, a being “missed,” and an unfulfilled “longing for something.” at the same time, being in a contactful relationship is a huge risk for them, the risk of being known and therefore possibly invaded or controlled by the other. some schizoid individuals express their internal confusion and hurt through script beliefs such as “no one is there for me,” “i’m on my own,” and “i’m not important.” moursund and erskine (2003/2004) wrote, “relationships in which one does not experience having an impact on the other person are onesided … ; just as with a thwarted need for self-definition, they foster the belief that one is unimportant and that others don’t care” (p. 112). guntrip (as cited in hazell, 1994) described this internal polarization of desire and fear as the schizoid compromise, that is, being half in a relationship while simultaneously being half out. this polarization then exacerbates an internal experience of loneliness. for instance, helen described the tension she felt as a duality between “feeling alone and needing others.” she noticed an uncertainty around depending on others and a “strange, uncomfortable” feeling when she felt others were dependent on her. helen had not planned to have a family but had two children whom she described as “like accessories” and “little friends.” fairbairn (1952) reported how it becomes possible to recognize essentially schizoid phenomena in clients’ experiences, such as full-fledged depersonalisation and derealisation, but also relatively minor or transient disturbances of the reality-sense, e.g. feelings of ‘artificiality’ (referred to the self or the environment), experiences such as ‘the plate-glass feelings’, feelings of unfamiliarity with familiar persons or environmental settings and feelings of familiarity with the unfamiliar. (p. 5) it was heart-wrenching to hear about helen’s struggle to be in contact with her current family members. she reported feeling unfamiliar within her own family, a jarring confusion of “who am i to these people? who am i when i’m with these people?” these are the exhausting challenges faced by those living with schizoid processes who attempt to be parents and to be in intimate relationships. this schizoid compromise results in the formation of a social self, a split-off part of the self that is adept at accommodating to different relational situations, including the relationship with a psychotherapist. this social self may dominate and distract from the person’s attempts to express the vital aspects of themselves such as international journal of integrative psychotherapy, vol. 12, 2021 99 various affects, unique interests, pleasures, desires, dislikes, or any aspect of vulnerability. helen’s strong need to remain safe within herself and to regulate the impact she had on the world around her meant she would repeatedly experience misattunement and misunderstanding from others. although her affect was often hidden and her stories were distracting, i committed to doing my best not to disregard helen’s relational needs for security and self-definition or to make an impact on me. although her needs were not obvious, i finally realized that they were being expressed in her stories and metaphors, enacted in her behavior, and engendered in my confusion and lack of involvement. (see erskine, 2015a, for a description of how unconscious early attachment patterns are expressed in psychotherapy.) this helped me to think about helen’s experience in her day-today life. i imagined what it would be like for her to go to work and her emotional struggles with the people in her life. i found myself willing to vicariously experience what life was like for her. after i started to work with this introspection, i found ways to attune to helen’s rhythms and affects. i allowed myself to drift in and out of contact with her and to notice where i went in my sensations, thoughts, and awareness. i began to allow myself to go with the experience of being in relation with her rather than asserting my image of how a psychotherapist ought to be. helen had become accustomed to the repetitive pattern of our sessions. she would arrive exactly on time. she would appear small and young-looking at the door. she would move into the room, making as little noise or impact on her surroundings as possible. she would present me with her payment in the same way a child might present a ticket for a fairground ride: nervously and deliberately. she would then find her position on the couch, careful not to intrude on the space around her. clients similar to helen may be in psychotherapy for a long time without making an impact on the therapist. they adapt to what they imagine are the therapist’s requirements and continue to hide their own needs. they rarely cause disruptions or act out. for instance, helen was shocked when i asked her to message me to let me know how an important medical appointment went. it was difficult for her to comprehend that she had made an impact on me, that her health mattered to me. many people who use a schizoid process to manage their emotional and relational life actively regulate both the impact they make on others and the degree and type of impact others make on them. they move through life without impacting others, and so they are often not aware of the effect they have. in the family stories, such clients reveal that their childhood was marked by the impossibility of defining themselves or of making any significant impact within the family. they report that international journal of integrative psychotherapy, vol. 12, 2021 100 their need to make an impact was not enjoyed or welcomed. growing up, they endured extensive disregard of their relational needs, so they stopped expressing their vital and vulnerable selves in favor of a version of themselves that worked for others. they were often without the experience of “making an impact” on others from an authentic part of them—the vital and vulnerable self, what winnicott (1965) called the true self. the relational need to make an impact becomes paradoxical for such individuals. the schizoid process often involves the individual working hard not to make an impact on the therapist, to control the space, to remain internally and relationally safe. with helen, i felt the “impact” in my countertransference, my confusion, my sense of the lack of emotional vibrancy in the work, and the fatigue i often felt. helen was making an impact on me; it was subtle but it was impactful. she was relating from her sequestered, vital, and vulnerable self. if we are to be effective with such individuals, we must maintain a belief that we are gradually having an impact on them. this is where understanding the object relations theories of fairbairn (1952), guntrip (1969), and winnicott (1965) can support practice so that we patiently trust what is going on behind the scenes, become aware of the phenomena emerging in the relating, and trust that the intrapsychic structure of the schizoid individual means that on some level we are becoming part of the person’s internal landscape even though it may not appear so in our session-to-session relating. we must hold an appreciation of the level of stress and shame that these clients can have when a social façade is strong. behind the scenes, the person may be observing words, responses, and expressions that can feed their fantasies about how they need to be in order to be acceptable to the therapist. fairbairn (1952) described his schizoid clients’ selfcriticisms with the term “internal saboteur” (p. 101). the withdrawn self splits further to create the internal saboteur who turns against the vulnerable self. one of the functions of this saboteur is to anticipate criticism from others and regulate the person’s behavior (erskine as cited in zaletel, 2010). the internal saboteur serves to keep the vulnerable self hidden and repressed. it is the antiwanting self that is contemptuous and despising of neediness and ensures the schizoid individual neither seeks nor obtains what they want (klein as cited in little, 1999, p. 6). self-definition international journal of integrative psychotherapy, vol. 12, 2021 101 in my work with helen, i came to realize that her relational need to make an impact and for self-definition were simultaneous and interrelated, both part of her need for self-expression and validation. a person relying on a schizoid process struggles with a lack of self-definition and also to comprehend that they have an impact on others: “if i don’t know me, how can i impact others?” erskine et al. (1999) described how “children who grow up in an environment that demands conformity, unquestioning obedience to rules and norms, may never learn how to be themselves” (p. 137). for example, when helen was in school, the teachers and other students defined her by her academic ability. in her adult life she was defined by her position and status at work. her sense of self seemed strongly anchored to her performance on the job and how others perceived her. helen was frustrated with repeatedly seeking validation through her role at work, particularly because it was “behind the scenes.” she often despaired and was confused about how all her efforts to “be good” and perform well were not acknowledged. one of the few times i saw her express anger was in response to the pressure she felt to perform a certain way at work. that anger led us to explore how she could get a satisfying response to her need for self-definition and to have a sense of making an impact on others. as the therapy progressed, my appreciation deepened for helen’s strong attachment to her work life and how meaningful it was for her to retell stories about her work experiences. i began to see these as essential to her sense of self and self-identity. her work life made her feel real and connected to something. it created structure, attachment, and fulfilled her needs according to her script beliefs of having to work hard and do well for others. all her energy would go into managing and surviving her week, although she was often exhausted by the weekend. she did not have friends she saw regularly and found it difficult to initiate and keep in touch with people (she spoke of people seeming to drift away). the effort she put into work, particularly interactions with others, meant she needed to withdraw internally on weekends in order to recuperate. for a long time, she viewed her therapy as supporting this process, a chance to verbalize her grievances so she could survive the next week at work. guntrip (as cited in hazell, 1994) described how the schizoid individual: without a satisfactory relationship with another person he cannot become a developing ego, he cannot find himself. that is why patients are so often found complaining “i don’t know who or what i am, i don’t seem to have a mind of my international journal of integrative psychotherapy, vol. 12, 2021 102 own, i don’t feel to be a real person at all.” their early object-relationships were such that they were unable to “find themselves” in any definite way. (p. 129) this reflects a core reason for the schizoid person to be in therapy: to find or reclaim their self-definition. i wondered how i could help helen with this when she needed such selfprotection. how could i find her without losing her again? i needed to continue carefully, always holding in mind her fears around interpersonal contact and her need to protect herself. further into our work together, helen arrived excited to tell me about a workaway day she had helped to coordinate around the theme of pirates. she had dressed up and organized games and activities. the excitement and change in her energy amazed me. i knew helen was showing me something new and different, a spark of vibrancy that i had been waiting patiently to see for a long time. this marked a turning point in her therapy as we began exploring her creativity and her enjoyment in planning creatively for others. helen was starting to allow herself to express a different, emergent energy, away from the structure of her daily life toward something creative, playful, and fun. these moments of vitality were polar opposites to the repetitive staidness of her social façade. i was excited to finally see them and at the same time careful not to overwhelm her with my responses. i did not want to scare her away by expressing too much excitement or suddenly changing how i was with her. as we explored fantasies about what she would do outside of her long-term workplace, she shared her dreams about wanting to teach. i encouraged that through my inquiry and involvement, and she eventually decided to volunteer as a classroom support at a secondary school. this was a hugely significant decision: to move out of her comfort zone based around work and home life and to work alongside children who needed individual support. i was deeply moved when she reported the connections and relationships she was forming with the children and how she was appreciating their particular needs in learning. helen began to reflect on her childhood through the experiences with the children, which led to richer exploration of her emotional memories. in greenberg’s (2016) words: i tend to find these particular clients difficult to connect with because their real self is so hidden, even from themselves. … all of their aliveness goes into their international journal of integrative psychotherapy, vol. 12, 2021 103 fantasy life. i have learned that if i am patient and those clients decide i am trustworthy, they will give me glimpses of the riches they have inside themselves. (p. 338) finding helen’s creativity came out of us exploring her inner world of metaphors and fantasies as well as from her experiencing me valuing and accepting the significance of those and letting her know about their impact on me. what had initially appeared as repetitive, superficial narratives around her work became a bridge to me appreciating how she made meaning within her world as well as glimpses of her vital and vulnerable self. helen described herself at work as “a computer stuck and going round and round doing the same thing” and a “machine with grit in the machinery/cogs, grinding and missing connections.” the more i attuned to and validated her wonderful metaphors and images, the more i heard faint expressions of unmet relational needs. such needs are often held within fantasy or “at a symbolic level” (yontef, 2001, p. 8). they can be kept out of cognitive awareness or securely compartmentalized internally, away from contact with others. within the safety of fantasy, an individual can imagine relational needs being satisfied but without genuine interpersonal contact with others. we can listen for and find these needs as our clients share subjects that feel safe to them. this interplay was described by orcutt (2018) as follows: the therapist begins with showing interest in what is of interest to the patient. this may be as pertinent as the patient’s intellectualized ideas about the presenting problem, or may diverge to topics of special interest to the patient such as books or computer games. this is to establish a mutual safe space with the patient, where verbal transaction can take place in an uncommitted way. this uses what ralph klein (1995) has called the schizoid patient’s ability to form “relationships by proxy” and so defensively “act against the risks involved in connecting to, and sharing with the therapist” (p. 90). this ability can allow the patient to test out a harmless reciprocity in the sessions. over time, the experience of this interplay may prove to feel safe enough so that the patient may begin to further test the possibility of a closer exchange. if all goes well, interchange becomes therapy as protective strategy transforms into relationship. (p. 44) international journal of integrative psychotherapy, vol. 12, 2021 104 instead of challenging or ignoring helen’s repetitive narratives around work, i moved into her work world with her. through cognitive attunement, inquiry, and involvement in her retellings, i became deeply knowledgeable about her workplace: the people, the systems, how she worked, what she did. she was teaching me about her inner world, and the therapy began to deepen when i accepted what had initially appeared to be trivial. i began to understand through working with helen to be involved in whatever is of interest to my client. work was safety for helen. it gave her an identity and provided for some of her relational needs. nevertheless, she was gradually able to verbalize how her work did not provide the valuing she needed. she realized how little impact she was having in her work life, regardless of how hard she worked to adapt to its requirements. our sessions became more about her making contact with herself in a reflective way rather than controlling the space with retellings of what had happened to her. she was able to speak more emotionally and vulnerably about her experience as a mother and her struggles in connecting with her son. forming an identity from a place of schizoid withdrawal or protection comes from acknowledging and accepting a relational need for self-definition. as a result, the “organization of a once-hidden self can now begin to form an identity” (o’reillyknapp, 2012, p. 8). through our work, i learned to appreciate my active part in facilitating helen’s growing awareness of a relational need for self-definition and how to move into the schizoid individual’s world by working within the client’s metaphors and fantasies, to sometimes share in her experience of a lack of selfdefinition. in doing this, it was important to remain present and in contact with myself, which requires a careful balance. my own sense of self-definition is often impacted when i cannot sense the other person’s vitality, when my client is withdrawn and i cannot reach them. i am left to wonder about my own capacity to make an impact. with helen, i learned to remain present as well as noninvasive and attuned to the nonverbal, the repetitions, and the clues that might be there in the person’s social façade. i came to appreciate the experience of the schizoid phenomena and to notice the spaces between our interactions, to pick up on and use all the sensations available to me, and to be able to sometimes drift with the process while staying defined at the same time. in my experience, there are observable phenomena that may signal the client’s absence of self-definition, for example, the phenomenon of someone seemingly not arriving in a room and appearing to drift in and out of transactions. i observed that helen lacked definition in terms of how she arrived in the therapy room. i understood this as a lack of “aggress” in the space and in the relating, a passivity and an unclear definition in her physicality. guntrip (as cited in hazell, 1994) international journal of integrative psychotherapy, vol. 12, 2021 105 described how “the regressive urge to remain identified for the sake of comfort and security conflicts with the developmental need to dissolve identification and differentiate oneself as a separate personality” (p. 50). interrelating needs self-definition means an assertion of oneself, an expression of “me” in contrast to “you.” developmentally this is a huge task under any conditions. for the schizoid individual, maintaining the security of the hidden self takes precedence over the risks of differentiating. this is an example of how relational needs interrelate and interplay and how one need can be compromised by or contrasted with another: “it’s not safe to define myself in contrast to others”; “i don’t know myself enough to make an impact on you”; “when you initiate with me it feels unsafe.” i found that helen’s relational needs often fused together in clusters and appeared “theoretically interrelated” (žvelc et al., 2020). i came to understand how the triad of relational needs to make an impact, for self-definition, and to have others initiate were all in the background of our relating. these were needs helen was not aware of and did not outwardly express. i believe it aided helen’s therapy for me to hold the potential for them to emerge in our contact together, to be curious, and to watch for clues or expressions of them. these relational needs were thwarted at various points during helen’s life. she had given up expressing or seeking satisfaction of them and had found creative ways to compensate or adapt. her therapy involved a slow growth in her awareness of her previously unmet, unknown relational needs. need to initiate helen’s need for me to initiate contact was in the background of our relating during our early work. her dominant need was to remain safe and in control of the space. my attempts to initiate beyond the safe parameters of what she was prepared for were brushed away. i could see from her physiology and her responses to inquiry how wary she was of initiations into relational contact. however, the more i stopped trying to do and the more i allowed myself to work within the schizoid process—to involve myself in whatever helen was prepared to involve me in—the more i began international journal of integrative psychotherapy, vol. 12, 2021 106 to see the fragments of the need to initiate coming through, particularly in the form of developmental imagery. as helen trusted me enough to share more about her inner world, i was often reminded of how a young child might share ideas and thoughts. i imagined her not having the experience in childhood of a significant other alongside her at different ages, someone listening, involved, and impacted by her sharing ideas. it began to occur to me that helen was, in her own way, initiating play in her therapy. she appeared to be enjoying my enjoyment of her sharing of ideas, concepts, and metaphors. if a child has not had others initiate with them, all their ideas for pl ay stay internalized and in fantasy. in her workplace, i imagined helen as a little girl trying to initiate and get on with the other kids, not understanding how they spoke and what they wanted from her. as stewart (2010) suggested: it is important to be aware of the dynamics of initiating since sometimes it is clinically astute to wait until the client initiates reaching out to us. … the presence of the therapist’s need to have the other initiate might be felt as a longing for the client to reach out to them, and a disappointment when they don’t. … [therapists should] be mindful of their own need in this regard and not make it an expectation of clients or withdraw when it’s not met. (p. 48) again, the need to have others initiate may be bound up in the schizoid process and the unique style of relating that this involves: “i need you as a therapist to initiate contact but i need to regulate contact by withdrawing and presenting a social façade.” how do we as therapists hold on to the crucial need the client has when it is in the background of the relating? a schizoid person survives in relationships and interactions with others by relying on certain manners or creative personality adjustments, such as detachedness, robotic politeness, self-containment, or selfreliance. the underlying need for others to initiate is repeatedly missed as people relate to the social façade rather than the hidden self. this relational need remains out of awareness or hidden away, but it is there and will be within the field of relating in the psychotherapy. i imagined this confusion of unknown or hidden needs being expressed by helen in statements such as “i need you as therapist to initiate contact with me but i am scared of what this is like” or “i need you to initiate but i can’t tolerate this and need to regulate with withdrawal.” international journal of integrative psychotherapy, vol. 12, 2021 107 for such individuals, the idea of initiating with others, including the therapist, might be an unknown or frightening: “i didn’t think it was ok to ask for what i need.” helen’s relational need for the other to initiate was there, but it was a long time before i could initiate contact and move into a more relational style of inquiry. as with the relational need for self-definition and impact, her need for the other to initiate emerged into the foreground of our relating. these needs were there in the relating but often expressed inversely. she appeared to lack self-definition and instead relied on a social façade, a compromised version of her that hid away the vital and vulnerable self. her efforts to minimize having an impact within the therapy conversely made an impact on me. her need to have another initiate was experienced by her as threatening and emerged through careful attunement to metaphor and her intellectual playfulness. could the out-of-awareness relational needs in the client relate to the ones the therapist picks up in the countertransference? i found how important it was to identify and track where helen’s relational needs were within our relating, that is, which needs were in the foreground, which could be noticed within my countertransference, and which were out of awareness or in the background. need for mutuality moursund and erskine (2003/2004) wrote, “the need for self-definition is the complement of the need for mutuality” (p. 112). for her part, helen’s relational need for mutuality was in the background of our relating until much later in our work together. her predominant needs were to feel safe and to have her experiences and way of surviving validated and accepted. any sense of mutuality between us would have been threatening and risky to her. her loneliness and independence as a child did not include much companionship or many shared experiences with others. her playfulness came through in her intellectual life and within fantasy. there was a gradual movement toward a more mutual relating as she grew in her self-definition and allowed me to be a more relatable presence. zaletel (2010) described how with her client “[in] this therapy phase she expressed her needs of both mutuality and self-definition. lara entered in contact with her real self and thus i, too, could become more of a ‘real’ person” (p. 23). the more attuned i was with helen, the more defended her vital and vulnerable self often became. i imagine the more we try to be in contact with the smoke and mirrors of the social façade, the more this increases a sense of unease or confusion for the client. however, as the person becomes more settled in the international journal of integrative psychotherapy, vol. 12, 2021 108 relating, the therapist can be as well. as helen’s therapy progressed, we were able to relate together in an increasingly equal, mutual way. working within a schizoid process, we might meet the social façade of the person who seems easy in conversation and willing to engage in therapeutic interactions. there may appear to be a need for a mutual or shared relating when, in fact, the hidden, vital, and vulnerable self does not need mutuality with the therapist at all. that part of the self needs the emergent process of self-definition, to move out from a cut off, defended place to reclaim their voice and a sense of their uniqueness. there can be moments when it feels like the client is seeking some kind of mutuality or sharing of experience with the therapist when they are actually not ready to hear this and instead need the therapist to remain in an idealized position: bigger, protective, and an object onto whom they can project ideas from a younger, more vulnerable self. it might be like a scene in which a young child is sitting with adults at the dinner table attempting to join in grown-up conversation. this appears as a need for mutuality and shared experience when actually the stronger need is to have their own experiences responded to, validated, and accepted in an age-appropriate way (or even to get down from the table and go and play with the other kids!). need for survival reflecting on the therapy with helen, i suggest that the relational need for survival describes the internal struggle for self-survival happening inside the world of the schizoid person and within the therapeutic relationship. as o’reilly-knapp (2001) reported in describing her work with a client’s schizoid process, “she used her withdrawal and dissociative states for protecting and sustaining her life” (p. 4). defensive processes reflect the individual’s need to survive in relationship. they are creative ways of maintaining safety in the maelstrom of relating with others. beyond the need for safety is the need for the vital and vulnerable self to have survived as described in the “encapsulated self” (p. 12), a process that goes on internally, privately, and silently. a client will show their struggle for self-survival through the transference. the philosophical principles of integrative psychotherapy include the idea that “all human behavior has meaning in some context” (erskine, 2013, p. 4). taking this into account, i think the person who uses silence, withdrawal, or a social façade to cope with extreme distress or trauma needed to create an internal closed international journal of integrative psychotherapy, vol. 12, 2021 109 relational system in order to organize experience and keep the vital and vulnerable self alive. the therapist needs to appreciate and honor the function of this closed system and how the vital and vulnerable self has been in exile: deadened, put in a kind of deep freeze, the idea that to survive one must keep that part of the self “dead to the world.” this becomes a need in itself. a client can show us in the therapeutic relating that “i need to be hidden,” “i need to withdraw,” or “to survive, i needed to seem dead in myself.” it is essential to acknowledge this need for solitary survival as part of a relational psychotherapy. otherwise we may rush to offer the kind of contact and relating the individual may yearn for but also be highly fearful of. as yontef (2001) outlined, from the perspective of the schizoid individual it is dangerous to move into intimate connection if you cannot separate when needed. if you think you are going to be caught up, devoured, or captured in the connection, it is terrifying to move into intimate contact. on the other hand, if you do not feel connected with other people, especially if you do not believe you can intimately connect again, the separation or isolation is both painful and terrifying. (p. 9) a relational need to survive involves the individual’s fears around intimate contact and threat to existence. the vital and vulnerable self is locked in a closed internal system of survival. guntrip (as cited in hazell, 1994) described the internal tension with a metaphor: “a closed picture frame, the inside edge of which was an unbroken array of sharp teeth all pointing in at the patient” (p. 142). this precarious, fragile, self-contained inner world has to be acknowledged by the therapist as part of an in-contact integrative relational psychotherapy. helen showed me that she needed to create a rigid structure of relating to others. her way of regulating interpersonal contact was a tolerable compromise born out of necessity in order to survive early experiences in which her relational needs were not met. conclusion international journal of integrative psychotherapy, vol. 12, 2021 110 to borrow woodman’s (cited in kullander, 2008) phrase about dreams, i like to think of the schizoid individual as “like a deer at the edge of the forest” (para. 13). at first you may catch only a glimpse of her, and then she is gone in the blink of an eye. but this is enough to know she is there. reflecting on the many hours i worked with helen, patiently listening and attuning to her repetitious narratives, hoping to catch something of the vital and vulnerable self that she guarded so well, i found in myself a unique love and care for her in our struggles to find authentic contact with each other. this was someone who found intimate relating frightening and risky. helen entered therapy not knowing what she needed or what possibilities lay ahead, but she followed a yearning inside herself for something different. therapy within a schizoid process is a like a slow rescue mission. it is our patient caring and careful involvement with these clients that eventually allows someone to “unfold, like a flower” (berne, 1961, p. 226) and emerge from the protected internal spaces in which they have hidden. guntrip (as cited in hazell, 1994) described therapy with these clients as being like “a steady recuperation from deep strain, diminishing of deep fears, revitalisation of the personality and rebirth of an active ego that is spontaneous and does not have to be forced and driven” (p. 186). the therapeutic relationship is a place of growth and healing, a symbolic space of potential in which someone can begin to emerge and express their vital and vulnerable self. within this growth, we must validate and accept the person’s unique ways of surviving. helen and i worked together early in my practice, when i was inexperienced and did not appreciate what i now know about the schizoid process. i wonder if this not knowing actually helped the initial phases of the therapy. i was not trying to impose myself too hard on the work or trying different strategies. i was prepared to work patiently and gently at the pace helen needed in order for her to gain trust in the relating and to allow her true self and needs to emerge. when i first met helen, i had no idea of the richness of her inner life or how creative she was in her fantasies, thoughts, and way of seeing the world. i was locked into relating with an adapted social façade that needed tight control over the therapy space in order to feel safe. the close consideration of how her relational needs shifted within the therapy offered anchoring in the often slow and repetitive early periods of our work. my attention to how her relational needs appeared out of awareness and yet longed to emerge gave me a guide to what could be happening in our relating. over the years we worked together, helen taught me about what it means to be a therapist. winnicott (1965) wrote of a “devotion” to the emergent self. this implies a commitment to cherishing the creative ways a person remains interpersonally international journal of integrative psychotherapy, vol. 12, 2021 111 safe, their styles of withdrawal, and the internal unknowns that epitomize the schizoid struggle to find contact with the external world, themselves, and others. references berne, e. (1961). transactional analysis in psychotherapy: a systematic individual and social psychiatry. grove press. erskine, r. g. (2001). psychological functions, relational needs, and transferential resolution: psychotherapy of an obsession. transactional analysis journal, 31(4), 220–226. https://doi.org/10.1177/036215370103100403 erskine, r. g. (2011, 21 april). attachment, relational-needs, and psychotherapeutic presence [keynote address]. international integrative psychotherapy association conference, vichy, france. https://www.integrativetherapy.com/en/articles.php?id=73 erskine, r. g. (2013). vulnerability, authenticity, and inter-subjective contact: philosophical principles of integrative psychotherapy. international journal of integrative psychotherapy, 4(2), 1–9. erskine, r. g. (2015a). life scripts: unconscious relational patterns and psychotherapeutic involvement. in r. g. erskine, relational patterns, therapeutic presence: concepts and practice of integrative psychotherapy (pp. 91–112). karnac. erskine, r. g. (2015b). life scripts and attachment patterns: theoretical integration and therapeutic involvement. in r. g. erskine, relational patterns, therapeutic presence: concepts and practice of integrative psychotherapy (pp. 73–90). karnac. erskine, r. g. (2020). relational withdrawal, attunement to silence: psychotherapy of the schizoid process. international journal of integrative psychotherapy, 11, 14–28. erskine, r. g., moursund, j. p., & trautmann, r. l. (1999). beyond empathy: a therapy of contact-in-relationship. brunner/mazel. erskine, r. g., & trautmann, r. l. (1997). methods of an integrative psychotherapy. in r. g. erskine, theories and methods of an integrative international journal of integrative psychotherapy, vol. 12, 2021 112 transactional analysis: a volume of selected articles (pp. 20–36). ta press. http://www.integrativetherapy.com/en/articles.php?id=63 (original work published 1996) fairbairn, w. r. d. (1952). psychoanalytic studies of the personality. routledge. greenberg, e. (2016). borderline, narcissistic and schizoid adaptations: the pursuit of love, admiration and safety. greenbrooke press. guntrip, h. (1969). schizoid phenomena, object-relations and the self. international universities press. hazell, j. (ed). (1994). personal relations therapy: the collected papers of h. j. s. guntrip. jason aronson. johnson, s. m. (1994). character styles. norton. kullander, j. (2008). men are from earth and so are women—marion woodman. awaken. https://awaken.com/2018/03/men-are-from-earth-and-so-are-women little, r. (1999). schizoid processes: working with the defenses of the withdrawn child ego state. transactional analysis journal, 31(1), 33–43. https://doi.org/10.1177/036215370103100105 little, r. (2011). impasse clarification within the transference-countertransference matrix. transactional analysis journal, 41(1), 23–28. https://doi.org/10.1177/036215370103100105 manfield, p. (1992). split self, split object: understanding and treating borderline, narcissistic and schizoid disorders. jason aronson. moursund, j. p., & erskine, r. g. (2004). integrative psychotherapy: the art and science of relationship. thompson–brooks/cole. (original work published 2003) orcutt, c. (2018). schizoid fantasy: refuge or transitional location? clinical social work journal, 46(1), 42–47. https://doi.org/10.1007/s10615-017-0629-2 o’reilly-knapp, m. (2001). between two worlds: the encapsulated self. transactional analysis journal, 31(1), 44–54. https://doi.org/10.1177/036215370103100106 o’reilly-knapp, m. (2012). organizing self-experiences. international journal of integrative psychotherapy, 3(1), 1–14. international journal of integrative psychotherapy, vol. 12, 2021 113 stewart, a. l. (2010). relational needs of the therapist: countertransference, clinical work and supervision. benefits and disruptions in psychotherapy. international journal of integrative psychotherapy, 1(1), 41–50. winnicott, d. w. (1965). the maturational processes and the facilitating environment: studies in the theory of emotional development. international universities press. yontef, g. (2001). psychotherapy of schizoid process. transactional analysis journal, 31(1), 7–23. https://doi.org/10.1177/036215370103100103 zaletel, m. (2010). journey towards integration: the case of lara. international journal of integrative psychotherapy, 1(1), 11–24. žvelc, g., jovanoska, k., & žvelc, m. (2020). development and validation of the relational needs satisfaction scale. frontiers in psychology. www.frontiersin.org/articles/10.3389/fpsyg.2020.00901/full https://doi.org/10.3389/fpsyg.2020.00901 the wisdom of the subcortical brain mario c. salvador abstract: this article discusses how early experiences shaped in the deepest neural networks become organizational schemas that colour our experiences during the lifespan. these basic organizational schemas inform the many ways clients relate with others through microphysiological reactions, gestures and physiological patterns. these patterns and reactions provide windows into early unconscious experiences (implicit memories), which are essential to explore in therapy. the importance of the therapeutic relationship is also discussed in terms of porges’ polyvagal theory, and how this relationship creates a safe environment to awaken the social engagement system and activate the neural circuits of healing, restoration and growth. key words: polyvagal theory, implicit memories, trauma treatment, therapeutic relationship, emotional regulation. ______________________ the intention of this article is to raise awareness among integrative psychotherapists as to the relevance of the primary and more primitive processes in our psychological functioning and how these related phenomena impact our observations and interventions in the field of psychotherapy. throughout this writing, i will draw conclusions and extrapolations, which will be of value to the practice of psychotherapy. for this purpose, i will discuss and link the following ideas: brain hierarchical architecture and hierarchical brain maturation the construction of relational schemas and acquisition of emotional learning, and subsequent impact shaping of experience the impact of polyvagal theory in psychotherapy and its implications in the therapeutic relationship international journal of integrative psychotherapy, vol. 4, no. 2, 2013 40 the hierarchical maturation of our brain our brain is the only organ in our body that still reflects in its stratified layers phylogenetic development as a species. in a vision already outdated, paul maclean (1990) �spoke of the triune brain to reflect this reality (fig. 1). at the bottom we have the reptilian brain, which is responsible for the management of our major life functions such as sleep, wakefulness, temperature, metabolism and breathing. we can say that this is 'part of the i' in which lies "the life force.” above the reptilian brain, we have the limbic brain, or mammalian brain because it appeared in lower mammals. this part essentially deals with emotional phenomena, transformation of narrated lived experiences and the regulation of the interpersonal world. this drawn representation includes the amygdala which is like a smoke detector for threats that activate our body toward the defence; the hippocampus which manages our narrative memories so we can put our experiences into a context and to arrange in sequence an experience. in addition, we see the orbitofrontal cortex, which is the great headquarters for information integration from the external and the internal world and that part which integrates our experience in the social world of our relationships and our ability for meta-reflection. here also lies the mind’s ability to observe itself (mindfulness). finally, in the upper layer we have the neocortex or neomammalian brain, where higher thought, language, and decision making functions take place. fig. 1 vertical section of the brain for the purposes of this article, i will discuss how the brain matures hierarchically and dependent on life experiences. we know that the brain goes through 'critical periods' in which it has to learn the skills corresponding to that evolutionary period. higher level skills in the hierarchy are based on what is built in lower subcortical layers, and they continuously shape our conscious experience. international journal of integrative psychotherapy, vol. 4, no. 2, 2013 41 neuropsychologist jaak panksepp (1998a) in his book affective neuroscience, speaks of 'emotional systems' for life which are embedded in specific neurobiological circuits that control the execution of particular emotions. these basic neurobiological circuits are genetically predetermined and designed to respond unconditionally to stimuli that have some significance to the organism. they aim to produce well-organized behavioural sequences. emotional systems are very "sensible" as they provide a neural substrate for various types of organismic coherence. they also make animals "active agents" in the world, as opposed to simply "information processors" or behaviourists. the evolutionary "sense" of having raw affective feelings (which panksepp called primary process) is to identify ‘unconditionally’ specific primary threats to survival. these brain states can also be used as elements of information for learning higher mental processes. we need to understand the powers of our ancestral minds. whereas the cognitive aspects are linked more to the programming of each individual’s development, raw emotions and affects represent our ancient, inherited tools for living. these basic emotional operating systems are organized in deep pre-propositional, pre-cognitive subcortical regions. knowledge of the “power of the ancestral mind” is highly useful in the psychotherapy of people subjected to a history of chronic cumulative trauma and life threatening circumstances. these systems, therefore, cannot become integrated in an organized and sequenced response for survival and may become fragmented as dissociated 'parts' that are activated by a threat to the sense of self and/or life. as a result, we often find a ‘part’ in our clients which contains, for example, experiences of fear, paralysis, rage attack, and/or crying for attachment. one of our first emotional systems involves the search for a caring relationship. the critical period for the consolidation of this 'action system' is between 0 and 1.5 years and involves emotional and internal states learning through interpersonal bond regulation (schore, 2000). these relational schemas are recorded in the lower strata of our brain (orbitofrontal area and right hemisphere) as procedural memories; those remembering forms of which we are unaware and which are recorded in our corporality. in other words, at this critical period the 'be related schemes’, or what bowlby (1979) calls internal working models, are consolidated, as well as the ability to regulate oneself emotionally and to calm down. these basic skills remain as somatosensory experiential traces that will permeate and condition our ways of being in the world thereafter, which they will do in an automatic way without our conscious participation in the decision. braas and haynes (2008) highlight in their research how our unconscious and visceral reality responds to external information milliseconds before we are conscious, and thus permeate our experience of external reality. in their research international journal of integrative psychotherapy, vol. 4, no. 2, 2013 42 they demonstrates how decisions we believe to have made consciously, have already been decided in our deep layers. the little child, as a subcortical creature, is unable to regulate his or her internal states alone. it is a 'good enough' mother, in winnicott’s (1964) words, who regulates the internal states of the child through the quality of interpersonal contact and intervention with physical sensations. emotional regulation is learned through attachment. initially the mother works as an "auxiliary cortex" that identifies and meets the needs of the child, calming him and intervening in his welfare, and creating homeostasis. so as schore (1994) claims, regulation of internal states begins as an 'interactive biological regulation’, in order to eventually effect 'autonomous biological self-regulation.’ in other words, when the child has been taken care of and responded to in a relationship of full contact and harmony with his inner world, he learns to 'take care of himself,' because he has internalized the other as a constant object and good care provider. when this has not occurred, the adult will demonstrate this legacy through difficulty with the ability to self-calm, and/or the experience of being overwhelmed by emotions. emotional regulation is one of the capacities most directly correlated with adaptive functioning and health of a human being. patients with whom we work are characterized by deficient upbringings that often created damage and/or deficiencies in the neurobiological structures necessary for brain maturation in these critical periods of development. this leaves lingering injuries in the way a person manages experience. early trauma leaves a legacy and traces that long affect the organism's maturation. people who have endured severe trauma, relational and otherwise, often have to disconnect or ignore their internal reporting and regulatory signals of their needs, causing damage to the body and core concept of the self. they often have not been able to consolidate a ‘felt sense' to deserve love. the goal of a deep relational-integrative psychotherapy is to restore the damaged sense of self and help the patient regain a sense of their own worth and being. for this we must look at the experiential substrata residing in these subcortical layers and their somatosensory memories. authors in the field of neuroscience such as antonio damasio (2010), jaak panksepp (1998a), louis cozolino (2002), daniel siegel (1999), allan schore (2000) and stephen porges (2002), among others, highlight the importance of hierarchical maturation of the brain and how psychological phenomena are based on the most ancient neurobiological structures that come programmed in our birth. these ancient structures, in the form of reflexes and instincts, represent an 'unconscious but necessary wisdom to govern life.’ it is this unconscious wisdom which provides the basis of our entire functioning and support the 'felt sense' of self, which damasio (2010) calls the 'proto-self.’ damasio (2010) expresses this idea in the following words: international journal of integrative psychotherapy, vol. 4, no. 2, 2013 43 "... the hidden knowledge of life management precedes the experience of being aware of any knowledge of this kind. i also argue that the hidden knowledge is quite sophisticated and should not be considered primitive. the complexity of this knowledge is huge and its apparent intelligence remarkable". …. by making this approach i do not demote the position of consciousness, however, i do give greater value to non conscious life management, while i suggest it constitutes the organizational plane that structures attitudes and intentions we find in the conscious mind." (p. 69) thus, damasio (2010) postulates that performance of the higher depends on good consolidation of the lower. the deepest and earliest traces of our history are still visible to the eyes of the therapist in the manifestation of procedural behaviours (erskine, 2008, 2010); patterns of being in relationship with the other, survival reactions to the perception of a threat, avoidance of eye contact with the therapist perhaps due to fear of seeing judgement in the therapist’s eyes, and other behavioural forms of implicit memories. according to panksepp (1998a) ancient minds still exist within our modern human minds, and we will not understand our higher mental processes unless we seriously address earlier neural solutions that still influence the complex mental apparatus in highly encephalized mammals. panksepp also claims that higher cognitive abilities have a life of their own. all that is on top is linked to the many emotional networks in ‘brain-mind’ lower regions. these subcortical systems may have ‘a life of their own’. for example, our ancestral affects (primary emotional systems) under a big stress can control and regulate our higher cognitive processes. i support the idea that every person’s individual history is essentially recorded in his/her corporality, and hence in brain regions that register maps of the state of body. just as the “black box” keeps tract of an aircraft’s history, so too does the body keep a ‘black box’ that records our history, as the body keeps the score. hidden layers of our neural processing pre-digest and organize our experience before it emerges into our consciousness. most of psychotherapy is dedicated to detect, understand and correct the content and organization of these hidden layers, and our implicit procedural schemata of being in relationship with another human being. we have windows to access the contents of these deep, damaged layers by observing the physiological manifestations of survival, subtle physical reactions, script conclusions and decisions, and the patient's interpersonal and intrapersonal way of being in touch. it is by paying attention to narrative and bodily experience that we help patients access their procedural and implicit history, thus helping them to access a deep inner contact with their corporality. international journal of integrative psychotherapy, vol. 4, no. 2, 2013 44 the brain is a sophisticated organ that integrates our experience. this capacity to integrate appears when we are facing developmental learning challenges and tasks appropriate to our abilities and maturity level; what winnicott (1956) called optimal disillusionment. as we grow in stable and secure environments our psychobiological system matures, restores and heals itself. the system is capable of self-healing and the brain is able to manage the internal and external world reaching homeostasis. self healing capacities requires the brain to cope with internal stimulus in a range of intensity that could be tolerable. ogden and minton (2001) note that the intensity of internal stimulus should be in between what they call the windows of tolerance (see figure 2 below). so, when the brain copes with an issue while under a good amount of stress, it is still able to heal itself, which means integrate experience and restore homeostasis. the immune system is just one example of our brain ability to heal itself. fig. 2 (adapted from ogden & minton, 2001) in a therapeutic setting, the therapist takes on the role of an interactive biological regulator (schore, 1994) through an attuned therapeutic relationship, helping the client’s internal world to regulate in a manageable way. he assumes the role of the external auxiliary cortex, helping to identify, support and regulate the patient's inner world through interpersonal involvement. in this way, the patient and his/her brain is helped to cope with new challenges, learning and assimilation of experiences, integrating that which is new with previous schemata and thus gaining maturity and resilience. implications of polyvagal theory for psychotherapy a very useful neurobiological model for psychotherapy is stephen porges (2001) polyvagal theory. his research shows how the vagus nerve evolved hierarchically alongside our phylogenetic evolution. the vagus arises from the brainstem and runs alongside the spine, and is involved in the regulation of our autonomic nervous system (ans) and regulation of our emotional states and responses of survival and health. traditionally, it was considered that our ans international journal of integrative psychotherapy, vol. 4, no. 2, 2013 45 consisted of a branch of sympathetic activation that triggered our survival responses (fight-flight from the threat), in addition to a parasympathetic activation system, involved in the energy restoration process, healing and growth. these two branches alternate and inhibit one another. when one is active, the other is inactive. however, in extreme cases of threat to life, situations in which the body cannot escape and/or fight, active defence itself becomes a danger because the abuser will potentially do more harm. for example, the predator can kill the weaker opponent if he attempts to continue defending himself. survival is then obtained by activating our passive defence system of surrender and freezing. this system is biologically determined to prevent the predator from continuing the attack and to avoid pain, as observed in all mammals and in invertebrates. we see this in all wild life when the prey is hunted and the first reaction is fake death. a new opportunity for escape is provided if the predator drops the prey. the defence system of freezing then stimulates endorphins, in an attempt to protect from physical pain. during freezing, the body enters a state of tonic immobility after 'faked death' and so employs dissociation as an extraordinary survival mechanism. when the body cannot escape, the mind seeks how not to be in reality, functioning as if nothing had happened; a sensation of no feeling or 'not being.’ children in their first two years of development tend to employ this dissociative mechanism when they live among negligent, aggressive and violent caretakers, conditioning them for a future in which their neurological system will react to threat by 'disconnecting’ and an attempt to paralyze their body and 'try to go unnoticed.’ in traumatic abuse, the individual dissociates not only from the external world and from the processing of external stimuli associated with terror, but also from the inner world of painful stimuli arising within the body. here we connect with contact interruption mechanisms that will be observed in the therapeutic relationship and to which we have to give recognition, validation and normalization through our involvement and careful observation. in his book, porges (2001) claims that the freezing-dissociation system, which he calls parasympathetic immobilization, is a survival system inherited from primitive reptiles and activated in situations of threat to life when the other two systems of social engagement and the fight-flight defence of mobilization have failed. freezing utilizes the dorsal-vagal branch of the vagus activation. this state is highly effective in reptiles, who may remain in extended states of immobilization, but not in mammals who require large inputs of oxygen to the brain to stay alive and functioning. thus, extending this freezing state involves serious risks to human life and health. people who have been exposed to life threatening chronic trauma early in their lives have learned to survive many times by paralyzing, freezing and dissociating. for them, ‘trauma is encapsulated in the body as body deregulation and somatic memories.’ thus, they are prone to psychosomatic illnesses, autoimmune disorders, visceral and digestive illness, and cardiovascular diseases, in addition to other disease processes. international journal of integrative psychotherapy, vol. 4, no. 2, 2013 46 according to the hierarchical activation model, we first regulate ourselves through social contact, which occurs in the ventral branch of the vagus, as developed in mammals. that is, we seek the safety and security offered by the figure of dependency. if this fails, we try to protect ourselves through sympathetic nervous system activation based on the fight-flight response. if all this is ineffective, we activate the oldest and most primitive system; the freezing response. helping patients to climb this ladder is a matter of necessity in therapy. it implies bringing them to the relationship in order to experience the other as present and secure. it compels connection and interest with the environment. porges’ (2001) valuable research shows how as mammals evolved, something special happened in the vagus. mammals developed a new vagus, which porges calls the social or mobilized parasympathetic vagus (porges, 2001). this new vagus attenuates or calms the sympathetic and adrenal circuits in order to enable the individual to engage socially and optimize metabolic resources that allow the activation of more sophisticated brain capabilities. so, as mammals we calm our alertness in social interaction. in social involvement, metabolic demands are reduced and health, growth and healing are optimized. what is relevant to life and to psychotherapy intervention is that mammals require opportunities to interact reciprocally to regulate the physiological states of each of those involved. in essence, we create relationships to feel safe and maintain health by facilitating the regulation of our energy. this is the most important relational need and is always present. in the therapeutic relationship we continually build this security for the patient to return to the interpersonal relationship for re-shaping and transformation of his/her inner world. another curiosity is that the brainstem area that regulates new vagus fibres (ventral branch) is attached to the brain areas that control the striated muscles of the face. this area of the brain stem controls our ability to listen through the middle ear muscles and articulate through the laryngeal and pharyngeal muscles, and our ability for facial expression. if we are speaking with a soothing intonation, as in the prosodic aspects of speech, or showing soothing facial expressions, this information goes to the vagus nerve. this is why mothers have that special way of talking to babies called 'motherese.’ so, when we listen to intonation we are reading the physiological state of the other person. if the physiological state is of calm, we calm down. in mammals, long before the acquisition of syntax or language, there are vocalizations, which are important components of social interactions. vocalizations express to other members of the species whether we can feel safe with the other. in nonthreatening contexts, the social engagement system regulates the sympathetic nervous system, facilitates involvement and interest in the environment and helps to form positive emotional bonds and social ties. even under conditions of threat, a well-adjusted person can use the social networking international journal of integrative psychotherapy, vol. 4, no. 2, 2013 47 system, for example, to try to reason with a potential attacker. therefore, what happens in our body (and particularly in our viscera) is also happening in our brains, through the information that runs alongside the vagus. we can say that mind-body responses during reciprocal interactions are not just correlations but are, in fact, one and the same, albeit different paths to the same reality. the vagus is the real body-mind connection. the conclusion is that we must provide and create security in the therapeutic setting and relationship so that the survival defensive responses may relax and therefore allow the social interaction system to help in the regulation of internal states. when we are scared, we cannot be creative, loving, or healing to ourselves or others. polyvagal theory (porges, 2001) emphasizes the physiological aspects of the reciprocal interaction, and documents how neural pathways of social support and social behaviour are shared with neural pathways supporting health, growth and healing. the main message is that we need to understand that the human nervous system, like that of other mammalian species, is aimed at the search for security, and we employ others to feel safe. in addition, we must understand that physiological states or circuits are not selected voluntarily. our nervous system is evaluating this at an unconscious level. porges (2001) uses the term neuroception to recognize that our nervous system, without consciousness, is evaluating the risk of the environment. this is a neural perception. our body works as a polygraph, continually responding to and evaluating people and places. the vagus is not just a motor nerve that runs from the brain to the viscera, it is also a sensory nerve that goes from the viscera to the brain. here we have the body-mind connection. once we feel secure, the social engagement system is activated. by responding with a positive facial expression and intonation, the therapist is stimulating the social engagement system. in this way, we must also consider the importance our own state of well being has for our patients. we cannot generate security if our own system is worried. in addition, the face is not only a mask, it is actually the manifestation of an extremely complex neurophysiological system that has evolved and, in fact, connects directly with the neurological regulation of our viscera. in relational integrative psychotherapy (erskine et al, 1999) we seek to create a relationship of continuous full contact attuned with the patient's intrapsychic processes. so it is through respectful inquiry and providing a deep involvement and therapeutic presence that we help the patient to return to the relationship. we create safety and thus, facilitate the dissolution of the defences so that the system need not be alert to the expected damage from the environment as in previous experiences. in this way, the patient can access and explore their previously avoided or denied inner world. in other words, through interpersonal and attuned contact we facilitate secure access to internal contact, and we provide that the self-healing system and experience of integration can take place. in this way, throughout the therapeutic relationship we help the brain to be in a state of being able to self-heal and integrate the inner experience that is held in the body and neural networks. some neuro-processing techniques international journal of integrative psychotherapy, vol. 4, no. 2, 2013 48 such as emdr (shapiro, 2001) and brainspotting (grand, 2013) can then act as powerful ways to help the brain reprocess the encapsulated memories. through an attitude of presence, the therapist stands as supporting and sustaining the patient’s experience, showing genuine interest, loving compassion and an absence of ulterior motives or preconceptions about what the patient’s experience is. looking at the experience as it is, we allow it to unfold, and what was retained or dissociated can emerge to now be associated, transformed and integrated. so therapy becomes a process for helping the patient to self-define their experience in a new way. this leads to a 'reconsolidation' of procedural and implicit schemata as they settle in a new and adaptive way. with this in mind, i tell my students and supervisees, 'do not seek anything from your patients'. with this principle i intend to shape the attitude of witnessing what the other is, as she or he is. as a result, we can 'call and wake' the patient´s experience, and assist and support the person on the path to reconnection, both internally and externally. helping the patient be present to experience, reallocation and new meanings patients with complex post-traumatic stress disorders (cumulative trauma) maintain their neurobiological states in an almost permanent hyper-alert state and corresponding sympathetic activation. or, they often live in chronic periods of dissociation with the dorsal-vagal branch of the parasympathetic immobilized. as previously stated, this brings them to live in a state of chronic psychobiological disruption. they are exposed to the intrusion of symptoms that lead them to feel a lack of control in their lives and internal states. when one lives with the experience of a chronic failure of the social system in order to manage security and protection, as is often the case of chronic childhood trauma, the system usually ‘turns off.’ without this modulation of internal states to function as ‘brakes’ for the social networking system, the sympathetic nervous system or the dorsal vagal system remain highly activated, causing physiological arousal that exceeds tolerance. in patients with these disorganization states, the therapist has to perform some important tasks to help the disorganized psychobiological system. in these patients the survival system lives as if exposed to the permanent life-threatening situation (see fig. 3 below). they alternate between hyper-arousal states, producing symptoms of emotional and intrusive imagery, obsessive thinking, tremor, uprooting, and hypo-arousal states (dissociation-freezing) which manifest in symptoms of flat affect, difficulty with thinking and concentrating, numbing, and/or collapse. they alternate states of over activation and international journal of integrative psychotherapy, vol. 4, no. 2, 2013 49 biochemical disorganization with states of emotional anaesthesia. when internal stimulation is beyond the range of tolerance, it cannot be processed, as cortisol excess inhibits the hippocampus functioning and the limbic brain area involved in the experience of symbolization and contextualization. the result is that in this state of biochemical alteration, integration is not possible. fig. 3 thus, the therapist has to: a) assist the patient to stay connected to the therapeutic relationship and, therefore, to the present context. the therapist needs to provide containment, support and accompaniment. the social engagement system provided by the therapist promotes calm and flexibly adaptive general states (porges, 2001), and because of this, allows physiological arousal to remain within the range of tolerance. b) act as an 'external auxiliary cortex' that helps to modulate and regulate the intensity of the experience. since these patients lack emotional regulatory skills, the therapist must modulate the amount of traumatic material the patient can handle, help regulate the intensity of the pain, and monitor the pace. the goal is for the patient to maintain the intensity of their experience within the 'window of tolerance' for possible integration. nevertheless, it is important to teach patients some practical techniques to learn how to self-soothe, in order to foster self-control, and not only be dependent on the therapist when they feel overwhelmed or dissociative. c) help restore the mechanisms that facilitate the integration of experience. this is what janet (1928) called presentification – keeping in awareness that today they are remembering something that already international journal of integrative psychotherapy, vol. 4, no. 2, 2013 50 happened – and personification (janet, 1903); feeling as authors and present in their own experience. in this process, the therapist helps the patient to stay in touch with their experience from the adult or the 'internal observer', facilitating the coconstruction of a new narrative, reassigning new meanings and reconsolidating implicit memory schemas in an adaptive manner. in other words, we help the patient to reconnect with their deep wisdom, to rediscover the natural meaning of their primary processes and to modify the shaping of their survival system. the presence and offering of a compassionate, supportive and secure relationship helps to create a ‘healing bubble’ or ‘a healing space’,’ in which we help the patient to loosen the defences and survival reactions from the outside world threat, so they can reach towards themself and find internal contact. we provide the circumstances for the brain to remain in a state of social involvement. this is where healing and growth can take place. from a neurological perspective, when we help the patient 'to be at and to observe' his experience, the prefrontal cortex area is activated; the sensory, bodily, interpersonal, self-regulatory integration area where the mind’s ability to observe itself lies. here, we are talking about mindfulness and meta-reflection to the experience itself. in mindfulness we create the experience of 'being today in the present and looking at something that comes from the history;’ an 'i observer' observing internal processes with acceptance, love and openness to whatever comes as it comes, and with curiosity, without expectations and without rejection of 'i experience.’ it involves the patient's own presence in their own experience. in this 'being present in their own experience,' dissociation is circumvented and 'association' is encouraged. in siegel’s words, "our ‘lived self’ resonates in a direct and clear manner with our ‘awakened self’, so we feel felt by our own mind" (siegel, 2007, pg. 91). the purpose is to enable the patient to embrace and welcome their inner experiences as they are, and to listen to the long retained message without judgment. with this, we facilitate what i call 'neuroprocessing;’ observing and learning about the experience that was interrupted and organized in order to survive, so that now it may express its full meaning, be completed and reconsolidated with a new meaning. this is trusting in the wisdom of our deep and subcortical brain. in conclusion, i want to highlight that the human brain is programmed to integrate experiences and heal itself. it only needs an environment that modulates and dispenses the kind of experiences it is mature enough to manage and digest, while at the same time providing the required nourishing elements such as a secure, supportive and stimulating environment. adapting winnicott’s term (1956), we would speak of a ‘good-enough therapist' that helps to modulate and shape the experience in order to re-construct the story. i end with what to me is the aspiration of a psychotherapist by quoting the tao te ching (2008, p. 80). international journal of integrative psychotherapy, vol. 4, no. 2, 2013 51 in it, i offer the attitude of presence that creates the 'healing bubble' and how doing less can help more. "the sage controls without authority, and teaches without words; he lets all things rise and fall, nourishes, but does not interfere, gives without asking, and is satisfied. reaches a state of inaction such that doing nothing, nothing is left undone " author: mario c. salvador is the director de alecés, instituto de psicoterapia integrativa y brainspotting españa (www.aleces.com), a trainer/supervisor for the international integrative psychotherapy association, provisional transactional analysis trainer/supervisor for the international transactional analysis association, brainspotting trainer and emdr clinician and consultant. references bowlby, j. (1979). the making and breaking of affectional bonds. london: tavistock. cozolino, l. (2002). the neuroscience of psychotherapy: building and rebuilding the human brain. �new york, ny: w.w. norton & co. damasio, a. (2010). self comes to mind: constructing the conscious brain. pantheon books, new york grand, d. (2013). brainspotting. the revolutionary new therapy for rapid and effective change. sounds true. boulder, colorado. ogden, p & minton, k (2001) sensorimotor processing for trauma recovery. psychotherapy in australia, vol. 7, no 3: 42-46 erskine, r.g., moursund, j.p., & trautmann, r.l. (1999). beyond empathy: a therapy of contact in relationship. brunner/mazel, philadelphia, pa. erskine, r.g. (2008). psychotherapy of unconscious experience. transactional analysis journal, 38: 128-138. erskine, r.g. et al. (2010). life scripts: unconscious relational patterns and psychotherapeutic involvement. in life scripts, a transactional analysis of unconscious relational patterns. richard erskine (ed). karnac books: london. janet, p. (1903). les obsessions et la psychasthenia [obsessions and psychasthenia] (vol. 1). paris: félix alcan. international journal of integrative psychotherapy, vol. 4, no. 2, 2013 52 international journal of integrative psychotherapy, vol. 4, no. 2, 2013 53 janet, p. (1928a). l’évolution de la mémoire et de la notion du temps [the evolution of memory and the notion of time]. paris: a chahine. maclean, p. (1990) �the triune brain in evolution: role in paleocerebral function�plenum, new york. panksepp, j. (1998a). affective neuroscience. the foundations of human and animal emotions. london: oxford university press. porges s. w. (2001) the polyvagal theory: phylogenetic substrates of a social nervous system. international journal of psychophysiology 42, 123-146 schore, a. n. (1994). affect regulation and the origin of the self: the neurobiology of emotional development. hillsdale, nj: lawrence erlbaum. shapiro, f. (2001). eye movement desensitization and reprocessing: basic principles, protocols, and procedures. guildford press siegel, d. (1999). the developing mind: toward a neurobiology of interpersonal experience. new york: guilford. siegel, d. j. (2007). the mindful brain: reflection and attunement in the cultivation of well-being. new york: ww norton. soon, c. s., braas, m., haynes, j. d., (2008) unconscious determinants of free decisions in the human brain: nature neuroscience. (11), 543-545. tsé, l. (2008) tao te ching. vladimir antonov eds. ontario, canada; (spanish translation printed by lulu http://stores.lulu.com/spiritualheart) trevarthen, c. (1993). the self born in intersubjectivity: an infant communicating. in u. neisser (ed.), the perceived self: ecological and interpersonal sources of self-knowledge (pp. 121-173). new york: cambridge university press. winnicott, d.w. (1956). the maturational process and the facilitating environment. new york: international university press. winnicott, d. w. (1964) the child the family and the outside world. london: pelican books date of publication: 23.4.2014 international journal of integrative psychotherapy, vol. 11, 2020 29 engaging with the schizoid compromise: a response to erskine’s “relational withdrawal, attunement to silence: psychotherapy of the schizoid process” ray little1 abstract this article presents a response to the paper “relational withdrawal, attunement to silence: psychotherapy of the schizoid process” by richard erskine in which he described his treatment of a client who made use of schizoid processes and defenses to manage her experience. the current author responds by focusing on the self-protective defenses of schizoid compromise and withdrawal that individuals with a schizoid presentation employ. their struggle with attachments is also examined, and various theoretical perspectives on developmental processes and the structure of the mind are discussed. the spectrum of schizoid processes is examined from the more extreme introverted schizoid personalities who exhibit severe withdrawn presentations to those who seek some form of attachment. the nature of the internal world and the difficulty of managing relationships is explored. therapeutic action in response to the schizoid compromise and withdrawn individual is considered. the article includes a number of clinical descriptions and concludes by exploring the processes involved when the therapist themselves occupies a schizoid compromise position. keywords: schizoid personalities, schizoid dilemma, schizoid compromise, withdrawal, relationships, transference-countertransference, therapeutic action richard erskine (2020) recently invited me to respond to an article he has written about his treatment of a schizoid client. we were both on a panel 20 years ago at a transactional analysis conference in san francisco, the theme of which was schizoid processes. the conference papers were published as a theme issue of the transactional analysis journal (daellenbach, 2001). it seems timely now to 1enderby psychotherapy & counselling associates, edinburgh, scotland, uk; e-mail: enderby@janeandray.ndo.co.uk mailto:enderby@janeandray.ndo.co.uk international journal of integrative psychotherapy, vol. 11, 2020 30 revisit some of those ideas, having worked extensively with them in the interim, and to share some current thoughts about schizoid processes. in erskine’s (2020) paper, entitled “relational withdrawal, attunement to silence: psychotherapy of the schizoid process,” he presented the case of violet and described how that work taught him the significance of relational withdrawal and the importance of attunement in psychotherapy. erskine’s article provoked me to focus particularly on the notions of the schizoid compromise, withdrawal, and treatment considerations. the schizoid’s behavior is marked by withdrawal and inability to form close relationships: “there is a consuming need for object dependence but attachment threatens the schizoid with the loss of self” (seinfeld, 1991, p. 3). the person protects themself by withdrawing from social contact. in my article “schizoid processes: working with the defenses of the withdrawn child ego state” (little, 2001), i examined several theoretical descriptions of schizoid processes. i pointed out how the term schizoid has been used to describe both a personality structure and psychological processes. melanie klein (1946/1975) employed the term both to refer to a splitting mechanism and to describe a developmental position. in discussing the splitting of the self, she highlighted how the other is experienced as a persecutor. fairbairn (1952) described three prominent characteristics of schizoid personalities: an attitude of omnipotence, detachment, and a preoccupation with fantasy and inner reality. he later described an intrapsychic structure that consisted of the splitting of the ego and repression as a defense. he pointed out that schizoid personalities may appear to fulfill a social role with others with what seems to be appropriate emotion and contact while actually remaining detached. before continuing here, i want to let readers know that i, as a white british male, will be drawing on my clinical experience to highlight some of the theory. the clients and supervisees’ clients described here are largely white european and north american. i acknowledge this because we need to ask ourselves whether the theory is applicable across all races, ethnicities, and cultures given that there is little research into these aspects of personality disorders. however, some papers relevant to these issues have been published in the last decade, including hossain et al. (2018), mcgilloway et al. (2010), and newhill et al. (2009). developmental theory international journal of integrative psychotherapy, vol. 11, 2020 31 a variety of theoretical models can be drawn on to elucidate the developmental history involved in schizoid processes and personalities (fairbairn, 1952; guntrip, 1968; kernberg, 1984; m. klein, 1946/1975; r. klein, 1995; mcwilliams, 1994). some of them refer to schizoid mechanisms, whereas others refer to schizoid personality disorders. one perspective on understanding the etiology of schizoid phenomena is to consider how the individual negotiated relationships as an infant/child and then internalized those experiences. ego state relational units (little, 2006) and object relations (fairbairn, 1952; guntrip, 1968) both describe how relational experiences, and the child’s perception of them, become organized and internalized as relational schemas (little, 2013; žvelc, 2010). on examining these schemas, we can distinguish between tolerable experiences that were integrated and intolerable ones that remain unintegrated. tolerable nondefensive experiences are an aspect of the integrating adult ego state and represent autonomous, here-and-now functioning from an open system (little, 2006, 2011) with the capacity for assimilation and accommodation (piaget, 1952; žvelc, 2010). intolerable experiences remain as a dissociated structure consisting of defensive or maladaptive schemas (eagle, 2011; žvelc, 2010). i describe these schemas as child-parent ego state relational units (little, 2006), which are located in unconscious, implicit memory. these relational units make up the internal structure of the schizoid individual. (for a full discussion of the theory of relational schemas, see eagle, 2011; little, 2006, 2011; piaget, 1952; žvelc, 2010). the basic need for attachment and object relatedness and the desire to “discover one’s reflection in the look of the other” (seinfeld, 1991, p. 33) exists in the schizoid personality, as it does in everyone. it is intrinsic to who we are as a species. when we think of the adult person who presents with a schizoid characterological structure, we may wonder what the nature of the person’s early experiences were, particularly with their primary caregivers, that led them to feel such hopelessness and fear in relation to being with others. those early experiences led them to feel a tension between attaching and not attaching (or nonattachment). for ralph klein (1995), the question revolved around “what kind of deal does the schizoid negotiate in order to gain the benefits of attachment while avoiding the anxieties and dangers of nonattachment?” (p. 45). r. klein (1995, p. 51) described two positions—nonattachment and attachment—that the schizoid individual may occupy. the first consists of the schizoid’s self-sufficiency and self-reliance. the second consists of being close and involved with another but runs the risk of being let down, rejected, or international journal of integrative psychotherapy, vol. 11, 2020 32 abandoned. as one client said to me, “relying on people is seen as a bad idea as they will eventually let you down.” guntrip (1968) and r. klein (1995) agreed on the nature of the schizoid condition. they disagreed, however, as to the point during development at which the condition originates. guntrip, following fairbairn (1952), suggested that in response to the traumas of postnatal life, we develop a split structure that he described as the schizoid position. this refers to the primary structuring of the personality. if the schizoid position develops to an extreme extent (gomez, 1997, p. 66), it may become the schizoid personality. for r. klein (1995, pp. 40–41), the condition occurs during the rapprochement phase of development. he stated that schizoid personalities are aware of the two sides of their dilemma, thus indicating a certain degree of psychological separateness. they are also aware of the difference between external reality and their internal world, which, as r. klein stated, reflects difficulties emanating from the rapprochement stage (mahler et al., 1971/1975). however, my experience is that more severely withdrawn and introverted schizoid personalities do not seem to experience the two sides of the dilemma as r. klein described it. they seem to only occupy the nonattachment side. it is as though they have relinquished any desire for attachment. in this way, r. klein’s notion that the schizoid develops at the rapprochement phase does not account for my clinical experience of working with schizoid personalities with whom there seems to be evidence of earlier trauma and relationship failings. i agree with kernberg and his colleagues, who suggested that schizoid personalities, like other personality disorders (clarkin et al., 2006), rely on more primitive defense mechanisms (e.g., projective identification), which suggests an early developmental struggle/failure. in light of this, it may be that r. klein was describing more integrated personalities. structure of the mind many of my schizoid clients have felt safest when they are at home, with solid walls around them for protection. as children they would frequently withdraw to their bedrooms, or somewhere similar, to feel safe, often playing on their own. for example, nicola worked as a doctor and was proud of her care for her patients. this care was something that she did not receive from her parents when she was a child. her mother was cruel, violent, and unpredictable. as an adult, nicola was phobic about socializing with people. she also located the cruel object of her childhood in animals and was fearful of them. she hated dogs and would not go near them, particularly if they were not on a leash. she viewed them international journal of integrative psychotherapy, vol. 11, 2020 33 as unpredictable and vicious. as a result, she would not go into her local park unless she was accompanied by her husband. nicola’s withdrawn state of being in exile was linked to her experience of a cruel and unpredictable mother. my countertransference picture of nicola’s childhood was of her in a cot terrified of the world around her as represented by her mother. marye o’reilly-knapp (2001), who was also on the 2000 panel in san francisco with me and richard erskine, described the schizoid individual as an encapsulated self “hidden from the world and even from himself or herself” (p. 44). she saw the schizoid’s withdrawal as an “autistic encapsulation [that is] the psyche’s most primitive form of organization and the earliest form of withdrawal” (p. 46). if the person’s experience as a child and the idea of closeness to others as an adult does not involve the internalization of a caring relationship, and instead is experienced as some kind of “master-slave” relationship ®. klein, 1995), this often results in an internalization of a bad object relationship as described by fairbairn (1952). he saw the good object internalized as memory, whereas the bad object relationship is internalized in a much more vital and fundamental sense than memory alone (as cited in guntrip, 1968, pp. 21–22). perhaps what fairbairn was referring to was that a good object is experienced as benign, whereas a bad object is experienced more intensely and as profoundly charged with affect and frustrated needs. r. klein (1995) used the term schizoid from the perspective of masterson (1988) to describe a further disorder of the self (in addition to borderline and narcissistic personality disorders). in taking an object relations view, klein saw the schizoid as either in a self-object relational unit as a slave attached to a master or as a self-in-exile fearful of a sadistic object. this view of the person’s internal world represents a split structure. some schizoid personalities may perceive the master/slave unit as more acceptable than being in exile and therefore attach to others at a cost to themselves; other schizoid personalities may prefer withdrawal and fantasies to that of being closer, which is felt as more threatening. for the withdrawn schizoid, fantasy serves to maintain some sort of link to the world of relationships when actual people and reality are intolerable. fantasy can be fulfilled by novels, films, pornography, and gaming, all of which can stimulate fantasy relationships (manfield, 1992). as children, such individuals may live, through fantasy, in the world of the stories they read and may imagine themselves playing a part in the adventures of international journal of integrative psychotherapy, vol. 11, 2020 34 the characters. they come to inhabit their fantasies. this is a more extreme version of what most children do and serves the function, as previously mentioned, of maintaining some link to the world of relationships. the fear of being in exile, with its experience of isolation and nothingness, may be avoided by maintaining a “tie to the bad object” (seinfeld, 1993, p. 65). fairbairn (1952) described these ties as “the libidinal bonds whereby the patient is attached to these hitherto indispensable bad objects” (p. 74). further, grotstein(1994) depicted this as “the unwavering loyalty that schizoids maintain towards their objects” (p. 116). the schizoid personality’s connection to the external world is usually superficial. they have withdrawn from the outer world and are living in an internal world of fantasy. however, by maintaining a relationship with the bad object, schizoid individuals keep in touch with the world, protecting themselves against a flight from reality and decent into nothingness. guntrip (1994) suggested that the individual preserves the ego by “taking refuge in internal badobject phantasies of a persecutory or accusatory kind” (p. 164). considering all of this, r. klein’s (1995) description of the withdrawn position as nonattachment may not be strictly true. withdrawal from the world of potential real-life attachments to an internal world may be a retreat to a position where attachments of a sort are maintained. the internal world of bad object relations consists of attachments, albeit to a bad object. this internal world is a world of attachments in a similar way that external relations constitute attachments. to live in this internal world is to occupy a world of relationships rather than an objectless/relationshipless world. i am suggesting that the nonattachment position r. klein described can also be seen as consisting of no external relationships but instead a retreat to an internal phantasy world of attachments that, to some extent, can be controlled. case study: a beautiful mind this process of internal attachments was brought home to me dramatically by the film a beautiful mind (howard, 2001), in which russell crowe plays the part of nobel prize winner and mathematician john nash. i will use this film and the biography it is based on to illustrate the schizoid withdrawn state and the internal world with its relational schemas and its defenses against objectlessness and the black hole of nothingness. in the film, nash initially comes across as withdrawn and obsessed with patterns and numbers. he is seen as strange by his fellow doctoral students, international journal of integrative psychotherapy, vol. 11, 2020 35 from whom he is socially isolated. they describe him as aloof, without affect, detached, and isolated. “he’s not one of us,” one of them was reported to have said (nasar, 1998, p. 13). in the film, nash has an exuberant roommate, charles, who appears to be everything nash is not. charles is heard to suggest that they get a pizza: “you know, food!” charles appears outgoing and interested in alcohol and women. at one point, charles asks nash about friends. nash replies, “i don’t much like people, and they don’t much like me.” nash fights with charles in his room, pushing a table to and fro, which charles pushes out of the window. in another scene, nash is sitting on the roof of the building chatting to charles and shouting at students below. there is a point later in the film when nash is helping the military solve a code-breaking problem and catches sight of someone watching him from the balcony. he calls that person “big brother.” the person later identifies himself as william and behaves with authority, telling nash he will arrange for nash to have top secret clearance to continue the work. later in the film, when nash tells william he needs to resign because his wife is pregnant, william responds by saying, “i told you attachments are dangerous.” what eventually becomes apparent is that charles and william are visual and auditory hallucinations and part of nash’s internal world of attachments. some of them are punitive and some more amiable. one of the things the film demonstrates is that nash’s life appears as an illusion with occasional excursions into reality. there seems to be a tension for nash between rational and irrational thinking. later in life, he considered that his “dream-like delusional hypotheses” (nash, 1994, para. 27) had been irrational. he went on to say that “one aspect of this is that rationality of thought imposes a limit on a person’s concept of his relation to the cosmos” (para 29). nash, age 31years, having worked for 10 years as a brilliant theoretical mathematician, is diagnosed as suffering from paranoid schizophrenia after having a breakdown. charles turns up again in the film, greeting nash with a hug. charles is accompanied by his niece, who expresses feelings with nash, something he does not seem to experience a great deal. she seems to be the repository of nash’s unexpressed affect. as nash later moves into remission, he realizes that, although he continues to see her over many years, she does not age. these characters are externalizations of nash’s internal world, his world of attachments and containers for his disavowed affect, attachments that, i suggest, are preferable to the black hole of nothingness. nash’s internal world is also a world of patterns and numbers, which is where he seems to feel safe and at home. international journal of integrative psychotherapy, vol. 11, 2020 36 when nash was a child, his parents were worried about him. he had a lack of childish pursuits and friends (nasar 1998, p. 32). according to his sister, he wanted to do things his own way. other children thought him weird and bullied or just tolerated him (p. 36). it seems that he learned to “armor himself against rejection by adopting a hard shell of indifference and using his superior intelligence to strike back” (pp. 37–38). nash used his superiority, standoffishness, and occasional cruelty to manage his loneliness, thus maintaining his self-esteem (p. 38). nasar, in her biography of nash, described some of those schizoid personalities who are brilliant scientists and thinkers from whom society benefits but who are strange and solitary, such albert einstein, isaac newton, immanuel kant, ludwig wittgenstein, and rené descartes. she draws on the writing of anthony storr, a british psychiatrist and psychoanalyst, who wrote that the schizoid state is characterized by a sense of meaninglessness and futility. creative activity is a particularly apt way to express himself … the activity is solitary … (but) the ability to create and the productions which result from such ability are generally regarded as possessing value by our society. (nasar, 1998, pp. 15–16). the schizoid’s experience schizoid personalities function at a borderline level of personality organization (kernberg, 1984), a position between neurotic and psychotic. this level of functioning suggests that they have not managed to individuate and integrate sufficiently. these individuals often suffer as a result of poor interpersonal ego boundaries. kernberg saw the schizoid personality disorder, with other personality disorders in this category, as having a poorly integrated sense of self and subsequent confusion about personal identity. these individuals have a predominance of and reliance on primary defenses (mcwilliams, 1994), primitive object relations (kernberg, 1984), and early persecutory anxieties associated with the paranoid-schizoid position (m. klein, 1946/1975). on entering therapy, an individual with a schizoid presentation will probably feel anxious as a result of projecting either a sadistic object or the master-object representation onto the therapist. alternatively, through projective identification, the person may locate the self in the therapist and inhabit the object aspect of the relational units. international journal of integrative psychotherapy, vol. 11, 2020 37 the various theories just discussed and my description of schizoid processes and personalities emerge from clinical experience. what is being discussed here are those individuals who present for therapy with these characteristics and who are struggling in some way. usually, they are seeking more contact and closeness but are fearful at the same time. there are also many people who could be described as having a schizoid personality who do not experience any tension and are content with their lives. i think of the schizoid personality structure as having developed as a defense and as a means of managing early experiences of trauma or developmental deficit and rupture. i see their internal world as consisting of a split structure that has come about as a result of failures in bonding and attachment. the infant retreats inwardly, maintaining a more superficial relationship with attachment figures. seinfeld (1996, p. 78), citing r. d. laing, wrote that in human development there is a polarity between separateness and relatedness, both of which represent profound human needs. the person with a schizoid personality experiences this process in a more extreme way. they are usually highly anxious, with the fear of closeness being experienced as a fear of dependency or a fear of merging with a subsequent loss of a sense of self. separation may be experienced as isolation or being in exile. both positions are experienced as frightening. thus, nowhere feels safe for the schizoid individual. this is in contrast to the narcissist, who feels safe when merged with an idealized object, or the borderline, who feels safe when clinging and merging with a rewarding object. withdrawal: home base everything starts and ends at home any description of a schizoid presentation will include the characteristics of withdrawal, self-sufficiency, detachment, aloofness, and lack of affect. withdrawal is often the home position of the schizoid individual. r. klein (1995) described this as a nonattachment position and mcwilliams (1994, p. 100) as a primitive defense. it is where schizoid personalities seem to spend most of their time and also how people often think of them. withdrawal into a different state of consciousness is an automatic, selfprotective behavior that can be observed in infants. the same can be seen in international journal of integrative psychotherapy, vol. 11, 2020 38 adults who may retreat from others to their internal world of fantasy. some infants’ temperament may lead them be more inclined to withdraw, and there is some suggestion that they may be particularly sensitive (mcwilliams, 1994, p. 100). for example, i often see a certain man who lives in our locality walking around the streets. he wears the same clothes most of the year, and his unkempt beard gives him a medieval appearance. i have never seen him with anyone. we nod at each other as we pass, occasionally exchanging a polite greeting. i make a point of saying hello, but nothing more is said. he walks on, not really looking at people. he buys his lunch at a local shop and then eats it sitting on a park bench. he does not appear to work. my fantasy is this is the sum of his life, that this is how he spends his time. i cannot imagine that he has ever had a relationship in his adult life. the appearance i am describing might be thought of as a more extreme withdrawn schizoid presentation. i doubt that he and others like him would seek out therapy. he may not even be uncomfortable with the way he is. his position may be a result of how he negotiated early-life experiences and his relationship with his caretakers (r. klein, 1995). his is a severe, introverted schizoid presentation, functioning in isolation, living in the citadel of his mind, perhaps living in imagination rather than in the external world with its possibility of relationships. the dread of relationships with the possibility of being smothered, suffocated, possessed, imprisoned, or absorbed (guntrip, 1994, p. 166) feels claustrophobic. this extreme schizoid withdrawal was described by guntrip (1968) as follows: womb fantasies and/or the passive wish to die represent the extreme schizoid reaction, the ultimate regression, and it is the more common, mild characteristics which show the extraordinary prevalence of schizoid, i.e. detached or withdrawn, states of mind. (p. 58) in considering these disorders, the description and behavioral elements need to be combined with a phenomenological and intrapsychic analysis in order to fully understand and possibly diagnose a schizoid personality disorder. returning to erskine’s (2020) work with violet, he initially focused on her withdrawal behavior, commonly exhibited by schizoid personalities. she was, for him, confusing and, at times, difficult. he described how in his work with her, he learned about relational withdrawal and the significance of attunement, particularly to silence, in psychotherapy (p. 14). violet’s internal world emerged early in her meetings with erskine when she described how “her husband international journal of integrative psychotherapy, vol. 11, 2020 39 alternated between ignoring her and controlling her” (p. 15). this also echoed her relationship with her mother. her comments about her husband were probably a transference projection of that internal world as well as the reality of her experience with her husband. that was a point at which her internal and external worlds came together. her experience of her husband became a hook on which she could hang her projections and probably represented the object from which violet withdrew. in my 2001 article, i wrote about sebastian, who usually started a session by saying something placatory that we could talk about but that did not reveal his vulnerability. sessions seemed to be isolated experiences for him, without continuity. he often seemed to have forgotten the previous session, having wiped it out: sebastian often withdraws and seems to be watching me. it is as if he is on the inside of his head looking out of his eyes watching my every move. he has described having retreated into a castle, staying in the dungeon where he feels safe. he leaves a guard on duty. the drawbridge is down but can be raised at any time. if i see an expression of emotion on his face and respond, he is moved at having been seen but feels he cannot call out. he feels it would be dangerous and frightening to do so. sebastian has retreated from the world and is detached from interpersonal relations. he has numbed his emotional responses to people and events. (little, 2001, p. 35) more extreme introverted schizoid personalities occupy what r. klein (1995) described as “the safe place or haven, the impenetrable fortress, and the point of no return” (p. 55). the citadel is a womb-like state free from demands or attacks, with no need to adapt (little, 2001, p. 38). the person is unlikely to experience any ambivalence about relationships. on the other hand, those schizoids with milder characteristics are more likely to want relationships with others. perhaps there is a continuum for those with schizoid personality: at one end, more integrated individuals and, at the other, more severe presentations. when thinking about schizoid individuals’ ambivalence about attachment— craving closeness yet fearing engulfment, seeking distance but complaining of loneliness (mcwilliams, 1994, p. 193)—i distinguish between these two aspects of ambivalence and the kind where withdrawal is more profound and individuals retreat into fantasy and their internal world. i refer to the latter as an “introverted regressed schizoid” (guntrip, 1968, p. 42), someone who does without relationships. international journal of integrative psychotherapy, vol. 11, 2020 40 maintaining withdrawal: attacks on the link withdrawal is both a behavioral process and a psychological strategy of retreating into fantasy and imagination and detaching from external reality and relationships. this entails withdrawing into an internal closed system to escape the dangers of engaging with the external world. over time, a schizoid client may establish a psychological and emotional link with a therapist, one that may be experienced as a threat or as dangerous. as a result, the person’s internal bad object relationship may attack the links to the therapist because the clinician represents a threatening external reality. this defensive process reinforces the client’s isolation. the closed psychic system, with its bad object, impedes the relational-seeking aspect of the personality. this is akin to fairbairn’s notion of the client remaining loyal to the bad object. for his part, bion (1967) described how the psychotic mind attacks the perceptual apparatus that links it to the object. i have experienced less severe attacks on the link between myself and a client as part of a schizoid defensive stance. for example, justine, on leaving a session, would sometimes say things to herself such as, “did you see how he took your money at the end of the session? he’s so greedy. all he wants is your money. you’re just a cash cow for him. you shouldn’t trust him.” this was an attack on her emerging link with me. this demonstrates how the desire to attach and connect may be prevented by the antirelational unit attacking the link between the client and the therapist as the needed object/other by devaluing and belittling the therapist. this kind of postsession attack usually occurred when justine had shifted in her position, taken a risk, and revealed more of herself to me. the attack was typical of the nonattachment, antirelational side of her personality and her attitude of not relying on others. the internal attacks would often leave her isolated and alone between sessions. at such times, she had destroyed the cocreated new relational unit. after such self-talk, when justine arrived at her next session, she was often wary of and less likely to trust me. i watched for this behavior and experienced it as “one step forward, two steps back.” the antirelational self will attack the relational-seeking self’s links to its attachment objects/others. these rejecting behaviors often echo the original caregiver’s response toward the person’s infantile dependency needs (seinfeld, 1991, p. 73). enforced withdrawal during lockdown international journal of integrative psychotherapy, vol. 11, 2020 41 writing this article in may 2020 during the lockdown resulting from the covid-19 pandemic highlights and affects my experience and understanding of these processes. when i venture out to the supermarket, i experience an increase in anxiety. i walk down the road wary of an unseen threat. another person becomes a threatening enemy who may be carrying a deadly disease. going around the supermarket picking up groceries i notice how watchful and anxious i am as other shoppers come close to me. there is an induced paranoia. it is not until i return home that i begin to relax. i can imagine that this is not dissimilar to what less anxious schizoid personalities experience much of the time when they are out among people, anticipating an attack and withdrawing to protect themselves from danger. for some, the experience is even more extreme, and it is appropriate to talk of terrors and horrors and fear of mutilation: a world occupied by monsters. the difference for me during the pandemic is that my withdrawal is not something i chose but something that was imposed on me and is not my preference. yet the danger is real. needing to withdraw and isolate from face-to-face contact with clients, colleagues, and friends when personal contact involves the risk of catching a lifethreatening virus has given me a perverted sort of empathy for the schizoid personality! listening to clients and talking to supervisees these days, i realized that being in lockdown suits some people more than others, depending on their characterological structures. another lockdown experience that spoke to the defense of withdrawal was something i noticed while working with clients remotely. because of the isolation that i experienced, and the lack of contact with colleagues and friends, i had a growing desire to be friendlier with clients than i would be normally. i felt the impulse to reveal more personal circumstances and experiences that had nothing directly to do with the therapy. i would end the session by saying, “i’ll see you next week,” which is something i would not ordinarily say. what i understood was that my need for attachment, connection, and contact was emerging as a desire to self-disclose as a result of my disconnection from friends and colleagues. it was also triggered by the abrupt end to the session. the process highlighted for me that, in a nonattached state— in this case imposed by circumstances—the need to connect was emerging and fighting to be met. i was thereby running the risk of a boundary crossing (little, 2020) and a loss of my therapeutic frame. countertransference reactions international journal of integrative psychotherapy, vol. 11, 2020 42 returning to erskine (2020), he wondered whether he had been caught in a countertransference reaction with violet through the methods he was using to treat her, which he appropriately discussed in supervision. the supervisor reiterated what erskine had already been doing and did not address his lack of attunement to violet, including during her long silences. erskine began wondering what was missing in the therapeutic relationship (p. 16) and stated that he “felt inadequate” (p. 17). one aspect of erskine’s countertransference was that he wanted something to happen in the therapy, so he focused on expressive methods, cognitive understanding, and behavior change. in my own work, sometimes my countertransference reaction to a schizoid client who has withdrawn has been that i want to “shake them up” and have them engage more with me. i can find it difficult to stay involved with someone who lacks affect and is self-sufficient and self-reliant. as therapists, with such individuals we can often feel useless or superfluous. other therapists have described the experience of frustration or even abandonment in the face of the client’s lack of lively emotional engagement in the work. on the other hand, i have clients for whom my aliveness can be threatening as if it were a prelude to danger, a sign that i will become an intrusive or dangerous other. one of the things that helps me stay engaged in such situations is understanding the nature of the client’s early trauma. with my client sean, i recall wanting to disclose something of my poor, working-class background, which was very similar to his. i was fond of him and felt a desire to verbalize my warm feelings. it was difficult to sit with him session after session with his affectless presentation. at times i had the fantasy that expressing my feelings with him would somehow bring him alive, breathe life into his lungs. however, in fact, my presence was threatening to him. as described earlier, countertransference reactions may include feeling tender while also struggling with how to connect and form a therapeutic alliance as well as to understand the client’s inner world without evoking too much anxiety or becoming too detached. the danger is in treating the client as an object of interest instead of as someone wrestling with a dilemma with its dual anxieties and helping them make meaning of their experience. schizoid dilemma my clinical experience is that those schizoid personalities who present for therapy often experience a dilemma (fairbairn, 1952; guntrip, 1968) with which they are international journal of integrative psychotherapy, vol. 11, 2020 43 struggling. on the one hand, the person wants connection and closeness but fears feeling unsafe, even entrapped; on the other, they want to withdraw and retreat into exile to feel safe with the accompanying experience of isolation and aloneness. manfield (1992) movingly described this process as “too distant from people, he believes he will disintegrate, dissolve into oblivion, vaporize, be lost. [but] … too close to someone, he is afraid of being co-opted, used, swallowed up, devoured, totally appropriated” (p. 215). this process also demonstrates a tension between the needed relationship— that is, the desire for closeness—and the repeated relationship (little, 2011) with its fear of retraumatization. working as i do in the here and now of the transference-countertransference relationship entails the therapist being both the longed for attachment object and the feared object. the more the therapist represents the longed for other, the more he or she will be feared as the process begins to trigger memories of early traumatic experience. as the client allows the need for contact to emerge, they may also experience the fear of retraumatization and the expectation that the therapist will let them down. thus, the therapeutic paradox is that the more the needs emerge, the more the fear of retraumatization is stirred. in the initial stages of therapy, the client has no idea that the therapist is going to be any different from those who were previously retraumatizing for them. this represents a transference expectation. the therapist’s stance when working with these presentations should include an understanding of this dilemma and the associated relational impasse (little, 2011). this understanding may be offered to the client as an interpretation. for example, the therapist might say, “on the one hand (you have an anxiety about getting close), and on the other … (you are anxious about being isolated).” being close means the schizoid has to face the fact that they cannot control the other and that being involved in relationships runs the risk of being rejected, attacked, and/or experiencing pain. some people prefer isolation rather than engaging with this process. for example, as a child, marcia retreated to her room to avoid the demands of her parents, whom she described as misattuned and not interested in her, only in her older sister. as an adult, marcia preferred being on her own, but her job required her to do certain things for people. this meant she had to leave the safety of her womb-like state, which echoed her childhood bedroom. in doing so, she had to encounter the world that she hated. in her therapy, her infant needs emerged, and she wanted her therapist to be perfectly attuned to her. she international journal of integrative psychotherapy, vol. 11, 2020 44 unconsciously wanted to incorporate him into her safe, womb-like space and have him be devoted to her, thus protecting her from disappointment, pain, and separation. for the schizoid individual, every place and every experience is fraught with anxiety, whether that is being with people or being alone. being self-reliant avoids the problem of having to rely on or be dependent on another, but it can leave the individual having to do everything themselves and having no significant social contact. the dilemma can be described as an experience between an antirelational self and a relational-seeking self (little, 2001; seinfeld, 1991). attending to the behavioral manifestations of the dilemma often highlights the person’s own split internal personality structure, and the manner in which they experience others represents a transference projection. erskine (2020) described violet as “unconsciously looking for interpersonal connection and simultaneously fearing any human closeness” (p. 22). the relational-seeking self desires connection, whereas the antirelational self wants to prevent that from happening. he described how violet’s “social self” has achieved some relational security by accommodating to the requirements of significant others, whereas her “vital and vulnerable self” remains “protectively internal” (pp. 18–19). erskine made a note to himself “to respect her silences, to support her withdrawal, and to create a safe place for the deeply repressed to express herself” (p. 20). he wondered if he “thought of violet’s silence and withdrawal as her attempt to protect a vital and vulnerable aspect of herself” (p. 20). he understood that her “polite, proper, and superficial presentation as a social façade had at least two important functions: protection and attachment” (p. 20). schizoid compromise in common with erskine, i (little, 2012) admire the writings of guntrip and his descriptions of working with clients who have withdrawn from relationship into a “schizoid compromise” (guntrip, 1968, p. 58). that phrase describes what the client is trying to deal with psychologically, and the compromise indicates how they are managing the dilemma, that is, finding a middle ground between the two anxieties. erskine (2020) described wondering how he might make sense of his client’s “superficial stories, the lack of interpersonal contact, and the absence of any vitality, emotions, or vulnerability” (p. 18). he saw violet as “someone who international journal of integrative psychotherapy, vol. 11, 2020 45 learned to hide her vitality and vulnerability,” who had “created a social façade (i.e., a false self) in order to maintain some form of relational attachment” (p. 19). previously, i (little, 2001, p. 39) discussed how retreating from contact leaves the individual isolated, lonely, and in pain. some schizoid personalities may attempt to avoid the pain through “workaholism, intellectualization and other distancing defences” (manfield, 1992, p. 205). in some cases, the longing for contact will reemerge, and the person may want to move toward others; however, such movement also brings with it the anxiety of being close with its sense of being entrapped. guntrip (1968) described this as the “in and out program” (p. 36), an expression of the hunger for and terror of contact and closeness, caught between the need and fears of close personal connection. they are driven “in” by their needs and driven “out” by their fears. some individuals manage this dilemma by establishing the schizoid “compromise in a half-way house position” (guntrip, 1994, p. 166). this is a way of keeping others around but preventing them from getting too close or becoming endangered by them. this may, for example, be achieved by maintaining contact at an intellectual level or by being present physically but absent emotionally. more often than not, relationships are kept emotionally neutral, an approach that undermines the possibility of forming friendships and romantic relationships. in the united kingdom there is an attitude known as the “stiff upper lip,” a cultural endorsement of the expression of the compromise that enables people to stay socially connected while hiding their emotions. many “polite” behaviors in certain cultures are also an expression of the same compromise, one that is, in essence, a defensive position between the two fears of isolation, on the one hand, and enslavement or merging/fusing, on the other. the question for the individual is, “how do i keep people around without getting too close or being alone?” the compromise is a remedy to the oscillation of the in-and-out program, but the individual does not give themselves to anyone or anything fully. therapy of the compromise: the therapist’s stance the initial therapeutic task with schizoid clients is to create sufficient safety (r. klein, 1995; little, 2001; o’reilly-knapp, 2001), including a containing, holding environment that is both nonwounding and unobtrusive and that creates an opportunity for the hidden, vulnerable, relational-seeking self to reemerge. the therapist needs to be curious regarding why the person went into hiding, what their terror is about, and the nature of the defenses involved. in addition, it is important to comprehend how attempts at contact by the therapist may be international journal of integrative psychotherapy, vol. 11, 2020 46 experienced by the client as intrusive and frightening. for example, in the work with violet described by erskine (2020), she was afraid to “go internal” in front of anyone because “what i have inside is private. no one can know it … my quiet hiding place. it has been my private place, all my life” (p. 21). the therapist needs to demonstrate an understanding of the schizoid dilemma and compromise and offer an attuned interpretation. in the inevitable push and pull of therapy, the therapist should try, as much as possible, not to behave as either a master or a sadistic object/other. ware (1983) encouraged us to go slowly: “it must be remembered that the cure of schizoids is a slow, painstaking process, taking only small steps at a time” (p. 15). i believe that we need to wait outside the “cave” until the person appears or invites us in. what may help them emerge from their particular cave is maintaining the clinical frame and boundaries, which will enable them to begin to feel safe from engulfment or intrusion. going in after them may repeat the experience of an intrusive caregiver/other. to establish safety for the client, i occasionally agree to a schedule that begins with meeting every other week and then, after some time, moving to weekly. in my consulting room, i have three sofas, and the client can sit wherever they choose so they can feel safe enough. the therapist needs to attend to variations in the client’s capacity to be present in whatever way they can manage. when a client does withdraw after having been more in contact, i wonder what went on that they became more withdrawn, which is often beneficial to interpret and discuss with them. schizoid clients generally begin treatment feeling anxious. during the therapy, this anxiety may be further triggered by moves toward the therapist and/or vice versa. these clients are sensitive to and impacted by changes in the therapist’s mood, demeanor, and/or behavior. in fact, the client’s withdrawal may well be triggered by the therapist’s behavior. for r. klein (1995, p. 71), therapy is oriented toward reality, which thereby disrupts transference expectations. in my view, this disruption results from a cocreated relational experience. erskine noted that both guntrip and winnicott encouraged a psychotherapy that focuses on the client’s internal processes and not specifically on cognitive insight or behavioral outcome, “a psychotherapy that provides a healing relationship to a traumatized and fragmented client (winnicott, 1965)” (erskine, 2020, p. 19). from a relational transactional analysis perspective, therapeutic action needs to entail working in the here and now of the therapeutic relationship in which the therapist is experienced as both an old object and a cocreated new object working directly with both relational units in the transference-countertransference international journal of integrative psychotherapy, vol. 11, 2020 47 relationship. the client’s experience of the transference expectations reinforces their withdrawal from relationships. this is the nature of unconsciously engaging in psychological games and enactments. as the therapist and client begin to develop a therapeutic alliance, the new cocreated self-other relational unit develops. for the client, this is a new lens through which to view and experience the world in contrast to their internal structure, which is projected onto the world of relationships. if the client begins to feel safe enough in the therapeutic relationship, they are more likely to experiment with taking risks with the therapist, such as sharing thoughts and feelings more freely. the nature of the client’s compromise changes through their experiments. for example, lizzie, a woman in her late thirties who has always been independent and self-assured, came to see me because she felt there was something vaguely wrong. she did not trust anyone and could not recall ever doing so. but some things she had read recently led her to wonder if there was something wrong with that. the only contact she had with people was as the manager of an education service. from what she said, it seemed she could be helpful to those for whom she was responsible but without really feeling for them because she had no real emotional relationships. she found it difficult sitting with me because the familiar roles of helper and helped had been reversed, and she was the one requiring help. her compromise position had always consisted of being helpful. any time i showed more than a bland presentation, lizzie would complain of being intruded on. over many years, in which i felt i had to sit patiently waiting for her to emerge, she began to tell me her early story of deprivation from an uncontained and intrusive caregiver. she gradually moved from her isolation, withdrawal, and a compromise position of being helpful and responsible for others to one in which i as her therapist became the one person who knew her story with its accompanying feelings. i felt that we had begun to cocreate a precious new narrative. with another client who began expressing more of her feelings, fantasies, and inner world, it seemed she was experimenting with expressing previously repressed feelings and in so doing shifting her compromise position. she could justify her new behavior on the grounds that as a therapist, i was a professional and therefore different from others. this enabled her to change while remaining the same, thus maintaining her compromise of not revealing her emotions to the world. however, we could also see that she was nullifying me to some degree. international journal of integrative psychotherapy, vol. 11, 2020 48 as therapists working with these presentations, we need to be wary of being excessively devoted to having our clients establish closeness, intimacy, and attachment to us or others in their lives, as if intimacy is a defining feature of psychological health and well-being. we might wonder if attachment is being fetishized, to quote a colleague, while acknowledging that to connect is a human need. dissociation dissociation is, in essence, disconnection from unintegrated states. one type of dissociation is depersonalization (a feeling that one is not in one’s own body and is disconnected from one’s sense of self), which guntrip (1968, pp. 41–44) listed as a characteristic of the schizoid. being disconnected from aspects of the self is a major defense of schizoid personalities. living in their heads, with apparently little relationship with their emotions, is a common mode of being, as if there is a cutoff or blockage between their hearts and their heads that prevents any communication between the two. dissociation is commonly used to protect the self from aspects that are felt to endanger existence or that are too painful to engage with. dissociation maintains the split internal structure, and the therapeutic goal in such cases could be described as moving from segregation and disconnection to association and integration. o’reilly-knapp (2001) highlighted how schizoids use dissociation to “protect the continuity of existence” (p. 45). aloof from the crowd under stress, schizoid personalities may withdraw either temporarily or permanently from their own affect as well as from external stimulation (mcwilliams, 1994, p. 192). internal dissociation from affect can manifest behaviorally as aloofness, with the individual seeming to look down on others. these individuals appear to hold others in contempt and disdain, on occasions patronizing them while fearing being patronized. this is an expression of the internal saboteur (fairbairn, 1952) who rejects the need of others. they appear to be proud of being independent and self-reliant (r. klein, 1995, p. 57). in such cases, the therapist’s countertransference reactions may include feelings of inferiority because of having an emotional response to the client. the tendency of the client to behave in an aloof manner may have its origins in the relationship with primary caregivers who were overcontrolling or overintrusive international journal of integrative psychotherapy, vol. 11, 2020 49 (mcwilliams, 1994, p. 195), although usually the main fear driving their behavior is of engulfment rather than abandonment. for example, many years ago i worked with a man who appeared quite aloof and superior. initially i thought him quite engaging, but over time i began to feel a strong desire to attack him and penetrate his defenses, even to subjugate him in some way. i felt quite aggressive toward him and wanted to show him how he was making things worse for himself. i arrogantly felt i knew better than he did. after some time and reflection, i realized that he had disconnected from any intense feelings. he could talk politely with me about emotions, but he dissociated from his more intense feelings. in discussion with my supervisor, i came to see that, through projective identification, i was experiencing the intense feelings with which he could not allow himself to connect. therapist’s defensive compromise lastly, i want to address a defensive position that therapists themselves may occupy: a schizoid compromise position, not a countertransference reaction. schizoid individuals can be very sensitive to other people and often bury their aggression. as mcwilliams (1994, p. 196) wrote, schizoid personalities are able to care about others while maintaining a protective stance (as was the case with lizzie as described earlier), and some even pursue careers in psychotherapy. in citing wheelis, mcwilliams described how people with a “core conflict over closeness and distance” may take up the profession of psychotherapy because it “offers the opportunity to know others more intimately than anyone else ever will, while concealing the self” (p. 196). for instance, therapy sessions are time limited. therefore, at an emotional level, the therapist knows that whatever may go on and emerge in the session, it will end at a given time. potentially, this time boundary permits the therapist to hide their own emotional response. in my experience as a supervisor, i have noticed that some therapists can avoid certain feelings or experiences by not commenting on them or by behaving in a particular manner that conveys the message that certain feelings do not have a place in therapy and therefore will not be addressed. an example would be the therapist who, every time sexual feelings enter the conversation, changes the subject. we all have our blind spots, but most of these are never examined. the therapist can “coast in the countertransference” (hirsch, 2008) and thereby avoid disrupting the therapy, which would otherwise involve moving out of the safety zone of the “compromise” and disrupting the transference-countertransference relationship. it is as if the international journal of integrative psychotherapy, vol. 11, 2020 50 therapist’s “[f]eelings can be identified and utilized interpersonally, although in a limited and circumscribed fashion” (r. klein, 1995, p. 56). working as a psychotherapist can in itself be a compromise position for some. during the pandemic, working remotely has suited some therapists and clients. they feel more at ease. hirsch (2008), citing buechler, described how therapists with schizoid qualities may be inclined toward retreating emotionally, especially with clients who are also comfortable with emotional distance. the therapy may then become politely inactive. in my view, therapy should help the client enrich their lives and not be an alternative for life. for some therapists, technique is often seen as the main method for facilitating the client’s integration and growth. thus, a further compromise for the therapist can be to use various techniques with the client while remaining affectively uninvolved. the therapist in a compromise position may not push themselves or the client beyond “states of comfortable equilibrium to states of disruption and surprise” (hirsch, 2008, p. 65). for some clinicians, the work of therapy provides some affective engagement in relationship while still maintaining emotional safety. in fact, schizoid personalities may “gravitate to careers in psychotherapy, where they put their exquisite sensitivity to use safely in the service of others” (mcwilliams, 1994, p. 196). having said that, it is important to bear in mind that most therapists have a course of therapy during their training and will have engaged in reading, supervision, and self-analysis. as a result, they should have developed a narrative that explains what happened to them as a child. managing to reconcile childhood experience in therapy and understanding the impact the past has on the present allows the possibility of developing an “earned secure” (wallin, 2007, p. 87) attachment style. if the therapist unconsciously retreats to a defensive withdrawal, or compromise position, this may be an indicator of them being under more extreme countertransference stress. therefore, the concerns already expressed here regarding the therapist’s compromise are a warning of the risks for the clinician. conclusion it has been interesting to reread the literature from the past 25 years since i first read and engaged with it and particularly in light of the clinical experience i now international journal of integrative psychotherapy, vol. 11, 2020 51 have. back 25–30 years ago, i had only limited clinical experience with schizoid processes. my first encounter with the literature was with guntrip (1994). as i reread him today, i continue to review my thinking and understanding and to examine my therapeutic approach. guntrip still has a good deal to offer the practitioner who wishes to understand the inner world schizoid individuals occupy. it is easy to overlook schizoid traits in clients, particularly when they are withdrawn, quiet, or enslaved and thus adapted to the other. they are not generally as disturbing to the therapist as borderline and narcissistic characterological presentations. if i think of schizoid processes in contrast to schizoid personality disorder, i no longer see the dilemma as belonging only to the latter. in the 20 years since that conference in san francisco where erskine and i presented, i have come to believe, as some others do (manfield, 1992, p. 204), that the schizoid presentation, with its flight from object relations and its subsequent compromise, is more prevalent and commonplace than we often recognize. references bion. w. k. (1967). second thoughts: selected papers on psychoanalysis. karnac books. clarkin, j. f., yeoman, f. e., & kernberg, o. f. (2006). psychotherapy for borderline personality: focusing on object relations. american psychiatric publishing. daellenbach, c. (ed.). (2001). the schizoid process [theme issue]. transactional analysis journal, 31(1). https://doi.org/10.1177/036215370103100102 eagle, m. (2011). from classical to contemporary psychoanalysis: a critique and integration. routledge. erskine, r. (2020). relational withdrawal, attunement to silence: psychotherapy of the schizoid process. international journal of integrative psychotherapy, 11, 14-29. fairbairn. r. w. d. (1952). psycho-analytic studies of the personality. routledge. gomez, l. (1997). an introduction to object relations. free association books. international journal of integrative psychotherapy, vol. 11, 2020 52 grotstein, j. s. (1994). notes on fairbairn’s metapsychology. in j. s. grotstein & d. b. rinsley (eds.), fairbairn and the origins of object relations (pp. 112–148). free association books. guntrip, h. (1968). schizoid phenomena, object relations and the self. the hogarth press and the institute of psycho-analysis. guntrip, h. (1994). personal relations therapy: the collected papers of h. j. s. guntrip (j. hazell, ed.). jason aronson. hirsch, i. (2008). coasting in the countertransference: conflicts of self interest between analyst and patient. routledge. hossain, a., malkov, m., lee, t., & bhui, k. (2018). ethnic variation in personality disorder: evaluation of 6 years of hospital admissions. british journal psychiatry bulletin, 42(4), 157–161. https://doi.org/10.1192/bjb.2018.31 howard, r. (director). (2001). a beautiful mind. dreamworks. kernberg, o. (1984). severe personality disorders: psychotherapeutic strategies. yale university press. klein, m. (1975). notes on some schizoid mechanisms. in m. klein, envy and gratitude and other works (r. e. money-kyrle, ed.) (pp. 1–24). hogarth press. (original work published 1946) klein, r. (1995). part 1. the self-in-exile: a developmental, self, and object relations approach to the schizoid disorder of the self. in j. f. masterson & r. klein (eds.), disorders of the self: new therapeutic horizons: the masterson approach (ch. 1–7, pp. 3–142). brunner/mazel. little, r. (2001). schizoid processes: working with the defenses of the withdrawn child ego state. transactional analysis journal, 31(1), 33–43. https://doi.org/10.1177/036215370103100105 little, r. (2006). ego state relational units and resistance to change. transactional analysis journal, 36(1), 7–19. https://doi.org/10.1177/036215370603600103 little, r. (2011). impasse clarification within the transference-countertransference matrix. transactional analysis journal, 41(1), 23–28. https://doi.org/10.1177/036215371104100106 little, r. (2012, winter). love made hungry: the schizoid problem. the transactional analyst, 19–22. international journal of integrative psychotherapy, vol. 11, 2020 53 little, r. (2013). the new emerges out of the old. transactional analysis journal, 43(2), 106–121. https://doi.org/10.1177/0362153713499541 little, r. (2020). boundary applications and violations: clinical interpretations in a transference-countertransference-focused psychotherapy. transactional analysis journal, 50(3), 1–15. https://doi.org/10.1080/03621537.2020.1771031 mahler, m., pine, f., & bergman, a. (1975). the psychological birth of the human infant: symbiosis and individuation. maresfield. (original work published 1971) manfield, p. (1992). split self/split object: understanding and treating borderline, narcissistic, and schizoid disorders. jason aronson. masterson. j. f. (1988). the search for the real self: unmasking the personality disorders of our age. the free press. mcgilloway, a., hall, r., lee, t., & bhui, k. (2010). a systematic review of personality disorder, race and ethnicity: prevalence, aetiology and treatment. bmc psychiatry, 10(33). retrieved from http://www.biomedcentral.com/1471244x/10/33 rch article open access mcwilliams, n. (1994). psychoanalytic diagnosis: understanding personality structure in the clinical process. guilford press. nasar, s. (1998). a beautiful mind. faber and faber. nash, j. f., jr. (1994). john f. nash, jr. biographical. retrieved from https://www.nobelprize.org/prizes/economic-sciences/1994/nash/biographical/ newhill, c., shaun, m., & conner, k. (2009). racial differences between african and white americans in the presentation of borderline personality disorder. race and social problems, 1, 87–96. https://doi.org/10.1007/s12552-009-90062 o’reilly-knapp, m. (2001). between two worlds: the encapsulated self. transactional analysis journal, 31(1), 44–54. https://doi.org/10.1177/036215370103100106 piaget, j. (1952). the origins of intelligence in children. international universities press. seinfeld, j. (1991). the empty core: an object relations approach to psychotherapy of the schizoid personality. jason aronson. international journal of integrative psychotherapy, vol. 11, 2020 54 seinfeld, j. (1993). interpreting and holding: the paternal and maternal functions of the psychotherapist. jason aronson. seinfeld, j. (1996). containing rage, terror and despair: an object relations approach to psychotherapy. jason aronson. wallin, d. (2007). attachment in psychotherapy. guilford. ware, p. (1983). personality adaptations (doors to therapy). transactional analysis journal, 13(1), 11–19. https://doi.org/10.1177/036215378301300104 žvelc, g. (2010). relational schemas theory and transactional analysis. transactional analysis journal, 40(1), 8–22. https://doi.org/10.1177/036215371004000103 international journal of integrative psychotherapy, vol. 10, 2019 47 “a tender mother may be there for me!”: forms of vulnerability and relational processes promoting the integration of the self isabella nuboloni abstract developed by richard erskine and his colleagues, integrative psychotherapy (ip) rests on a deeply relational view of the person. the case study presented in this article demonstrates how the application of ip theories and methods facilitates the establishment of a healthy therapist-patient relationship and the implementation of relational processes promoting the healing of the self. the story of stella, a 40year-old woman suffering from a severe form of dissociation, withdrawal, and body armoring, provides a clinical, theoretical, and methodological reflection on how the therapeutic approach of ip as integrated with other theoretical and methodological contributions facilitated her therapeutic process. among these contributions are stern’s fundamental dynamic pentad and levine’s somatic experiencing. keywords: integrative psychotherapy, dissociation, relational needs, contact in relationship, keyhole diagram, vital forms ------------------------------------- working with people suffering with severe psychological disorders has validated my view on the necessity of therapists maintaining a cautious approach when establishing a connection with their patients. evidence shows that traumatic experiences occur in therapy because of interruptions to contact in the relationship (erskine & trautmann, 1996/1997a; levine, 2010; schore, 2003a, 2003b; van der kolk, 2015). the therapist is in charge of reestablishing healthy contact in relationship, which can replace failed relational experiences in the patient’s life so he or she can finally heal. international journal of integrative psychotherapy, vol. 10, 2019 48 integrative psychotherapy (ip) includes complex, coherent theories and methods that promote contact in relationship. a therapist may provide the kind of “therapeutic love” (o’reilly-knapp, 2001b) that the patient needs in order to heal his or her wounds and reintegrate the split-off aspects of the self through the therapist-patient relationship (schore, 2003a, 2003b). this relationship should rely on inquiry, attunement, and involvement (erskine & trautmann, 1996/1997a, p. 25) as shown in figure 1. figure 1. methods of an integrative psychotherapy (erskine & trautmann, 1996/1997a, p. 25) this diagram was later called the keyhole (erskine, moursund, & trautmann, 1999). this visual representation shows “all the facets of a therapy of contact-inrelationship together, in dynamic relationship” (p. 159). a therapist can use the keyhole diagram to identify the patient’s developmental level through countertransference (erskine, 1991) and, as a result, work most effectively. the case study of stella presented in this article offers an example of true therapeutic love, which promoted the healing of one of the most traumatized patients with whom i have worked. the study demonstrates the transformative international journal of integrative psychotherapy, vol. 10, 2019 49 power of contact in relationship and shows that the therapist’s methods (the how) and actions (the what) lead to change in the patient. in the first section, i recount the development of my therapeutic relationship with stella, particularly the relational processes that promoted the (slow) emergence of her traumatic history as well as her vulnerabilities. i describe the settings, contracts, and difficulties in the development of the therapeutic relationship and how i handled my failures in that relationship. in the second section, i offer some clinical and methodological reflections on stella’s script system (erskine, 1980), which allowed stella to self-stabilize her deepest forms of vulnerability. i also introduce the major relational processes that promoted the integration of stella’s self, the interventions that were most effective with her, and the successful implementation of some theoretical and methodological models that are coherent with ip theories. my conclusions emphasize what i learned about the processes that promote psychological change and about the therapist’s responsibility for establishing an authentic relationship with the patient. such a relationship needs to be coconstructed (stolorow & atwood, 1992; stolorow, atwood, & brandchaft, 1994; stolorow, brandchaft, atwood, fosshage, & lachmann, 1999), deeply human, and constantly evolving. beginning and development of the therapeutic relationship it was a warm march morning when i received an unexpected call. “hello? isabella? this is stella. i have called because i would like to do therapy with you.” i was surprised by the determination i sensed in those words. stella was part of a group of couples from a distant city where i used to hold training sessions. however, i had not visited there for more than 2 years and explained to stella that i had stopped working there long before. without hesitation, she answered, “yes, i know you have not been here for 2 years, but i also know you hold sessions on skype.” once again, her determination caught me unaware. after explaining to her how difficult it is to do therapy in that way, i felt that i had to have at least one meeting with her to help her find a therapist in her city. during our first online meeting, stella told me that she had been experiencing a period of deep confusion. she told me her life story, which was marked by physical and sexual violence that had started before she was 3 years old. at the time of our conversation, stella was 40, the third of four daughters, and married with five children. she was feeling profoundly inadequate as a mother, was suffering from various diseases, and had miraculously survived a heart attack after the birth of her last daughter. stella timidly revealed that she had suicidal fantasies. she told me about arguments with her husband that often culminated in screaming international journal of integrative psychotherapy, vol. 10, 2019 50 and beatings that she passively endured. she told me that she had previously done therapy at a state-owned counseling center. however, she was never able to speak in front of “those psychologists with a stern look”; they made her “freeze.” i asked her what had made her think of me as her therapist, and she replied, “your voice, your kind manner, your sensitivity, and your great calm. i know you are talented, but i felt good because of the way you looked at me and smiled first!” i faced an ethical issue: could i send a suffering person who had just found the relational style she needed to another professional? my body-centered countertransference allowed me to understand that stella was a little girl, perhaps about 3 years old, abandoned and lost, and she was trying to cling to me with all her strength. this child was vital, sensitive, intuitive, and had a bundle of unmet needs. how could i refuse her request for help? how would she take my refusal? too many questions came to my mind. on the one hand, theories on therapeutic love were throwing me a challenge. indeed, i was frightened by the high level of flexibility, engagement, and creativity that i felt were necessary to work with stella. i felt called, like never before, to express in practice the consistency existing between my values and the philosophical principles of ip. i needed to find a channel that would allow me to respect stella completely and, at the same time, respect myself. could i do this? i did not know for sure. on the other hand, i could feel that the little girl needed someone to trust. therefore, i decided to be her therapist. exploring stella’s world of confusion in the beginning, stella and i agreed to meet once a week. she would travel to rome once a month to see me in person, and for the remaining sessions, we would use skype. in this phase, it was important for me to understand what kind of contact we could establish; later, we could start meeting twice a week. stella began to come to rome as agreed, always dressed—or rather covered—in her dark baggy clothes and armored in her excess weight. she did so notwithstanding her depression, shame, and sense of failure. in those first months, i began to understand that stella’s most neglected need was for security (erskine & trautmann, 1993/1997b; erskine et al.,1999). therefore, i offered her a safe space from the beginning, one in which she could be in contact with herself and with me in a way that was sustainable for her. she was highly adaptive, which was challenging for me and probably the hardest aspect of my work with her because it was almost impossible to detect. i had to pay attention to any tiny signal that could help me identify her interruption to internal and external contact. i also took the opportunity to repair my failures in the international journal of integrative psychotherapy, vol. 10, 2019 51 therapeutic relationship (erskine, 2011) by working on stella’s need to be respected, namely, her need for security. this approach acted as a balm for stella, as powerful as unexpected. stella and i worked for several months on reconstructing the fragments of her story of sexual harassment and abuse. at first, the perpetrator seemed to be a 12year-old boy who was partly related to stella. later, we discovered that it was a small group of youngsters who had engaged in rituals of sexual harassment with children. these rituals involved boys and girls between ages 3 and 10 who lived in the same district as stella. she felt guilty for failing to escape and defend herself better as well as for being unable to protect her little sisters, who were also involved in the rituals. it took a long time for me to recognize stella’s neglected needs. much work was needed to normalize her terror, which had caused significant immobilization (erskine, 1993; erskine & trautmann, 1996/1997a; fraiberg, 1982a, 1982b; van der kolk, 2015). my work was characterized by a good deal of interposition whereby i proactively interposed myself between stella’s parent and child ego states (erskine, 2015, p. 256). when performed effectively, interposition counters the patient’s “intrapsychic influence,” and as a result, stella began perceiving me as fully protective of her. only then did she realize that she was too young to defend herself. “it was normal that no one would defend me. i only knew that i had to obey, stay there, under his body, and wait for him to finish and go away. i was not aware that he was stronger than me. i never thought about it. now that i think about it, i truly wonder how this could be all my fault!” as she began to allow herself to feel and think, stella’s eyes became brighter, her shoulders relaxed, and she breathed deeper: her body was alive, even for a short time. some fortunate coincidences in those first months of therapy facilitated the development of awareness and proactivity in stella. the first was that bianca, one of stella’s sisters, began therapy as well. stella had told me about her sense of guilt toward bianca and how stella felt unable to relieve her psychotic sister’s anxiety or to be close to and help her. i normalized her feelings and encouraged stella to go to a mental health center with bianca, where she was able to find a good psychiatrist to begin taking care of bianca. stella felt reassured and decided, with great relief, to set new boundaries in the relationship with her sister. when they met, she would enjoy their time together, but then she would let the psychiatrist take control of the rest. a second fortunate coincidence was that the red cross opened an antiviolence center for women in the city where stella lived. the psychologist in charge promoted creative workshops for abused women and invited stella and her sisters to join. during the workshops, stella and her sisters had to represent their traumatic experiences through drawings. the workshops allowed them to tell each international journal of integrative psychotherapy, vol. 10, 2019 52 other their stories of abuse, which until then they had kept secret. by doing so, the sisters validated each other’s story: “it was true! it wasn’t just a nightmare!” stella said to me one day. a few months into the therapy, i asked stella how she felt about our skype sessions. her answer was, “they’re all right. there’s a screen between us, and that makes me feel quite calm. i feel great!” “of course,” i thought, “she has experienced extreme violations. probably the screen offers her shelter, a boundary she cannot set by herself, one that she did not even think she needed for her entire life.” my later inquiry confirmed that assumption: she was afraid of being dependent on someone, even though what she wanted most was to depend on me. she needed to find someone she could trust (bowlby, 1988; erskine, 2009). stella’s ambivalence was intense. through withdrawal and negation, stella had attenuated the chasm of loneliness and abandonment for her entire life. she had relieved the pain of having no one she could trust. the laptop screen was helping us establish a first, safe contact in relationship (erskine, 2001b). our initial agreement was working. stella’s story of trauma and the development of the therapeutic relationship childhood slowly, stella started recalling in fragments episodes from her dramatic story of sexual, physical, and psychological abuse inside and outside her family of origin. stella’s mother was depressed and narcissistic. she took little care of her four daughters, barely remembering to feed and dress them. often, she spent time doing her make-up and preparing to welcome a man into the house. she encouraged her little daughters to be open to any sexual contact with such men. the man would pay them a small amount of money after the “contact” ended. stella was ashamed of telling me this episode and could not remember what kind of contact it was. still, she said she remembered this event as another profound humiliation (bromberg, 1998/2001). however, stella remembered some more significant events. a 12-year-old boy sexually harassed her at her grandmother’s house beginning when she was 3 years old. the sexual ritual was always the same. by blackmailing her, the boy forced stella to go to the restroom every time the hands of the clock struck a certain hour. once stella was in the restroom, he would join her, make her lie down, then lie on top of her. “he moved, he touched me, but i did not want him to. … i waited international journal of integrative psychotherapy, vol. 10, 2019 53 until it was over, and i came home with my dress dirty, but my mother never looked at me. if i talked to my mother about it, she would tell me that it was my fault.” for this reason, stella made some script decisions (erskine, 1980, 2010; o’reillyknapp & erskine, 2010) and adhered to them. as a result, she decided to never say a word about any event or person: “i felt like i was dead inside” she told me. stella also decided to stand between her father and her sisters. stella’s dad lacked empathy, just as her mother did. he was judgmental, violent—both physically and psychologically—and ready to punish his daughters for no valid reason. his painful and sadistic punishments varied every evening, depending on what stella’s mother told him about their daughters’ behavior during the day. most of the time, stella was the one who took the blame because she did not want to see her sisters suffer. in such situations, stella relied on dissociation, which schore (2003b, p. 110) defined as the last resort of the child to protect himself or herself, a way to escape reality when it becomes too traumatic. the child stops working on interpersonal relationships and just focuses on himself or herself. dissociation protected stella from a desperate existence, unable as she was to bear the pain of her father’s cruel parenting. “when i felt bad, i would fly with my imagination. i imagined being on the ceiling or in my world of fantasy. that world was beautiful. i was happy, and nothing bothered me,” she said to me. the self-portrait in figure 2 depicts stella’s experience of herself at the beginning of our therapy. completely alone, she was living in a bubble, and her soul was full of bleeding wounds. this space served to protect her (o’reilly-knapp, 2001a). i was surprised by her trust in me when she showed me this picture, but i believe it was possible only because of her intelligence. her intelligence also allowed her to focus on the painful realities of her story. i committed to expressing my support through attunement to affect and rhythm. i had managed to establish contact with her through a sympathetic look and a reassuring tone of voice (erskine, 2011). these elements played a significant role in stella’s therapy. international journal of integrative psychotherapy, vol. 10, 2019 54 figure 2. in front of the mirror adolescence during adolescence, stella’s suffering reached its climax. she hated her body and mind and thought she suffered from an impairment because she could not communicate effectively. even at school, her life was hard. she could not concentrate in the classroom or when teachers asked questions or while taking oral exams. her professors believed she was absentminded and distracted. her mother accused her of looking like a fool. stella always felt guilty because of her learning difficulties; she believed she was stupid. we worked a long time to replace this script belief (erskine, 1980, 2010; o’reilly-knapp & erskine, 2010) with other explanations as to why her mother so despised her. we also worked on stella’s maternal and paternal introjects (erskine, 1988, 2010), with which she had unconsciously merged. a good deal of the preparatory work i did with her was to normalize those difficulties, delicately inquiring into what had been happening inside her while she sat in the classroom and what all that meant to her (erskine & trautmann, 1996/1997a). in addition, a careful and attuned inquiry into the life stories of stella’s mother and father (erskine, 2011; erskine & trautmann, 1996/1997a) helped her to understand different perspectives on why her parents had been so inadequate and punitive. meanwhile, i continued to name and validate stella’s relational needs (erskine & trautmann, 1996/1997a). i often took on a parental function, offering the necessary mirroring to her suffering and responding sensitively to what had happened to her at school (kohut, 1971, 1977). i always had in mind that abandoned little girl and was committed to offering her the experience that there international journal of integrative psychotherapy, vol. 10, 2019 55 was now someone there for her who understood her position and needs. i was always ready to intervene to protect her. this kind of intervention, generally of interposition (erskine, 2010), worked as a solvent to stella’s shame (erskine, 1994). stella rapidly realized that her difficulties in class—especially when she had to answer questions—were caused by her father’s violence, judgment, and punishment. she realized that at school she had continued to confirm her initial script decision (erskine, 2010) not to talk to anyone. more deeply, stella wanted to stop thinking and feeling. situation by situation, i helped stella put words to her thoughts and feelings from when she was a little girl at school. she told me that she had always wanted to say those words but that she had never found the right ones. these sessions often ended with stella hugging me intensely, putting her arms around my neck, kissing me on the cheek, and thanking me with a radiant look. i had established contact with the little child affected by a deep fixation (erskine, 1988, 2010) dating back to her early years. i had established contact with the tender child who had never had someone who understood her and put words to her feelings, thoughts, or needs. stella had never had someone to thank. therefore, i assumed—and later found evidence—that her outpouring of love was her way of saying, “thank you. you understand!” it was her way to demonstrate her relational need to express love. two key symptoms: self-harming behaviors and nightmares we worked a significant amount on the fact that stella often cut herself with a razor blade, a habit that made her scared and ashamed. she could not understand why she did it and spent a good deal of time accusing herself. a historical and phenomenological inquiry showed that stella cut herself at times of high emotional tension, especially when she was being criticized or asked to run demanding errands for her mother or husband. locked in anger and sadness, stella became used to the fact that she was not able to react, explain, or ask anything. cutting was her strategy for self-stabilizing (erskine, 2010): “through cutting, i release some tension,” she said. i worked to normalize stella’s self-harm and to help her to understand its function. within our validating and supportive relationship, we normalized and recognized her suffering, which she had long denied. the normalization and recognition of her suffering helped stella cope with her past. she stopped feeling so overwhelmed and began recognizing and understanding her deep emotions and unsatisfied needs (erskine & trautmann, 1996/1997a). as stella learned how international journal of integrative psychotherapy, vol. 10, 2019 56 to accept and express her experiences in our relationship, she diminished cutting herself until she stopped completely. in the same way, we started working on stella’s dreams. wounded and mangled bodies populated her dreams, which also involved phalluses entering her mouth and kinking around her body like snakes. there were also broken roads, lost children, and children who were born and later died. containing, recognizing, and linking stella’s anguish to the traumatic experiences of her present and past was a relevant aspect of the work of mentalization (fonagy, gergely, jurist, & target, 2002), which i approached from an intersubjective perspective (stolorow & atwood, 1992; stolorow et al., 1994). i rarely interpreted stella’s dreams, preferring instead to complete the inquiry process: she herself would lead me to her most profound wounds, isolation, and anxiety and to where they had originated. for stella, such an approach was a path toward recovery from the sense of neglect and abandonment that she had constantly experienced. a few months into the therapy, stella told me that she had confided to one of her friends, a priest, that she liked to draw. she had a good deal of talent, which had been recognized by a professor at school. however, during adolescence, her parents had discouraged her and pushed her to slow down, against her teacher’s opinion. the priest—a man rich in intuition—commissioned her to decorate a small chapel in the parish church. i was enthusiastic about the news. a vital aspect of stella’s personality had emerged (as i will describe later) and would eventually become a fundamental resource for her. the contract what did our contract entail? we agreed on reconstructing her forgotten, unconscious, and untold history. when we began, her narrative was disorganized and her inner world was full of interruptions to contact in relationship. for a long time, we followed a step-by-step or transaction-by-transaction contract. normalization was a significant part of the process. i combined normalization with my respectful, balanced , and loving presence. particularly for the first 2 years of the therapy, my presence aimed to help stella understand that she was not guilty. rather, her abusers were, and they had to feel ashamed. slowly, stella became aware of the truth to the point that after a year-and-ahalf of therapy, she decided to report her rapist to the police. this decision marked an important step toward stella’s integration of her self. her dissociation slowly gave way to scraps of rage, which until then had remained unconscious and embodied. because stella’s traumatic experiences had begun at a preverbal age, international journal of integrative psychotherapy, vol. 10, 2019 57 she was not able to express trauma-related feelings verbally. moreover, her script decision to stop talking also further paralyzed her. when i offered her respect, protection, and reassurance, i was taking on myself the psychological functions of the self—that is, predictability, identity, continuity, and stability (erskine, 2001a)—so that stella could feel safe enough to say a few words. the drawing in figure 3, which stella completed about a year after the beginning of her therapy, shows her changes well, especially when compared to figure 2. stella is no longer alone inside her bubble, although she is still ambivalent when relying on the relationship with me, and visible wounds are still present on her body. figure 3. reliance “go slowly, please!” stella would urge me every time i lost my attunement to her rhythm because of my enthusiasm. at those moments, i was going faster than she could tolerate, losing the affective and rhythmic attunement that was fundamental in order for stella to stay in contact with her needs and emotions (erskine, 2011). every time i pushed stella to take another step, she would return the next session asking me in her little girl voice, “do you love me?” she would explain that her doubt arose because she had not been able to take the step i was encouraging. it became clear that behavioral specifications were not effective with stella. indeed, she would entrench to her loyalty to her maternal and paternal introjections and the terrifying expectancy coming from their criticisms and punishments. these failures in the therapeutic relationship were important to me. i would apologize because i was sorry for being unable to work at the rhythm she needed and looking to repair my failures. in these moments, stella looked at me with her eyes wide: no one had ever apologized to her before, nor had they tried international journal of integrative psychotherapy, vol. 10, 2019 58 to fix their failures (erskine, 2011). such interventions contributed to enhancing stella’s awareness of her value and dignity. a new setting and some delicate aspects of the therapeutic relationship two years after beginning stella’s therapy, i was able to reorganize my schedule in order to meet her in person twice a week. she welcomed this change with enthusiasm because she felt ready for it. our contact became even more intense and intimate. the computer screen had become a useless defense for her, and, as she told me, she no longer needed it. during the first 4 years of the therapy, we worked on the need for protection and depending on someone (figure 4) by relying on interposition and supportive regressive therapy (o’reilly-knapp & erskine, 2003). when stella rested her head in my lap, a position she loved and often chose, she would often be at odds with herself. “can we do this?” she would ask. “it makes me feel like criticizing myself. i think that i do not need it, i am acting like a little girl. … well, since this kind of contact makes me feel good, that’s it!” the regressive work (erskine, 2008) of leaning toward me and enjoying my warm embrace always made her extremely happy. she had finally found a tender mother. figure 4. the healing process some more delicate aspects also affected the development of our therapeutic relationship. for a long time, stella struggled to remember our appointment time. she did not use an scheduling agenda because having an appointment meant looking at a clock, and, because of her history, that was something terrible for her. international journal of integrative psychotherapy, vol. 10, 2019 59 relying on the keyhole of methods (erskine & trautmann, 1996/1997a) (as described earlier)—and especially on interposition, normalization, and affective and rhythmic attunement—was crucial in facilitating stella in separating the face of her rapist from mine and the meaning of those appointments from that of ours. other signs of stella’s transference would often occur during summer, christmas, and easter holidays. although she knew that she could call me when she wanted to, making demands was new for her, and she often denied herself the possibility. thus, i began to take the initiative and occasionally text her when i was on vacation (erskine, 1991). it was my way of letting her know that she was on my mind (fonagy et al., 2002), even if we were far away from each other and could not meet. her joy on receiving those texts was moving. in an intermediate phase, stella began to ask for help indirectly. for example, she would text me asking how i was feeling. in those moments, i would immediately understand her request for help, which we then addressed together. for a long time, another significant moment in transference terms occurred right before starting the session. i noticed that every time stella entered the waiting room, she would give me a quick glance, as if she had to check on what to expect from me that day. she later explained that it was her way of understanding her mother’s feelings before they could cause her trouble. my inquiry often revived childhood memories in which stella was terrified by her mother’s glares and threats. those memories were, in some cases, an opportunity to work on maternal introjections (erskine, 2008). another delicate point in our therapeutic relationship was stella’s contact with her anger. the respectful relationship we had built together—a safe harbor for her—slowly allowed stella to begin recognizing her anger without being afraid of it. it was challenging for me to understand the fear behind her blank face and still body. i eventually discovered that an exercise of muscle activation (levine, 2010) was particularly pleasant and feasible for her. one day, stella looked terrified and paralyzed. i proposed that we performed a simple exercise that would have required her to slightly move an arm and a leg as a way to search for and perceive the strength inside her arm and foot. stella slowly started lifting her leg; then her pushes became gradually stronger to the point where she started kicking. in her mind, she was kicking her tormentor and her mother while i was helping her put words to her anger. our contact was genuine and occurred thanks to the long preparation period we had shared together. stella’s energy was flowing, and i was there as a participant witness. at the end of the work, stella said that she was surprised by the outburst of strength, which she liked feeling. she added that she had felt my words were helpful, words that she had not been able to say because she was too small and frightened. that session and similar ones resulted in several behavioral changes international journal of integrative psychotherapy, vol. 10, 2019 60 related to the definition of her self and the establishment and regulation of boundaries with intrusive people. a special resource: stella’s drawings in the beginning, i often wondered what prevented stella from either going insane or committing suicide given that she was dealing with such severe violence and chronic neglect. as a result, i assumed that two factors played a vital role in stella’s story: the presence of a particular aunt in her life and stella’s passion for the fine arts. after a few years of therapy, stella remembered the presence of her aunt, who was affectionate and caring. the aunt had taken care of stella for months when she was about a year old when stella’s mother had been hospitalized because of a depressive crisis. the later death of her aunt deeply saddened stella, so we worked on coping with that loss. stella became more aware of how loving and supportive her aunt had been and how nurturing the relationship had been for stella. indeed, the aunt had loved stella and had taught her many good habits, which stella unconsciously followed her whole life. second, i believe that stella’s love and talent for the fine arts—especially painting and drawing—were other important resources for her. although her parents always opposed her talent, stella kept drawing in secret until the day her friend commissioned her to decorate the small chapel. stella threw herself into that work, feeling both amazed and scared of the criticism she might have received from others and of being incapable. when she was close to completing the church decorations, she invited me to go and see them. i gladly accepted because i knew how important my attunement to her need for validation would be. this resulted in stella’s decision to attend an advanced course in religious painting so she could begin teaching it. through painting, stella could establish contact with her inner self and define herself. her love for the fine arts often made me think of the fundamental dynamic pentad described by stern (2010/2011, p. 6). it represents every “vital experience,” namely, a person’s experience of being alive, that one may encounter. “movement, time, force, space, and intention” are the five dimensions of “the vital experience” and constitute a unique gestalt (p. 6). the modalities of the vital experience are many and varied, but most are related to the arts. painting was stella’s vital experience, which she always contrasted with her immobilization and sense of being dead inside. stella relied on self-portraiture during key moments in her healing process. she would sometimes bring to a session a folder containing a drawing of her stage of self-development and our relationship (see figures 2, 3, 4, and 5). the more international journal of integrative psychotherapy, vol. 10, 2019 61 progress she made in therapy, the more her artistic initiatives expanded and the more confident and autonomous she grew. a couple of years ago, stella started a session by telling me that she had enrolled at university: “i have some huge news! i enrolled at the academy of fine arts!” i was surprised and moved by her decision because she had not talked to me about it beforehand. i asked her why she had not enrolled in university before. she said that she had prioritized dealing with more serious issues, and she stressed with a smile that she could finally enjoy her achievement and stop focusing on solving her problems. the goals we achieved and the one yet to be achieved at the time of this writing, stella was in her junior year at the academy of fine arts, scoring the highest marks in almost all of her freshman exams. she holds training and workshops for art students and exhibits her work in a small gallery in her hometown, thus profiting from her art. over the previous 2 years, she faced predictable problems with two of her five children. stella stopped cutting herself 3 years ago and has established many healthy boundaries with relatives and friends. she is successfully supporting the growth of her children and is deeply committed to her professional development. a year ago we began meeting once a week. figure 5 shows stella’s current self-portrait. she has placed herself at the center, her arms raised and her body leaning forward toward the future. behind her, she drew her children, whom she wants to protect. in front of her, stella drew me as someone who provided her with guidance and helped her to take a healthy direction. i was surprised that she portrayed me with thick, long hair, exactly as it was when she met me. today, my hair is not the same, but stella’s imprinting of me is evident in the drawing. international journal of integrative psychotherapy, vol. 10, 2019 62 figure 5. journey of the self we have not yet managed to untangle every knot for stella. she and her husband began couples therapy 2 years ago. unfortunately, stella’s husband interrupted the therapy only a few months into it. right after his decision to stop therapy, a drama teacher sexually harassed their 16-year-old daughter, maria. the teacher, 20 years older than maria, had harassed her at a theater school, and he is now under investigation on charges of pedophilia. the investigation began when stella reported what happened to the police and forced her husband to do the same. he was reluctant to do so and thought the abuse was maria’s fault. he considered his daughter to be lacking moral values and a sense of responsibility and failed to take action to protect her. as a result, stella was the one fighting to protect her daughter, regardless of her husband’s position on the matter. today stella is well aware of her need to share some parental functions with her husband. in the last 2 years, we have often worked on this awareness as well as on stella’s needs as a woman in the couple. after what happened to maria, stella’s husband decided to do therapy individually. this decision came after several people put him under pressure, including the police, counselors, and his family. today, stella has stopped accepting her husband’s discouraging and provocative attitudes toward her. consequently, she is seriously thinking about divorce. her husband does not accept stella’s changes: he would like her to drop out of the university and return to being the passive, submissive wife she used to be. we still need to work on this theme in order to complete the decommissioning of the introjected parent (erskine, 2008). international journal of integrative psychotherapy, vol. 10, 2019 63 some theoretical-methodological considerations stella’s script and her vulnerabilities shame was an omnipresent experience in stella’s life along with depression, a sense of impotence, self-devaluation, and passivity. surrender was stella’s only defense (fraiberg, 1982a, 1982b). we understand surrender as an interruption in the contact between a person and his or her pain, something that is functional for survival. stella built and reinforced this strategy beginning in early childhood. stella’s body looked “dead,” abandoned, and intangible (van der kolk, 2015). i often wondered how to reach that little girl. on the one hand, she trusted me; on the other, she built high walls with everyone, including me because she did not want to be violated again (erskine, 2001b). for a long time, stella did not manage to protect herself from physical and verbal violence whether it came from her mother, father, friends, or husband. she was completely exposed to violence. as with every abused child, when stella had to explain the reason for all that violence, she would blame herself: “it’s my fault. i had to defend myself!” she would say. the pain she repressed in her body resulted in a series of diseases: a heart attack, obesity, hip joint problems, fibromyalgia, rheumatoid arthritis, and so on. despite being tormented, her body was full of vitality, which stella attributed to her love for her children. stella’s family never satisfied her relational needs. as a child, she rarely experienced protection from a trustworthy adult, and her unsatisfied need for security prevented her from satisfying other needs as well. this situation was worsened by the fact that stella was 3 years old when the abuse began, and she had not yet fully developed her speaking ability. consequently, stella protected herself by interrupting any contact between her, her early memories, and her frustration coming from unsatisfied needs (erskine, 2008). she implemented freezing and withdrawal as extreme defenses from such overwhelming pain. in attempting to stabilize these tensions, the “cutting-myself-to-feel-better” solution clearly showed the absence of anyone stella could trust. meanwhile, she secretly developed a sense of pseudoautonomy that covered her sense of shame, profound impotence, and inadequacy. by this sense of pseudoautonomy, stella perceived herself as “capable” of protecting her sisters from her parents (erskine, 1994). all these elements—stella’s forms of vulnerability expressed in all the domains of her personality (erskine & trautmann, 1993/1997b)—merged into her script system (erskine, 1980; o’reilly-knapp & erskine, 2010), which rested on beliefs such as “nobody sees me, nobody thinks of me, i’m worthless” and on others such as “i’m strong and invulnerable.” among her script decisions were “if i international journal of integrative psychotherapy, vol. 10, 2019 64 keep quiet, i will escape,” “i won’t cry,” “i’ll save everyone,” “i’ll never talk to anyone to protect my mom and dad,” and “i will imagine a parallel world where everything is perfect.” it was becoming clearer that a powerful self-stabilizing function characterized stella’s script system, one that was especially related to her feelings of shame, powerlessness, and sense of guilt, all of which overwhelmed her. effective therapeutic interventions and integration with other theoreticalmethodological models continuously processing my countertransference allowed me to recognize and attune to stella’s often variable developmental ages and unconscious relational needs. i was particularly prone to bodily countertransference because many of stella’s traumas occurred when she was preverbal. however, i was able to adjust our work depending on the developmental stage stella was experiencing as well as provide answers and put words to her feelings. such work varied depending on the trauma we were working on and when it had occurred. i relied extensively on affective regulation, particularly through my nonverbal communication (eye contact, tone of voice, rhythmic attunement), my reassuring attitude, and my ability to hold stella in my mind and to verbalize her most overwhelming emotions (erskine & trautmann, 1996/1997a, 1993/1997b; fonagy et al., 2002). stella managed to calm down, be reassured, and stay in touch with reality thanks to relational modalities such as containing, calming, thinking together, remaining optimistic, and infusing hope. we gradually rebuilt reality thanks to the slow reemergence of preverbal and subconscious memories (erskine, 2008; winnicott, 191165/1970). facing a destructive introjection, i offered stella a relational experience that was sufficiently different, that is, the experience of a “good-enough mother” (winnicott, 1970, pp. 183–184). i also relied on therapeutic interventions such as interposition, the supportive of regressive therapy, therapy with the introjection, and body awareness activities (o’reilly-knapp & erskine, 2003). these effectively promoted the integration of the self and the “personality domains” (erskine & trautmann, 1993/1997b, pp. 86– 89) of stella. however, our work was effective thanks primarily to my continuous affective and rhythmic attunement, some delicate historical and phenomenological inquiry, frequent normalization, and my therapeutic involvement. above all, i was present, an empathic witness (levine, 2010) to what stella experienced moment by moment (stern, 2004, 2010/2011). even the psychological functions (erskine, 2001a) that i gradually took on helped stella build and consolidate her secure attachment (bowlby, 1988) in her relationship with me. session after session, we international journal of integrative psychotherapy, vol. 10, 2019 65 reestablished contact between her experiences and her unconscious and painful memories. a couple of years ago, i finally received validation about the relationship stella and i had built. i understood that i had become a secure base for her. during a session, i proposed that stella engage in one of the exercises developed by levine (2010) in his somatic experiencing method. we tried it to learn how she could overcome the fear of immobilization when she wanted to be active and assertive. i want to emphasize that stella became increasingly secure in staying in contact with her anger and expressing it openly thanks to the work of those years. we built together methods, strategies, and moments that stella relied on to express herself through her body and to give words to her anger. it was exciting to see her sense of security becoming stronger as a result of alternating moments in sessions in which we focused on her fear of expressing herself in front of those who disqualified her and then daring to kick or punch a pillow. as the therapy progressed, stella showed impressive sensitivity and resilience. i remain convinced that one of her great sources of energy and positivity was her passion for art. despite the seriousness of the traumas she had suffered since childhood, she had managed to preserve her mental health. she stayed active, intuitive, and proactive. her vital energy, which surprised and engaged me, became particularly intense when she spoke about her passion for painting, drawing, and sculpting. i would feel a vital energy permeating her body and transforming her, making her eyes and smile brighter. stella knew only too well how immobilization characterized her relationships and a feeling of death permeated her life. from reading stern (2010/2011), i understood that stella had found a creative and powerful solution that allowed her to survive the loss of contact in relationship. she desperately needed to survive her limiting script system, the way it manifested in her life, and its consequences. thus, when it came to explaining stella’s vital energy, which made her alive and living in front of others, i felt that stern’s question on vital energy and how it translated into the real world reflected my own questions and feelings (p. 5). when introducing the fundamental dynamic pentad, stern explained how vitality, relationship, and intersubjectivity are strictly connected and interdependent. whatever happens always happens in terms of five dimensions: movement, space, force (intensity), time (duration, rhythm), and intention (direction, destination). each of these dimensions is indivisible from the other four. one of stella’s vital dynamic forms was undoubtedly drawing. it allowed her to experience movement, intentionality, and dynamism. when she drew, all of stern’s vital forms were present as described in the fundamental dynamic pentad. for example, drawing constituted a vital space for stella. it allowed her to experience movement, intentionality, and dynamism. it was a powerful strategy by international journal of integrative psychotherapy, vol. 10, 2019 66 which stella could feel alive because it addressed both her preverbal and verbal stages of life. even though in drawing she was “building a relationship” only with some paper, she was doing it her own way. drawing allowed stella to express intentionality, agency, and rhythm (stern, 1985). for her, this meant being alive again, and her regained vitality resulted in the gradual emergence of her sense of self. if she did not lose contact with her sense of self, it was thanks to art, an indispensable part of her life. “art is life,” she would say. the most significant part of my work with stella involved paying attention to my closeness or distance from her as well as my tone of voice, gaze, smile, rhythm, intensity, and intentionality. it is thus possible to view my approach through the lense of the fundamental dynamic pentad and its vital forms. vital forms go beyond contents and provide the child with a primary relational experience. the child’s relationship with the external world depends on whether an adult provides the child with stabilization and affective regulation. this depends on the way the adult expresses himself or herself at the level of the vital forms, which also constitute the background of the pentad. humans write over the surface of the pentad every word and content of communication among them. my intention with stella was to build a relationship that permanently focused on her relational needs. our communications worked simultaneously on two levels: a verbal (or social) level and a nonverbal (or psychological) one. the former relied on her words, which stella was not directly saying to me—namely, one of her needs. she wished i could understand her needs from her nonverbal communication, especially her tone of voice. i would understand her and act or speak according to the relational need she was trying to express. the relationship between us rested on this nonverbal communication. she had the chance to experience with me the healthy kind of communication that she did not have with her mother. conclusions my approach in therapy rests on a view of the person that is deeply relational and on philosophical principles that consider psychopathology to be the result of failing to tune in to a person’s developmental needs, on the relationship as the basic motivation of behavior, and on contact as the way to satisfy a person’s need to relate. from my experience with stella, i learned that the way the therapist relates with a patient is more important than what the therapist says or does. indeed, what promoted stella’s healing began with my calm, my tone of voice, and my gaze. my nonverbal communication is the result of constant work on myself, which means continuously studying, updating, monitoring, and training about international journal of integrative psychotherapy, vol. 10, 2019 67 contact in relationship. the methods (the keyhole of methods) resulting from ip principles are deeply interconnected with the theories of motivation and of personality compatible with a relational view of the individual (erskine & trautmann, 1996/1997a). the findings of neuroscience (schore, 2003a, 2003b; siegel, 1999) confirm and reinforce this view of the nature of the person—and of the human mind—as essentially relational. stella also taught me that respect should be the guiding principle of therapy because it restores the self permanently. i understand respect to be careful of the individual’s inner and outer world and his or her points of contact with these two worlds. this also entails understanding the extent to which the person can maintain contact in relationship in the here and now. this helps avoid experiences of retraumatization and/or hyperadaptation. i validate my assumption that the interruptions to contact in relationship—commonly known as defenses—are functional for survival; one cannot violate another person’s defenses without reinforcing them or creating new ones. in stella’s case, she needed to test me again and again to make sure i respected her. once she understood i respected her pace, rhythm, and difficulties, she gradually lowered her defenses, and i managed to be in contact with her pain. a deep integration of the self encourages profound change. integration results from a therapist’s careful work of inquiry, attunement, and involvement with the patient. however, integration is ephemeral when the therapist does not strive to improve himself or herself continuously. indeed, the greatest factor contributing to therapeutic success rests on the therapist’s relational competence. continued professional and personal training develops and fosters this competence: it is the therapist’s capacity for authentic therapeutic love (o’reilly-knapp, 2001b). moreover, competence is made up of knowledge of theories, technical ability, and personal ability. it is, above all, knowledge of how to be in relationship (guarrella, 2013). a therapist who stops working on his or her personal growth is doomed to failure or, at best, to producing adaptations that will not last. therapists who take care of themselves enjoy the success of their patients. they witness their patients’ success as enthusiastically as a mother looks at her son smiling for his achievements after experiencing failure. no matter how many attempts, failures, and successes they had to experience, they shared each of those moments together with complicity, trust, and hope. author: dr. isabella nuboloni is a certified psychotherapist, trainer, and supervisor in the international integrative psychotherapy association. she is also a certified international journal of integrative psychotherapy, vol. 10, 2019 68 transactional analyst in the european association for transactional analysis. isabella currently lives in rome, where she works in private practice and volunteers for the psychosocial services of the italian red cross. she can be reached at; email: info@isabellanuboloni.com. acknowledgments the author expresses her gratitude to dr. gregor žvelc, without whose guidance this paper would not exist. she also thanks the team of professionals who edited her work and dr. giulia francesca primo, who translated it from italian to english with great care and professionalism. references bowlby, j. (1988). a secure base: clinical applications of attachment theory. new york, ny: routledge. bromberg, p. m. (2001). standing in the spaces: essays on clinical process, trauma, and dissociation. hillsdale, nj: the analytic press. (original work published 1998) erskine, r. g. (1980). script cure: behavioral, intrapsychic, and physiological. transactional analysis journal, 10, 102–106. doi:10.1177/036215378001000205 erskine, r. g. (1988). ego structure, intrapsychic function, and defense mechanisms. transactional analysis journal, 18, 15–19. doi:10.1177/036215378801800104 erskine, r. g. (1991). transfer and transactions: a critique from an intrapsychic and integrative perspective. transactional analysis journal, 21, 63–76. doi:10.1177/036215379102100202 erskine, r. g. (1993). inquiry, attunement, and involvement in the psychotherapy of dissociation. transactional analysis journal, 23, 184–190. doi:10.1177/036215379302300402 erskine, r. g. (1994). shame and self-righteousness: transactional analysis perspectives and clinical interventions. transactional analysis journal, 24, 86– 102. doi:10.1177/036215379402400204 erskine, r. g. (2001a). psychological function, relational needs, and transferential resolution: psychotherapy of an obsession. transactional analysis journal, 31, 220–226. doi:10.1177/036215370103100403 erskine, r. g. (2001b). the schizoid process. transactional analysis journal, 31, 4–6. doi:10.1177/036215370103100102. mailto:info@isabellanuboloni.com international journal of integrative psychotherapy, vol. 10, 2019 69 erskine, r. g. (2008). psychotherapy of unconscious experience. transactional analysis journal, 38, 228–238. doi:10.1177/036215370803800206. erskine, r. g. (2009). life scripts and attachment patterns: theoretical integration and therapeutic involvement. transactional analysis journal, 39, 207–218. doi:10.1177/036215370903900304 erskine, r. g. (ed.). (2010). life scripts: a transactional analysis of unconscious relational patterns. london: karnac books. erskine, r. g. (2011, 21 april). attachment, relational needs, and psychotherapeutic presence [keynote address]. international integrative psychotherapy association conference, vichy, france. erskine, r. g (2015). relational patterns, therapeutic presence: concepts and practice of integrative psychotherapy. london: karnac books. erskine, r. g., moursund, j. p., & trautmann, r. l. (1999). beyond empathy: a therapy of contact-in-relationship. philadelphia, pa: brunner/routledge. erskine, r. g., & trautmann, r. l. (1997a). methods of an integrative psychotherapy. in r. g. erskine, theories and methods of an integrative transactional analysis: a volume of selected articles. san francisco, ca: ta press. (original work published 1996) erskine, r. g., & trautmann, r. l. (1997b). the process of integrative psychotherapy. in r. g. erskine, theories and methods of an integrative transactional analysis: a volume of selected articles (pp. 79–95). san francisco: ta press. (original work published 1993) fonagy, p., gergely, g., jurist, e. l., & target, m. (2002). affect regulation, mentalization, and the development of the self. london: routledge. fraiberg, s. (1982a). an object-relations theory of the personality. new york, ny: basic books. fraiberg, s. (1982b). pathological defenses in infancy. the psychoanalytic quarterly, 51, 612–635. doi.org/10.1080/21674086.1982.11927012 guarrella, e. (2013). il training in analisi transazionale integrativa [training in integrative transactional analysis]. quaderni dell’ istituto di analisi transazionale integrativa, 1, 3–33. kohut, h. (1971). the analysis of the self: a systematic approach to the psychoanalytic treatment of narcissistic personality disorder. new york, ny: international universities press. kohut, h. (1977). the restoration of the self. new york, ny: international universities press. levine, p. a. (2010). in an unspoken voice: how the body releases trauma and restores goodness. berkeley, ca: north atlantic books. o’reilly-knapp, m. (2001a). between two worlds: the encapsulated self. transactional analysis journal, 31, 44–54. international journal of integrative psychotherapy, vol. 10, 2019 70 doi.org/10.1177/036215370103100106 o’reilly-knapp, m. (2001b). therapeutic love, intellectual truth, and theoretical understanding: a clinical application of the theory and methods of integrative psychotherapy. transactional analysis journal, 31, 274–282. doi.org/10.1177/036215370103100411 o’reilly-knapp, m., & erskine, r. g. (2003). core concepts of an integrative transactional analysis. transactional analysis journal, 33, 168–177. doi.org/10.1177/036215370303300208 o’reilly-knapp, m., & erskine, r. g. (2010). the script system: an unconscious organization of experience. international journal of integrative psychotherapy, 1(2), 13–28. schore, a. (2003a). affect dysregulation and disorders of the self. new york, ny: norton. schore, a. (2003b). affect regulation and the repair of the self. new york, ny: norton. siegel, d. j. (1999). the developing mind: toward a neurobiology of interpersonal experience. new york, ny: guilford. stern, d. n. (1985). the interpersonal world of the infant: a view from psychoanalysis and developmental psychology. new york, ny: basic books. stern, d. n. (2004). the present moment in psychotherapy and everyday life. new york, ny: norton. stern, d. n. (2011). le forme vitali: l’esperienza dinamica in psicologia, nell’arte, in psicoterapia e nello sviluppo [forms of vitality: exploring dynamic experience in psychology, the arts, psychotherapy, and development]. milan: raffaello cortina editore. (original work published 2010 in english) stolorow, r., & atwood, g. e. (1992). contexts of being: the intersubjective foundations of psychological life. hillsdale, ny: the analytic press. stolorow, r. d., atwood, g. e., & brandchaft, b. (1994). the intersubjective perspective. lanham, md: roman & littlefield. stolorow, r. d., brandchaft, b., atwood, g. e., fosshage, j., & lachmann, f. (1999). psicopatologia intersoggettiva [intersubjective psychopathology] (m. casonato, ed.). urbino, italy: quattro venti. van der kolk, b. a. (2015). the body keeps the score: brain, mind, and body in the healing of trauma. new york, ny: penguin books. winnicott, d. w. (1970). sviluppo affettivo e ambiente: studi sulla teoria dello sviluppo affettivo [the maturational processes and the facilitating environment: studies in the theory of emotional development]. rome: armando armando editore. (original work published 1965 in english) international journal of integrative psychotherapy, vol. 5, no. 1, 2014 21 nonverbal stories: the body in psychotherapy richard g. erskine abstract: emotional experience is stored within the amygdala and the limbic system of the brain as affect, visceral, and physiological sensation without symbolization and language. these significant memories are expressed in affect and through our bodily movements and gestures. such body memories are unconscious nonsymbolized patterns of self-in-relationship. several methods of a body centered psychotherapy are described and clinical case examples illustrate the use of expressive methods within a relational psychotherapy. key words: body centered psychotherapy, body therapy, relational psychotherapy, inhibited gesture, retroflection, integrative psychotherapy, emotional experience, touch in psychotherapy, music therapy ____________________________ some of my earliest memories are the sensations in my body, my physical movements, and being cuddled in another person’s body. i must have been about three years old when my mother woke me each morning by rubbing my back. her touch provided a warm secure feeling -an emotional memory that i periodically recall today when i am in need of nurturance. there is a particular spot on my back that i relate to being unconditionally loved, a spot that my mother always touched with firm tenderness. this physiological memory of nurturing is in such contrast to another early childhood experience of my parents having a loud argument in the kitchen. i tried to escape the emotional turmoil by going to the next room and pounding on the keys of the piano. yet i also kept watching to see if my father would hit my mother again. my shoulders and neck were tense. i must have been scared. i cannot recall a sense of fear but i know that making noise on the piano was a distraction from the emotional havoc caused by their screaming. the tension in my neck and shoulders remained within my body for years. the tension was intense whenever i faced conflict until i attended a music therapy workshop conducted by two colleagues. when i arrived the room was full of people so i sat on the floor next to the piano. there was some discussion among international journal of integrative psychotherapy, vol. 5, no. 1, 2014 22 the presenters and the audience that made me feel uncomfortable. i spontaneously reached up and began to tinker the base notes on the piano. before i could stop myself one of the music therapists encouraged me to continue, to close my eyes, and let myself hear and feel the sounds i was making. i pounded the piano harder and then even harder. i began to shake with fear. i was nauseous. a deep cry burst out of me as i screamed for my parents to stop fighting. this cry expressed the natural protest that i had inhibited as a fear-based reaction to my parents fighting. for more than forty years my tight neck and shoulder muscles had inhibited my need to make an impact; my need to protest had become retroflected, immobilized, and transformed by distraction (perls, hefferline, & goodman, 1951). the body keeps the score is the title of bessel van der kolk’s 1994 article about trauma and memory. my body kept an unconscious “score” of emotional and physiological memories of the trauma of witnessing my parents fighting. until that day of music therapy i had no conscious memory of those early events in my life. so it is with many of our clients. they say they have no memories of being younger than ten or twelve years of age yet they describe having anxiety attacks, bouts of depression or loneliness, digestive problems, back aches, or like me, the tensions in their shoulders and neck. each of these emotional and physical symptoms may be the memories -often the only memories -of despairing loss, neglect, or traumatic events. these significant memories are expressed in our affect and through our bodily movements and gestures. such body memories are without form or thought, what we often refer to as unconscious: a non-verbal, non-symbolized, pattern of self-in-relationship. my body yearned for an opportunity to release the physical tension, to scream, to make an impact, to be protected and comforted. in not having parental affect regulation and psychological protection i had retroflected my fear and inhibited my protest; i held in my scream and distracted myself. the retroflection of my need to protest and the physical tension in my neck served the psychological function of affect self-stabilization in a situation where i needed my parents to provide the stabilization of my overwhelming fear. my therapy experience was an expression of visceral, physiological, and emotional memories -memories that were pre-symbolic, implicit, and relational coming to awareness as i sat below the piano and began to tinker the keys. this was an emotionally laden story waiting to be told. in my ongoing therapy i had talked about inhibiting my protest, being afraid of conflicts, and the tension in my neck. but, my therapy had been completely verbal and my examples were of current life. the stimulus and safety of the music therapy demonstration made it possible for me to have a supported and therapeutic reenactment of my early trauma. international journal of integrative psychotherapy, vol. 5, no. 1, 2014 23 our bodies hold our pre-symbolic, implicit, and procedural memories within the nervous system, muscles, and connective tissues. these emotional and physiological memories may be expressed as gestures, inhibitions, compulsions, physical tensions, and unique mannerisms. eric berne referred to such tensions and gestures as the “script signal”. he said, “for each patient there is a characteristic posture, gesture, mannerism, tic, or symptom which signifies that he is living ‘in his script’”. (berne, 1972, p315). gestalt therapy defines such habitual mannerisms and interrupted gestures as a “retroflection”, a holding in what is needed to be expressed in order to avoid awareness of psychological discomfort (perls, hefferline & goodman, 1951). people tense the muscles of their body as a distraction in order to self-stabilize after being flooded with overwhelming affect. often the retroflection becomes habitual and interferes with internal contact, the awareness of sensations, affect, and needs. unconscious or in the body? most of what we colloquially refer to as “unconscious” may best be described as pre-symbolic, sub-symbolic, implicit, or procedural expressions of early childhood experiences that constitute significant forms of memory (bucci, 2001; kihlstrom, 1984; lyons-ruth, 2000; schacter & buckner, 1998). these forms of memory are not conscious in that they are not transposed to thought, concept, language, or narrative. such sub-symbolic or implicit memories are phenomenologically communicated through physiological tensions, body movements, undifferentiated affects, longings and repulsions, tone of voice, and relational patterns (erskine, 2008; 2009). freud postulated that “the unconscious” was the result of “repression” where uncomfortable affect-laden or traumatic experiences were defensively prevented from coming to awareness (freud, 1912/1958, 1915/1957). in working with many clients in psychotherapy it has become clear to me that particular memories, fantasies, feelings, and physical reactions may be repressed because they may bring to awareness relational experiences in which physical and relational needs were repeatedly unmet and related affect cannot be integrated because there was (is) a failure in the significant other person’s attuned responsiveness (erskine, 1993/1997; erskine, moursund, & trautmann, 1999; lourie, 1996; stolorow & atwood, 1989; wallin, 2007). i have had clients who were extremely afraid of remembering their own childhood experiences. they knew that their memories were emotionally painful, even overwhelming, and they did not want me to do anything that disturbed their selfprotective equilibrium. they actively repressed awareness of what they “sensed” had occurred in their past. these clients often found clever and sometimes international journal of integrative psychotherapy, vol. 5, no. 1, 2014 24 destructive ways to distract themselves from remembering. i found that it was essential that i build a solid therapeutic relationship with these clients before doing any historical inquiry or body focused therapy -a therapeutic relationship based on patience, respect for their fear of remembering, and a sensitive responsiveness to their affect and relational-needs. experience that is unconscious is not only the result of psychological repression and distraction. research has shown that trauma and cumulative neglect produce intense overstimulation of the amygdala and the limbic system of the brain such that the physiological centers of the brain are activated in the direction of flight, freeze, or fight. there is little activation of the frontal cortex or integration with the corpus callosum so that time sequencing, language, concepts, narrative, and the capacity to calculate cause and effect are not formed (cozolino, 2006; damasio, 1999; howell,2005, salvador, 2013). the brain is then unable to symbolize experience (bucci, 2001), but the experience is stored in the neurological interplay of affect and body. this neuropsychology research provides a basis for the psychotherapist to work directly with the clients’ visceral sensations, muscular reactions, movements and interrupted gestures, imagery, and affect. along with body centered methods i often used phenomenological inquiry and therapeutic inference to help the client construct a symbolized mosaic composed of visceral sensations and emotions, body reactions and physical tensions, images and family stories. this coconstructed mosaic allows the person to form an integrated physiological, affective, and linguistic story of their life’s experiences. some developmental experiences may be unconscious because the child’s emotions, behaviors, or relational needs were never acknowledged within the family. when there is no conversation that gives meaning to the child’s experience, the experience may remain as physiological and affective sensations but without social language (cozolino, 2006). a lack of memory may also appear unconscious because significant relational contact did not occur. when important relational experiences never occurred, it is impossible to be conscious of them. if kindness, respect, or gentleness were lacking, the client will have no memory; there will be a vacuum of experience but the body may carry a sense of emptiness, loneliness, and longings. this is often the situation with childhood neglect. lourie (1996) described the absence of memory in clients with cumulative trauma that reflects the absence of vital care and an ignoring of relational needs. psychotherapy that integrates a focus on body sensations and affect with a sensitive phenomenological and historical inquiry provides the opportunity to address that which has never been acknowledged and to create a verbal narrative that reflects the body’s story. a consideration of methods international journal of integrative psychotherapy, vol. 5, no. 1, 2014 25 in the previous story about my music therapy experience, the safety and nonverbal aspect of the music therapy made it possible for me to re-experience a trauma that had previously not been available to my consciousness. as cited by bruscia (1987), merle-fishman and katsh have developed the technique of metaphoric improvisation therapy; a form of music therapy which works with pre-symbolic and procedural memories (pp. 319-334). art therapy provides additional methods of working with preverbal memories. movement and dance therapy may also be evocative of early memories. as a psychotherapist i use a number of body oriented methods such as these to facilitate my clients’ psychotherapy. however, i am not a body-therapist who relies on either evocative or provocative techniques alone, i am a psychotherapist who focuses on the body and the unconscious stories requiring resolution. i often engage in doing body oriented therapy that involves clients becoming aware of their breathing. i facilitate their experimenting with various forms of breathing to find their own natural rhythm. sometimes this alone is enough to stimulate an awareness of memories or where they are holding muscular tension in their body. or, the therapeutic work may focus on grounding, that is, helping the client to feel a solid and dependable base under his or her feet or buttocks. i watch for the inhibited or interrupted gesture. these are often the “script signal” that reflect a much larger emotion filled story embedded in the body. i carefully watch for interruptions in internal contact, that is, a loss of physiological awareness: smell, taste, sound, sight, skin sensations, and digestion. i periodically inquire about or devise awareness enhancing exercises that stimulate a consciousness of various body sensations that may either be blocked or that may serve as a way into sub-symbolic and procedural memories which are physiologically retroflected and therefore not-conscious. with other clients i may either encourage them to exaggerate the inhibited gesture, to tighten their jaw or fist even harder. i may ask them to complete the interrupted gesture and explore what sensations, affects, fantasies, or associations come to mind. this may revamp into work with larger muscles where the clients explore moving in space. movement, movement awareness, and awareness of body tensions is often evocative of unspoken childhood experiences. i may have the clients focus on where they feel sensations in their body, where there is little or no sensation, and the cognitive and sensory imagery that this type of inquiry brings (such as the memory of smell, taste, touch, sound, and visceral sensations). it is essential that i remain aware of my own body process when doing any physiological work with clients. in my attempt to have a physiological resonance i often vicariously experience their body tensions. through attending to my own breathing and body sensations i seek an awareness of the difference between international journal of integrative psychotherapy, vol. 5, no. 1, 2014 26 my sensations and the clients’ sensations, even though i am simultaneously identifying with their bodily experience. for some clients body awareness work can be done through fantasy. i ask them to imagine using their body in a different way such as running away, hitting back, standing up for themselves, or embracing and cuddling. some of the time the body focused therapy involves working with imagination such as having them visualize reaching upwards and then imagining someone picking them up. in some groups what begins as one person’s body awareness and movement work may morph in a psychodrama involving the whole group. psychodrama is a powerful method of facilitating clients’ resolution of traumatic or neglectful experiences. communicative sounds such as “oh, “uh”, “thisst”, or a sigh all have a physical and affective component. i often respond to these communicative moments by asking questions similar to “what is happening in your body right at this moment?” or “what do you experience internally when you say, “uh”? if the client seems open to such an inquiry, i may say something that reflects my observations of his or her body tensions: “pay attention to your left shoulder,” or “feel what just happened to your throat,” or “you made a sigh just now. your body may be expressing something important.” each of these body centered techniques and methods can be highly beneficial as an adjunct to a relationally focused, in-depth psychotherapy. when using body oriented approaches i am focused on the necessity of titrating the technique or method to the affect tolerance of the client. i am watchful that the awareness exercise, art expression, body movement, hitting or kicking a cushion, or psychodrama experience is at a level where the client can affectively process the experience without becoming emotionally overwhelmed, triggering a reinforcement of the strategies of archaic self-stabilization. titrating of the clients’ level of affect requires constant phenomenological inquiry and observation of the clients’ body movements before, during, and after using body centered methods. i strive to attend to the subtle physiological shifts that occur when clients are talking, such as the changes in volume, inflection, rhythm, and tone. these utterances may reflect the sub-symbolic, implicit, and procedural memories embedded in the client’s affect and body. i am also watching for the little physical gestures such as pupil dilation or contraction, the tensing of the neck or jaw, changes in breathing, tightening the pelvis or legs, and looking away that may indicate that the client is becoming overwhelmed with unexpressed affect. my therapeutic goal is to stimulate and enhance the client’s sense of visceral arousal and awareness so that he or she has a new physiological-affectiverelational experience. i want to activate the client’s inhibited gestures and relax the retroflections while being attentive to the possibility of overstimulation and re international journal of integrative psychotherapy, vol. 5, no. 1, 2014 27 traumatization. if the physical gestures that reflect possible affect overstimulation and potential re-traumatization do appear it is my responsibility to shift the focus of our body work or the content of our conversation, to ease up or stop any touch, to change the physical activity, and to cognitively process the emotional experience with the client. returning to phenomenological inquiry and an interpersonal dialogue is often the best way to provide the client with the needed physiological stabilization and affect regulation so that the he or she can integrate the therapeutic experience physiologically, affectively, and cognitively (erskine, moursund & trautmann, 1999). body oriented therapy without touch before i talk about body therapy that includes touch i would like to describe a therapy situation that was primarily body focused and did not involve touch during the early phase of the psychotherapy. jim came to group therapy because he could not maintain friendships or find a life partner. in the first few sessions it was obvious he tended to invade people’s space. when he entered the office he piled his coat on top of other peoples’ coats rather than using his own hanger. he left his shoes where others tripped on them. he often plopped down on the sofa almost on top of others. he put his feet on someone’s lap. people in the group began to find him a nuisance. when the group members first confronted him about his behavior and how they felt invaded, he seemed to have no awareness of what they meant. after a few sessions of such discussions he gained some awareness of his own behavior but he seemed to have little selfmanagement. i observed that he was lacking in exteroceptive sensitivity and limited in knowing the boundaries of interaction between his own and other peoples’ bodies. in the following session i had him close his eyes and feel the chair, to touch his legs, to then feel his feet solidly on the floor, to then spread his arms and feel the dimensions of his external space. he slid off the sofa onto his knees. i suggested that keep his eyes closed and to feel his knees and hands grounded into the carpet. he began to crawl like a toddler. i encouraged him to pay attention to each sensation in his body. as he crawled along the floor he seem tight and restricted in his legs and shoulders. he was tense. i assumed that he was afraid. after several minutes of crawling he began to cry, at first softly, and then with deep sobs. he remained on his knees, eyes closed, with his arms stretched in the air crying to be picked up. in a later session he reported that he had a reoccurring dream in which he is crying for someone to take his hand, to help him walk, and to hold him on their lap. international journal of integrative psychotherapy, vol. 5, no. 1, 2014 28 in several subsequent sessions he surmised about the parental neglect that he may have received between the ages of one and two years. through our group therapy sessions he created a mental mosaic composed of some explicit memories, physical sensations, observations of his mother’s dismissive behavior toward his brother’s children when they were toddlers, and family stories of mother’s abuse of alcohol when he was pre-two years. he was forming a narrative of his sense of his own body in space and in relationship: lost, lonely, and longing for body contact with someone. he also became aware that he had a deep fear of rejection if he did reach out to touch someone. we spent several months in group therapy with jim taking a portion of time each week to become aware of his body-based emotions, to explore space and the touch of others, to resolve his anticipation of rejection, and to receive encouragement from the group members for experimenting with new ways of being in relationship. therapy through healing touch i touch some of my clients, yet i have had many clients that i have never touched. the decision to touch or not to touch depends on the therapeutic needs of the client, the quality of our psychotherapeutic relationship, and the level of body awareness and accompanying affect that the client can integrate. the decision to touch must be a mutual agreement, based on the welfare of the client as determined by the client and psychotherapist in consultation, and should not be based solely on the therapists theoretical or technique preferences. each client, at various times in the ongoing process of psychotherapy, may therapeutically benefit from touch -touch from the psychotherapist that may range from a gentle holding of the hand to deep massage of the back or shoulders to help the client vigorously move the large muscles to release previously retroflected emotions such as sorrow, disgust, terror, or anger. some clients benefit from a warm soft touch that to them feels supportive and protective. with one seventy year old woman i initiated holding her hand during a session as she talked about her despair and panic in having cancer. as i held her hand she had a pleasant memory of feeling secure when she was touched as a child. she experienced our hand holding as saying, “you can manage this crisis. i am with you”. that triggered a memory of her father sitting at her bedside holding her hand when she had a high fever at age nine. for more than sixty years she had forgotten the warmth and security that this memory provided and she contrasted it with living alone as an older woman. this hand holding session opened the door for us to do an in-depth psychotherapy that focused on her body sensations, emerging associations and memories, the intersubjectivity of our therapeutic relationship, and the construction of a personal narrative that repaired the relational disruptions that had occurred before and during the time her mother was hospitalized with depression. the hand holding and good-bye international journal of integrative psychotherapy, vol. 5, no. 1, 2014 29 hug were the only touching that we did but my initiating the handholding remained meaningful to her. i used therapeutic touch in a very different way with another person. jennifer was an experienced psychotherapist. she had attended a series of training workshops where she was actively engaged in learning and supervision. on a couple of occasions she talked in the training group about her feelings of despair, the lack of energy she often felt at home, her growing resentment in providing therapy to others, and her desire to “withdraw and just give up.” she was disappointed in her personal therapy. she said, “i just talk and talk. my therapist is very supportive but i seem to go around and around on the same old subjects. i either need a different kind of therapy or i should just quit.” her posture reminded me of previous clients who's bodies were encumbered with a sense of hopelessness. on the strength of our already established supervisory relationship (and with the support and permission of her therapist) she came to a five-day therapy marathon where i was doing personal therapy with a group of psychotherapists. i did not yet have a therapy plan but i sensed that once thcoheasion and internal security had developed in the group something significant would emerge within our therapy relationship. i did consider the likelihood that she was already slipping into an enactment of some significant childhood memory and the possibility that she may benefit from some form of body therapy but i needed more observations of her breathing patterns, physiological movements, body tensions, and how she related to both me and others in the group before i formed a sense of direction. my intention in the first couple of days was to create a secure and cooperative group environment where it was safe for clients to have a supportive therapeutic regression to resolve fixated fear, trauma, or neglect. importantly, i want clients to feel protected so that they can relax their physiological retroflections, to finally put into movement what was previously inhibited, and to have a chance to make the therapeutically necessary physiological and affective expressions -expressions where the neurological system is transformed and healed. on the afternoon of the third day i was working with another woman who was crying and talking about the neglect and physical abuse she suffered at the hands of her mother when she was young. i noticed that jennifer was curling up, rocking herself, and whimpering like a very young child. as the work with the other woman ended i went over to jennifer and quietly sat with her. after several minutes she opened her eyes and acknowledged that i was with her. she said, “i am terrified. my body is so stiff. this is what happens to me when i am home. i just want to disappear.” i talked to her about the possibility of our doing some touch therapy. i described both the advantages and possible adverse effects of such emotionally inducing work. we talked about how she could stop my touch at any time by either pulling on my shirt or saying the words “richard stop.” i knew international journal of integrative psychotherapy, vol. 5, no. 1, 2014 30 intuitively that it would be essential for her to have a sense of choice and control. she agreed to the contract that gave me permission to do some therapeutic touch on her tight muscles. with the protective presence of the group, i invited her to go back to the physical and emotional experience of curling up and rocking. as she tightened into a fetal position, with eyes closed, she wiggled away from me and tried to hide under one of the many mattresses. i put my hand on her back, over her heart. she was extremely tense as though her back was an iron barrel. i began to massage the tight muscle of her upper back, at first lightly, and then with more strength. during the massage she squirmed and wanted to escape being touched. i had her look at me and reminded her that i would stop immediately if she said, “richard stop”. she pushed on the cushions; i sensed that it wasn’t me that she was pushing away. i encouraged her to make sounds, any sounds that reflected what she felt inside. as i did a deeper massage in the thoracic area of her back she clawed at the mattress, cried like a young child, and struggled to move away. for the next few minutes she repeatedly howled “go away,” “don’t touch me,” “don’t feed me,” “i don’t want you,” while alternately squeezing and scratching a cushion. i could hear her sounds of helplessness and see that her full expressions of natural protest were still inhibited. if she was going to have a therapeutic closure that could alter the neurobiology of the original neglect and/or trauma, she needed to move her body in a grander way and to feel the sense of anger that she was still retroflecting. i had her roll onto her back. i sat behind her head and began to massage her tight trapezius muscles. in this supine position she was able to move her legs and slowly began to push with them. i asked the group members to surround her with mattresses and pillows. as i continued with a deeper massage she began to kick. i encouraged her to kick harder and faster and to say out loud anything that came to her. she kicked wildly, with such a great force that it took six people to hold the mattress. during the intense kicking she screamed in a strong and determined voice: “i don’t want your touch, mother.” “you have always hated me.” “you squashed me, but now i know the truth.” “it was never my fault.” “you are the hateful one ... not me.” “i was a good child and you never saw who i was.” “all my life i have blamed myself and kept myself hidden -no longer, mother. i am now free.” “i don’t want to carry your depression.” “i am not going to hide who i am.” throughout this therapy my body resonated with jennifer’s physiological and affective expressions. i experienced a series of alternating sensations: compassion, worry, anger, relief, as well as the ongoing processes of my own internal somatic and affect regulation. my shoulders, back, and legs tightened as i vicariously sensed the retroflections in jennifer’s body. i resonated with the inhibited, frightened, and disgusted little girl. each of my internal sensations served to keep me attuned to jennifer’s changing affect and body reactions and provided me with a sense of direction in our psychotherapy. international journal of integrative psychotherapy, vol. 5, no. 1, 2014 31 although jennifer's words sound as though she made a cognitive redecision, the significance of the therapy was not in the words she screamed or what she was thinking or saying. the principal and predominant change was physiological and affective -a neurological reorganization facilitated by the working directly with the retroflections in her body. she changed some brain-body-affect neurological circuits by allowing herself to feel the deep touch on her back, the related emotions that had been disavowed, and the sub-symbolic and procedural memories that were housed in her tight muscles. she kicked, screamed, and released her retroflected anger at her mother’s disdainful and neglectful behavior. then she relaxed into the caring touch of several group members who gathered around to hold her and express their support. conclusion there are many other case examples of body centered psychotherapy that i could use to illustrate the great variety of therapeutic methods available when working with protracted affect, retroflected movement, and sub-symbolic memory. most of the methods involve a combination of focused awareness on breathing and body sensations, experimentation with movement and body tension, fantasy, grounding, and self-expression. these methods may include touch that is warm and protective, or deep and evocative of body memories. of particular concern is the ethical practice of the client having the choice over the nature of the interventions and the control to stop any form of body oriented psychotherapy. all experience, particularly if it occurs early in life or if it is affectively overwhelming, is stored within the amygdala and the limbic system of the brain as affect, visceral, and physiological sensation without symbolization and language. instead of memory being conscious through thought and internal symbolizations, our experiences are expressed in the interplay of affect and body as visceral and somatic sensations. to again quote the title of van der kolk’s article, “the body keeps the score.” it is our task, as psychotherapist, to work sensitively and respectfully with our clients’ bodily gestures, movements, internal images, and emotional expressions, to stimulate and enhance the client’s sense of visceral arousal and awareness so that he or she has a new physiologicalaffective-relational experience. such sensitivity and respectfulness requires us to be attentive to the possibility of overstimulation and re-traumatization and to take ameliorative action. the narrative of the body is a special language with form, structure, and meaning. through a body centered relational psychotherapy we are able to decode the stories entrenched in our client’s affect and embodied in their physiology. international journal of integrative psychotherapy, vol. 5, no. 1, 2014 32 author: richard g. erskine, ph.d., is the training director, institute for integrative psychotherapy. he is a licensed clinical psychologist, a licensed psychoanalyst, and has integrated body centered methods in his practice of psychotherapy for forty years. references berne, e. (1972). what do you say after you say hello?: the psychology of human destiny. new york: grove press. bruscia, k. e. (1987). improvisational models of music therapy. springfield, ii: charles c. thomas bucci, w. (2001). pathways to emotional communication. psychoanalytic inquiry, 21, 40-70. cozolino, l. (2006). the neuroscience of human relationships: attachment and the developing social brain. new york: norton. damasio, a. (1999). the feeling of what happens: body and emotion in the making of consciousness. new york: harcourt brace. erskine, r.g. (1993). inquiry, attunement, and involvement in the psychotherapy of dissociation. transactional analysis journal, 23: 184-190. republished 1997 in r. g. erskine (ed.). theories and methods of an integrative transactional analysis: a volume of selected articles (pp. 37-45). san francisco, ca: ta press. erskine, r.g. (2008). psychotherapy of unconscious experience. transactional analysis journal, 38:128-138. erskine, r.g. (2009). life scripts and attachment patterns: theoretical integration and therapeutic involvement. transactional analysis journal, 39:207-218. erskine, r. g., moursund, j. p., & trautmann, r.l. (1999). beyond empathy: a therapy of contact-in-relationship. philadelphia, pa: brunner/mazel. freud, s. (1957). the unconscious. in j. strachey (ed. &trans.), the standard edition of the complete psychological works of sigmund freud (vol. 14, pp. 159-215). london: hogarth press. (original work published 1915) freud, s. (1958). the dynamics of transference. in j. strachey (ed. & trans.), the standard edition of the complete psychological works of sigmund freud (vol.12, pp. 97-108). london: hogarth press. (original work published 1912) howell, e. f. (2005). the dissociative mind. hillsdale, nj: the analytic press. kihlstrom, j. f. (1984). conscious, subconscious, unconscious: a cognitive perspective. in k. s. bowers & d. meichenbaum (eds.), the unconscious reconsidered, (pp. 149-210). new york: wiley. lourie, j. (1996). cumulative trauma: the non-problem problem. transactional analysis journal, 26:276-283. international journal of integrative psychotherapy, vol. 5, no. 1, 2014 33 lyons-ruth, k. (2000). “i sense that you sense that i sense. . . ”: sander’s recognition process and the specificity of relational moves in the psychotherapeutic setting. infant mental health journal, 21, 85-98. perls, f. s., hefferline, r. f., & goodman, p. (1951). gestalt therapy: excitement and growth in the human personality. new york: julian press. salvador, m.c. (2013). wisdom of the subcortical brain, international journal of integrative psychotherapy, 4:40-53. schacter, d. l., & buckner, r. l. (1998). priming and the brain. nevron, 20, 185195. stolorow, r. & atwood, g. (1989). the unconscious and unconscious fantasy: an intersubjective developmental perspective. psychoanalytic inquiry, 9: 364374. van der kolk, b. (1994). the body keeps the score: memory and evolving psychobiology of post traumatic stress. harvard review of psychiatry. 1:253 265. wallin, d. j. (2007). attachment in psychotherapy. new york: guilford press. date of publication: 15.11.2014 alcoholism is such a common condition that therapists must be exposed to clients who suffer from it, whether the therapist is analysis of contributing factors to development of self when exposed to violence deb davies-tutt abstract: this paper outlines case studies of two men who were subjected to abuse during their childhood. sociological and psychological theories are considered when an individual experiences inconsistent and dysfunctional caring. the sociological elements in the development of self will be addressed and how cultural norms can impact on the balance of power within society. the history of society’s view of violence within the family is considered and the historical context in which it emerged as a social problem are compared to the abuse suffered by the subjects of the case study. the paper addresses the need for a psychosocial approach when violence disrupts the formation of self and impairs psychological development. key words: abuse, violence, mirroring, a psychosocial approach ________________________ to be that self which one truly is (kierkegaard, as cited in rogers 1976, p. 110) the aim of this paper is to examine, in detail, case studies of two men who were born around the same time and both who suffered abuse. having been exposed to domestic violence through my developmental years, i was drawn to this area of analysis in an attempt to reveal why i survived such trauma and others did not. also, is my survival due to some innate strength i was fortunate enough to possess? or was it due to a combination of events that ensured my survival? since writing this paper i have decided to start a journey of discovery in my own on-going therapy to better understand how i survived as a young child. the case studies used in this paper were selected from a published biography and autobiography. they provided the opportunity to compare and contrast two vastly different outcomes for victims of abuse. one appears to display remarkable resilience, in contrast to the second, whose life ends in tragedy. to international journal of integrative psychotherapy, vol. 2, no. 2, 2011 62 try and fully understand the reasons why their lives took such differing directions it is necessary to adopt a psychosocial approach. to comprehend why an individual’s mind develops in a certain way, consideration must be given to the structure, development and functioning of the society within which the person exists. to start, it is necessary to delve into the experiences of childhood, through their engagement with their carers, and then how they draw from this engagement to equip themselves or not with the required tools to function within society. the chosen area is vast and one can easily be drawn down various avenues of enquiry. this report will focus on the early interaction between infant and care-giver, and how that contributes to the development of the self or, as fonagy and colleague’s term, the ‘psychic self’ (fonagy et al, 2002, p.4). their work focuses on the psychological self, which they believe evolves from infancy through childhood and whose development is critically dependent upon the interaction with the more mature minds, which are both benign and reflective in their turn. consideration will be given to the possible outcomes if a child is exposed to dysfunctional caring. the work of john bowlby and his theory on attachment styles, written in 1969, will be included. he believed the child adopts a similar style of attachment to that of their parent. also, during the early years, a child will form strong affectional bonds to a particular other and if unwilling detachment arises this could lead to emotional distress and personality disorder (bowlby, 2005). gerhardt (2004) also believes “our minds and our emotions become organised through engagement with other minds, not in isolation” (p. 15). she addresses the biological process that takes place within the development of the child’s brain in the early stages. she believes without the appropriate interaction with others the development of the brain will be impaired. again reinforcing the argument that the social forces an individual are exposed to in the early years has an immense impact on the developmental process. therefore, if one takes the studies of bowlby, gerhardt and fonagy in isolation, and posit that the environment a child is exposed to hugely affects the early years of development, it would then follow that all siblings should emerge in very similar ways. this is an area that is addressed by james (2002), who claims “each individual child’s nurture is particular to that child and she develops her own niche in the family as a result of receiving radically different care” (p.39). james believes that each child enters the family environment a different stage from those of their siblings. the marriage could be gradually deteriorating and therefore the environment more hostile. also, parent’s treatment of each of their children is different, and he suggests that one of the reasons for this is due to gender. international journal of integrative psychotherapy, vol. 2, no. 2, 2011 63 the final area addressed in part two is the question: is an individual’s psychic reality innate; or is it, as suggested above, a product of the influences children are exposed to in their early years? an understanding of this area might contribute towards understanding why one victim appeared to survive his abuse and the other did not. was the first born with some inherited inner strength, or self-belief, or was he fortunate to be exposed to the right environment at the right time? doctor susan blackmore (2005) addresses this area when discussing consciousness. she believes to talk about consciousness is to talk about subjectivity. this area of research is vast and will therefore only be touched on briefly. to reflect its complexity, chalmers phrased it ‘the hard problem’ (chalmers, 1995 as cited in blackmore, 2003, p.21). also, blackmore claimed that to try and locate exactly how our subjectivity emerges is like trying to look into the darkness (blackmore, 2005). having looked at psychological approaches to development, the final section will examine the sociological aspects. it will pose the question of why no intervention was forthcoming when the victims were being abused and also why the victims themselves did not inform anyone outside of the family about the abuse. it will begin by examining some of the changes that modern living has brought on individual behaviour. craib (1994) believes the systematic social changes that have occurred have led to the notion that an individual’s emotional life can be managed and organised; this leads to the phantasy of the all-powerful self (p.97). bettleheim (1960) refers to the intolerance society shows when individuals do not match the social norms. horley (2005) tackles the issue of violence within the family, in particular the imbalance of power that is found there and the apparent tolerance society attributes to it. barnett and colleagues highlight exactly when violence within the home was deemed a social problem, and not just a social condition (barnett et al, 1997). this will help to give possible reasons why the intervention mentioned above did not take place. when examining the modes of intervention that are available, yllo raises the issue that there is yet no over-arching theory when addressing violence within the home (yllo as cited in hansen et al, 1998). having pulled back and examined the broader sociological issues, the final section of the paper will address the issue of social isolation and the lack of social integration, which was evident in both case studies. john demos illustrates clearly how social changes have had an impact on how society self-monitors (demos as cited in hansen, 1998, p.661). it also considers how society reacts to individuals when they do not conform or meet social norms. the emotion of shame will be adduced to help address the possible reasons why the victim did not feel able to notify the authorities and why society did not intervene sooner. international journal of integrative psychotherapy, vol. 2, no. 2, 2011 64 part one: psychosocial selves to begin this analysis it is first necessary to outline the areas of david’s and stuart’s lives that had the most impact on the development of their psychological selves. in the first five years of david pelzer’s life his environment seemed stable, but his mother’s behaviour was extreme. she pushed herself to maintain most aspects of her life to the highest standards possible, instilling in her children the mentality that they must do their best at all times whatever the task. one reason for this extreme behaviour could be what fonagy (2004) terms an imbalance in an individual’s psychic reality. ‘psychic reality’ is the subjective experience influenced by unconscious processes. for example a neurotic adult will attribute more importance to their internal reality than their external. when trying to plot the first five years of stuart shorter’s life, difficulties are encountered. when asked about them stuart would reply, “i blew it out” (masters, 2005, p.271). when pushed for an explanation he claimed he could not remember events from his past due to the amount of prescribed anti-psychotic drugs he had taken. “cos that’s what a lot of the anti-psychotic i’ve had over the years are designed for, to stop you from lying there brooding, going over and over the same things. when i go on a really bad one, start smashing things up, cutting meself, it’s because of all the thoughts that are still there, but there’s no reality to them any more, there’s no visual reality, it’s just feelings within” (masters, 2005, p.272). research into stuart’s past revealed that during his initial years he was exposed to a violent relationship between his parents. stuart’s mother claimed his father would beat her whether sober or drunk. the grandparents declared they could hear the screams from two houses away. by the time stuart was five his parents had divorced and his mother went on to marry a quiet placid man (masters, 2005, p. 201). by this time bowlby’s (1988) theory would predict stuart’s attachment style had been formed. bowlby believed the tendency to treat others in the same way that we have been treated is deep in human nature. this could account for the emergence of violence, which dominated stuart’s life in later years. having been exposed to extreme violence in his early years stuart joined a mainstream school. unfortunately he inherited a condition from his father termed muscular dystrophy. during a p. e. lesson he fell and cut his mouth, an event which led to the school declaring him unfit for mainstream education and he was sent to a school for the severely disabled, which involved him being picked up from his home in what the local children called the ‘the spaggy bus’ (masters, 2005, p.196). if they saw the bus coming by they would run alongside it, laughing and waving their arms. whilst attending the school stuart was described by one teacher as “an affectionate little boy, but could sometimes be a little bugger”. i always felt i wanted to rescue him and take him home – from what international journal of integrative psychotherapy, vol. 2, no. 2, 2011 65 i did not know” (ibid p.5). stuart had to endure the stigma enforced on him by his peers; scrambler defined “stigma is a societal reaction that spoils normal identity” (scambler, 1987, p.139). one of the types of stigma goffman (1963) identifies is attributed to an individual suffering from physical deformities, the consequence in which ordinary social intercourse is turned away. in contrast, the period between the ages of five and twelve was when david was subjected to extreme physical abuse at the hands of his mother. he was made to wear the same clothes to school day after day and he was not allowed to travel to school in the family car with the rest of his siblings, but made to run (pelzer, 1995, p.58). due to the lack of food he was given at home david began to steal food from his fellow pupils. he was eventually caught and his mother notified, which led to further beatings and his becoming an outcast at school. she started to refer to him as ‘it’ in an attempt to psychologically disassociate herself from him. he was made to sleep in the garage, having been told he was not good enough to sleep upstairs. his father appeared powerless to intervene in david’s suffering. at the age of twelve david was taken into care due to the intervention of his teachers. he had suffered abuse at the hands of his mother for seven years, and during that time he had displayed various injuries. the school had recorded his injuries for several months before they alerted the police. the lack of intervention is a reflection of the reluctance of society to intervene within the family unit. it is important to note that david’s abuse did not start until he was five years old; therefore he had a time in his life to develop a secure attachment style. it could be suggested that this would have sustained his psychological well-being during his most trying times. siegel (1999) claims longitudinal studies of attachment styles have found that early relationship styles can promote social competence, cognitive functioning and resilience in the face of adversity. in comparison, around the age of nine stuart’s brother gavvy would climb into his bed at night and sexually abuse him, “touch him up” (masters, 2005, p.254). a few months after this gavvy involved a male babysitter and the assault became more penetrative and aggressive. in the years ahead when stuart was consumed with the memories of these assaults he would reach for the nearest available implement and injure himself. when asked if it hurts he replied ‘yes, but at the same time it’s pleasurable. not sexually pleasurable, but it’s not like ordinary pain. it’s like you are separated from it. there is a sense of unity, the physical act displaces the mental pain” (masters, 2005, p.123). at the age of twelve, whilst walking home, stuart was tormented by local youths, who called him ‘spaghetti legs, bandy boy, vegetable’. he eventually turned around and head-butted the tallest bully. this was to prove to be a pivotal moment for stuart; he discovered violence and felt it gave him power. later stuart confessed that this incident released or created an aspect of his personality that he had always toyed with, but kept at arm’s length. it became too strong for him and began to dominate his behaviour. international journal of integrative psychotherapy, vol. 2, no. 2, 2011 66 later in his life stuart describes this feeling: “somebody who’s educated could probably control it better, because they’ve got a stronger mind. the more i try and control it the worse it gets. there’s no set pattern for my rage now. i don’t even ever see it coming. i have these conversations with myself, where the more i try and calm myself often the worse i get. that’s the bit i hate. i lie there fantasising, talking to myself, having mad conversations. i won’t get out of bed for a couple of days, won’t go out the house, won’t undo the windows, won’t answer the door, won’t answer the phone. then i start getting paranoid. well, i call it paranoid, but the doctors keep saying to me, that’s not paranoid, it’s anxiety. i beg to differ” (masters, 2005, p. 228). stuart’s doctor diagnosed him as having borderline personality disorder (bpd). at the age of twelve stuart was sent back to a mainstream school, but he had now developed a coping mechanism using violence to silence the bullies. he claimed “the same people who use to be cruel, were now cautious” (masters, 2005, p. 259). after six months he was expelled. applying sigmund freud’s theory of development to stuart, the way stuart describes the violent incident as releasing or even creating an aspect of his personality. freud would believe that this incident tapped into stuart’s unconscious; the violence he had witnessed as a very young child was now being re-enacted, the behaviour which he had internalised and repressed within his id. crain (1980) describes the id as “containing basic drives and reflexes, along with images and sensations that have been repressed” (p. 265). at the age of twelve stuart repeatedly demanded to be put into care; he had run away from home constantly for the past year. one night he smashed the house and threatened his mother with a knife, screaming he would kill the young children if she did not let him go. years later he disclosed that whilst his mother had been out gavvy and the babysitter had sodomised him with a milk bottle. the trauma stuart was exposed to and the fact he did not disclose to his mother what he was being subjected to was, added to his psychopathology. the more consistent, chronic and intense the insufficiency of the carer the more likelihood there is for the child to develop negative and unhealthy characteristics. “more significant than the trauma itself is the absence of the healing and supportive relationship following the traumatic experience; it is this absence that transforms the experience from a painful, one-time incident to a script-forming trauma” (moursund and erskine, 2004, p.52). both boys were placed into care at the age of twelve, but the main difference was that david was immediately placed with foster parents whereas stuart was placed in a care home. david received the love and support he had lacked for many years, but stuart continued to be sexually abused by the man who ran the care home. stuart continued to run away from the home, became involved in crime, which resulted in his incarceration in one of her majesty’s international journal of integrative psychotherapy, vol. 2, no. 2, 2011 67 prisons. this was to become a pattern in his life, at the time of his death he had ninety-eight criminal convictions. whilst in prison his violent behaviour continued. when the prison officers tried to restrain him during a violent outburst, it would only serve to increase the violence. stuart would say “i used to go in such a state, just so i didn’t feel nothing. get yourself so fucking psyched out, so you couldn’t feel it when they are jumping on you, pinning you down” (master, 2005, p.262). when his mother was attacking him, david’s coping mechanism was to totally disconnect himself from all the physical pain. he states “whenever mother struck me, it was as if she were taking her aggressions out on a rag doll. inside, my emotions swirled back and forth between fear and intense anger. but outside i was a robot, rarely revealing my emotions; only when i thought it would please the bitch and work to my advantage” (pelzer, 1995, p.131). in contrast to stuart, between the ages of twelve and fifteen, david did get himself into trouble with the law but this behaviour did not last. david entered the local school suffering some disadvantages. his social skills were poor and he had to have extra lessons to improve his speech. he suffered numerous disappointments from his father who would arrange to spend time with him but fail to turn up. this resulted in david becoming very rebellious; because his social skills were so poor he found it hard to make friends. he began to steal from local shops to impress his peers. he became embroiled in an allegation of setting light to the school and was placed in a juvenile hall. this appeared to be a turning point in david’s life; he started to work extremely hard at everything he did. this was to become a trait; it could be suggested that it was mirroring his mother’s previous trait, and that he would carry it for the rest of his life. he struggled to enlist in the united states air force, having to undertake extra tuition to ensure entry. throughout his early adult years he was plagued by self-doubt, always looking for answers to why he was abused as a child. he felt drawn to work with children who had been abused to, encouraging them to break the cycle of abuse. he found it hard to commit to his first serious relationship, always keeping his girlfriend at a distance. she became pregnant and they married, but it was not to be a happy marriage as david could not bring himself to truly open up to his wife or indeed to trust her. their marriage ended and this sent david crashing into a solitary existence, where he spent most of his spare time cleaning his new home to extreme lengths. he did not feel worthy of even going to the cinema, full of self-loathing because he felt he had let his son down by allowing the marriage to fail. he eventually married again, and it was only when he met his second wife that he realised he had been fighting for most of his life to be the best he could be. oliver james believes children find their own place within the family; he terms it as ‘scripting our place in the family’ (james, 2002, p. 44). he believes each child develops particular strategies to gain their parent’s attention. one such strategy a child can adopt is the ‘dominant goal’. many successful people are afflicted by self-criticism, feelings of unworthiness, inferiority and guilt. they may set themselves impossible standards, strive to international journal of integrative psychotherapy, vol. 2, no. 2, 2011 68 achieve perfection and are highly competitive. unfortunately they are always plagued with the feeling that their best is never good enough (p. 62). stuart’s life became a cycle of self-abuse and violent outbursts. in between prison sentences he lived on the street. the author of the book, alexander masters, first met him whilst he was sitting in a doorway in cambridge city centre. stuart informed him that he planned to kill himself and to make it look like murder. when asked how he would achieve this stuart replied, “i’ll taunt all the drunk fellas coming out of the pub until they have to kill me if they want a bit of peace. me brother killed himself in may. i couldn’t put me mum through that again. she wouldn’t mind murder so much” (masters, 2005, p.13). stuart had supportive family, loyal friends and could even get a job, but he chose to remain on the streets. when asked why he had messed it up, he replied, “i don’t know, sometimes it gets so bad you can’t think of nothing better to do than make it worse” (ibid p.39). david displayed resilience in his life, always striving to be the best he could be, and he later became a successful writer. stuart showed a different determination. throughout the stories of stuart’s life he would always show a grim willfulness, a determination not to be thwarted. “sometimes it would come across as a display of spirit, sometimes as idiotic defiance in the face of failure. he simply keeps going until either brute force or exhaustion steps in and puts a stop to him” (masters, 2005, p.177). before stuart died he made a tape recording of his thoughts one night for the author of the book. in this recording he summarized his feeling about his life. he felt anger towards the injustice he had suffered whilst young, and he recalls reporting the abuse he had suffered at the hands of his brother and babysitter but frustrated no action was taken. stuart claimed the more he spoke about it the more people did not believe him, so he just carried on, not wanting to be here anymore, feeling dirty and disgusting. he stated, “i wanted just to lay down and die. i felt so dirty, and fucking horrible and hated and attacked anyone i got close to. i can’t even have a relationship if i want it because i think sex is dirty and disgusting. i just wish once there could be an escape from this madness” (ibid p.191). comparing the lives of these men, it is clear that they hold similarities in the fact that they both suffered abuse from their families, but there would appear to be some crucial differences. firstly, david’s first five years were free from physical abuse, while stuart witnessed the physical abuse towards his mother from his father. they both did endure abuse from the age of five years to twelve. they both experienced the shame and stigma forced onto them by their peers. david displayed poor social skills and stuart had a physical disability. stuart responded with violence but david strived to impress by stealing from local shops. both boys were placed into care at the age of twelve. david went to a caring foster home, and developed a supportive and caring relationship with his carers. stuart was placed in a care home where his abuse continued, and he international journal of integrative psychotherapy, vol. 2, no. 2, 2011 69 responded by continually running away, eventually to live on the streets. finally, david pursued the need to help others and as a consequence became a successful writer, but stuart could never find peace, always fighting the painful memories of his past. to try and delve into the reasons why one man took one route and not the other, it is necessary to start at the beginning of the development of the self, to apply psychological theories to the relationship a child experiences with their carers and how they emerge with a sense of self. part two: the psychological self the first developmental theory that will be applied is that of bowlby, who is one of the most prominent voices in this field, and renowned for his attachment theory, which was presented in 1969 in a paper called ‘attachment and loss’ (cassidy and shaver, 1996). bowlby believed children should achieve a sense of security from the attachment they form towards their carers, by their interaction with them from birth. through the responses they receive, such as touching, holding and soothing, this will strengthen their attachment. the experience of security is the goal of the attachment system, which is thus first and foremost a regulator of emotional experience; a child will adjust its behaviour according to the responses he or she receives from the carer. when frightened by a new experience it will seek out the caregiver for reassurance. bowlby believes that by the end of the first year the child will have developed its own representational systems which he terms as the internal working model (iwm) (stroufe, 1996 as cited in fonagy, 1999). the child’s iwm will effect how it interacts with others throughout its adult life. it provides a prototype for all later relationships, and such models are relatively stable across the lifespan (collins and read, 1994 as cited in fonagy, 1999). however, bowlby (1988) also states: “although the capacity for developmental change diminishes with age, change continues throughout the life cycle so that changes for the better or for the worse are always possible. it is this continuing potential for change that means that at no time of life is a person invulnerable to every possible adversity and also that at no time of life is a person impermeable to favourable influence” (p. 154). david’s first five years were relatively stable, although he was subjected to his mother’s obsessional behaviour of striving for high standards in all areas of her life. due to this stability david should have initially developed a sound internal working model. in contrast, stuart witnessed a violent relationship between his parents in his first year. bowlby (1988) believed this can lead to the child showing an unusual sensitivity towards the needs of his carer. this could go some way to explaining why stuart was reluctant about telling his mother about the abuse he was suffering at the hands of his brother. international journal of integrative psychotherapy, vol. 2, no. 2, 2011 70 fonagy and colleagues build on bowlby’s theory and the (iwm). they believe its development creates a processing system for the self, the capacity to interpret human behaviour, to make sense of each other. fonagy terms another process as having an ‘interpersonal interpretive mechanism’ (iim). he differentiates this from bowlby’s iwm because the iim does not just process previous attachment experiences, it processes new experiences. he compares it to possessing a ‘theory of mind’, the ability to attribute independent mental states to others in order to explain and predict their behaviour (leslie, 1987 as cited in fonagy 2002). the ‘theory of mind’ (baron–cohen, 1995) demonstrates how a child’s psychic reality develops from 0 – 4 years. the definition of the theory of mind is: “the ability to attribute intentional mental states – goals, desires and beliefs to oneself or others as an explanation for actions, and this is not fully developed until 4 years of age” (wellman, 1990 as cited in fonagy, 2002, p.261). at around 3 the child displays psychic equivalence, where ideas are not felt to be representations, but rather direct replicas of reality and consequently always true. alternatively the child uses pretend modes, through play it enables ways of functioning that are rarely used, developmentally suppressed, or only just being formed to occupy centre stage (fonagy, 2002). this playing or pretending at times reveals surprising competencies, while at other times it offers opportunities for regression and the expression of unconscious concerns. it is at this stage that it is crucial that the child receives a secure loving environment and effective mirroring, to explore these new skills. in the fourth or fifth year, the psychic equivalence and pretend mode normally become increasingly integrated, and a reflective or mentalizing mode of ‘psychic reality’ is established (gopnik,1993). it could be suggested that both men in the case studies failed to receive the secure environment to ‘play with reality’; stuart experienced deep rage when life became difficult and david displayed compulsive tendencies. the term ‘psychic reality’ is usually used to describe a subjective experience that takes place as a result of an unconscious process (michels, 1984). freud’s original concept was “thought reality” versus “external reality”. laplanche and pontalis (1973) give the definition of psychic reality as: “whatever in the subject’s psyche presents a consistency and resistance comparable to those displayed by material reality” (fonagy, 2002, p.255). freud believed that psychic reality poses danger when there is imperfect discrimination between stimuli from the outer world and stimuli that stems from products of the unconscious process. for example an obsessional person “knows” that the door is locked but still checks several times, because for him the internal image of the unsecured house has much more meaning and power than the external images provided by his senses. this could contribute to explaining david’s preoccupation with cleanliness and how this intensified at times of stress and anxiety. he would repeatedly clean the house over and over again even though the external reality was that it was already clean. international journal of integrative psychotherapy, vol. 2, no. 2, 2011 71 fonagy (2002) and colleagues claim the self is originally an extension of the experience of the other. caregivers and siblings are crucial in helping three to four year olds to accept the two realities, the internal and the external, without needing to split their ego functioning to maintain dual modes of thinking. there is a need for adults to play along, to adopt a ‘as if’ attitude to pretend games. so they know that his thoughts or feelings are not ‘for real’. linking his internal state to a perception of that state outside offers a representation – a symbol – of internal state. if the adult’s attitude precludes the duality of holding the frame of external reality while offering mirroring or reflection, the child’s transition towards integration and mentalization may be jeopardized, as in the lives of david and stuart. the importance of the process is not simply play, but play that breaks away from psychic equivalence, while refraining from contact with reality. in other words, the child, using the parent’s mind, is able to play with reality. ‘this provides us with the capacity for seeing ourselves in interaction with others and for entertaining another point of view whilst retaining our own, for reflecting ourselves whilst being ourselves’ (britton, 1987). to fail to do this would then lead to the claim that the true self is lost, as the individual merely adopts the image of the carer and those around them. a weakened sense of self perpetuates the feeling of detachment and emptiness. when david was asked to explain why he always strived to achieve the best, no matter what the task, he replied “because that’s all i had! i got nothing else! it’s all i am! it’s all i’ve ever known. if i quit back then, once for just a second…it could have been all over. i got nothing else all my life” (masters, 2005, p.376). this is a clear example of what fonagy termed as the self-being an extension of the experience of the other. david internalised the mother’s behaviour he witnessed in his first five years. fonagy and his colleagues claim that we must assume, as do most cognitivists working in this area, that the development of theory of mind is as waddington’s (1966) use of the term, canalised, but the canal is dug not by biology, but by infant-parent interaction. so to understand the nature of the mental world is a task that cannot be done alone; it requires the understanding of the self in the eye of the other. fonagy suggests that where the parent is unable to incorporate and think about a piece of reality and cannot then enable the child to do so safely, through playing with the frightening ideas, this reality remains to be experienced in the mode of psychic equivalence. neither child nor parent can ‘metabolise’ the thoughts, and so the ‘unthinkable’ thoughts are passed on from one generation to the next (fonagy, 2002, p.287). the essence of what fonagy is saying is that the self arises out of the infant’s perception of the intentionality of the caregiver, and if the child experiences insensitive miss-attuned parents, a fault will develop in the construction of the psychological self. he also believes that the understanding of subjectivity is essential in understanding the mental mechanisms that emerge from early development. he suggests the infant attachment function makes possible the development of the ‘interpersonal international journal of integrative psychotherapy, vol. 2, no. 2, 2011 72 interpretive mechanism’ and the quality of this early development plays a major role in determining the robustness of this capacity throughout life. siegal (1999) addresses the issues surrounding the regulation of emotions resulting from attachment styles. he believes that human emotions represent the primary value system the brain uses to help organize its functioning. he states “the communication with and about emotions between parent and infant directly shape the child’s ability to organize the self” (p.278). gerhardt (2004) addresses the development of the brain. she claims “the orbitofrontal cortex of the brain is developed in the first three years of a child’s life, and is responsible for managing emotional behaviour and responding to other people and their emotional cues” (p.36). its development is dependent on the child’s interaction with her carers and without appropriate contact the development will be impaired. gerhardt describes the process as “when we are babies, our brains are socially programmed by the older members of our community, so that we adapt to the particular family and social group we must live among” (ibid: 38). in a sense, the human baby is invited to play a part in human culture. regarding the development of the self, fonagy builds on gerhardt’s concept by claiming that infants who experience disorganised attachment develop a preoccupation with self-generated perfect contingencies in the attachment context. this is supported by evidence by koós and gergely (2001). they go on to state “it is clear that, associated with certain extreme social dysfunctions – such as childhood maltreatment, environmental trauma of various kinds – an individual’s capacity to behave with any degree of flexibility comes to be compromised” (fonagy, 2002, p.250). they go on to suggest that this level of inflexibility could be due to the individual’s unconscious need to rediscover the self in response to the other and therefore reactivate the need for higher levels of anticipated responsiveness. this could contribute to explaining stuart’s display of inflexibility, his refusal to be thwarted when circumstances were stacked against him. on one occasion he recounted how he had entered a shop to try and buy a tin of glue, but the shop assistant refused to sell it to him. stuart returned to the same shop later that day and took the glue off the shelf and attempted to run out of the shop. considering the fact that stuart had to leave his first shop because it had too many steps, the likelihood of him out running the shop assistant was minimal. the incident led to his arrest. it could be surmised that this is a good example of stuart’s unconscious need to rediscover the self in response to the other and therefore reactivate the need for higher levels of anticipated responsiveness. in acting out these familiar scenarios there lies a hope that it will be different. the question fonagy asks is psychic reality experienced like pain or are thoughts, beliefs, desires and mental states a construction of our minds, built up in the early years of our development. searl (1983) believes psychic reality is intrinsic, that we are born with it, it is ‘a given’. c g jung also believes that deep international journal of integrative psychotherapy, vol. 2, no. 2, 2011 73 in our unconscious is an inherent primitive archetype; he proposes this represents the self, it is our unconscious striving for centeredness and meaning (jung 1961, as cited in crain, 1980, p.341). freud believed that the unconscious contains the developmental process in the individual child but also reflects the entire history of the human race. therefore individuals have their own private life history, which emerges during dream work and analysis, but there is also a bigger picture common to all of us, which is not acquired by learning (snowdon 2006). blackmore believes that to talk about consciousness is to talk about subjectivity (blackmore, 2001). when exploring this area the dualism argument cannot be ignored because to study consciousness by sticking purely to the neurological aspects would be to deny one’s own subjectivity. to accept that the physical brain causes experiences and subjectivity then is to bridge the gap, or as william james would call it, “ ‘the chasm’ between the inner and outer worlds” (james, 1890 as cited in blackmore, 2001, p.19). an australian philosopher, chalmers (1994) proposed that the challenges consciousness presents could be divided into two groups, the ‘easy’ problems and the ‘hard problems’. the easy problems are those that can be explained by cognitive science, such as accessing and reporting mental states, deliberate control of behavior, make a distinction between different stimuli. all these areas can be explained by using scientific methods. “the really ‘hard’ area is how one can ‘experience what it is like to be an organism, or to be in a given mental state” (blackmore, 2003, p.20). when an individual performs all the functions that can be explained by cognitive science why do they have to be accompanied by experience? chalmers states ‘why doesn’t all this information processing go on ‘in the dark’, free of any inner feel? (chalmers, 1995 as cited in balckmore, 2003). it is the ‘inner feel’ that leads to extensive, continued debate. to try and drill down to what developmental factors contributed towards david’s survival and stuart’s demise, involves examining a plethora of complex developmental stages, each one vastly influenced by environmental factors. from the attachment styles the men were exposed to, the forming of their internal working model or as fonagy termed it, the interpersonal interpretive mechanism, to the forming of the theory of mind and psychic equivalence to psychic reality are to be considered. all these stages of development contribute to the individual’s unconscious and conscious drives. it is here that the uniqueness of the individual emerges, why no two individuals are exactly the same. ultimately, whatever external experiences individuals are exposed to, they and only they can arrange and organise them internally. international journal of integrative psychotherapy, vol. 2, no. 2, 2011 74 part three: the sociological impact on the self having addressed the psychological developments of the self it is now necessary to draw back from the minutie and focus on the sociological aspects of david’s and stuart’s lives. both men were exposed to violence within their family unit, with disastrous consequences. the aim of this part of the paper is to ascertain why no intervention was forthcoming and also why the victims did not inform anyone of their plight. two theorists who help to pose key questions when examining human behavior in a wider context are bettleheim (1960) and craib (1994). craib addresses the issue of disappointment and how important it is for the individual to acknowledge and accept it. he claims that in today’s society individuals are led to believe that any goal can be achieved and any obstacles overcome. he states that society has suppressed the reality that individuals can never be all they wish to be and as a result of this suppression there is a feeling of being incomplete and empty. craib also states “it is about the necessity of conflict, and the necessity of both liberation and repression the result being summed up in freud’s classic phrase ‘normal human misery’” (craib,1994, p.39). this desire to feel the master of one’s destiny could account for the need to distance oneself from the suffering of others; by doing so individuals can create the illusion that it could never happen to them. bettleheim addresses the internal and external realities and also the compromises that individuals have to make within these realities. he believes individuals must integrate the internal and external realities in order to permeate their surroundings with their own personalities. he states “one must develop a clear concept of what can be given to the environment without compromising the inner-self” (bettleheim, 1960, p.15). bettleheim claims psychoanalysts suggest it is not society that creates all the difficulties in man, but the contradictory nature of man that creates the difficulties in society. jung believed that the self is an inner urge to balance and reconcile the opposing aspects of our personalities, to achieve a psychic balance, but one which also separates ourselves from our ordinary conformity to the goals and values of the mass culture (jung 1933 as cited in crain, 1980, p.89). bettleheim (1960) believes unless an individual’s life bears the flavour of personal preference and individual style it will seem barren. he also addresses the intolerance that society shows when individuals fail to live up to standards that may be culturally desirable but not essential for society to continue. this could go some way towards explaining the social taboo that surrounded domestic violence for many years and to some extent still does today. violence within the family has a huge impact on society, both financially and emotionally. in london a minimum of £278m is spent each year responding to domestic violence, and this figure does not take into account the medical and legal costs (horley, 2001). horley advocates that alcohol, unemployment, drugs international journal of integrative psychotherapy, vol. 2, no. 2, 2011 75 or stress alone do not cause violence within the home. she claims “it is as a result of a complex interplay of psychological and social factors, which have created an imbalance of power between the sexes. where there is an imbalance of power, it may be abused, and it is this, coupled with society’s tolerance, which has allowed domestic violence to flourish” (p. 11). when looking back in history to account for society’s tolerance to domestic violence, one of the more revealing aspects and one that will throw the most light on the question proposed above is to pin-point when violence within the family was deemed a social problem that needed to be addressed. barnett (1997) and colleagues state that family violence was a social condition long before it became a social problem. many sociologists point out that social problems are socially constructed (spector & kituse, 1977 as cited in barnett et al 1997, p.5). the social problem is dependent on social reaction and this is produced by a number of different sources from social movements and organisations, such as the church, media and political interest groups. barnett refers to the interest groups as claim-makers who are actively engaged in raising society’s awareness. as a social condition comes to be recognized by society more generally, the social condition becomes a social problem. it would then follow that the levels of acceptable violence within society are culturally led. a very clear example of this is that in the japanese language there is no word for the english concept of ‘domestic violence’ (yoshihama & sorenson, 1994 as cited in barnett et al 1997, p. 6). due to the fact there is no social condemnation of intimate violence within japanese culture, it is not perceived as a social problem. david and stuart were born in the nineteen-sixties; it was from the late sixties into the seventies that violence towards women received renewed attention. in 1971 the first women’s aid shelter was opened for female victims of domestic abuse in britain. therefore when stuart was witnessing the violence between his parents, the acknowledgment of violence against women being a social problem was only just emerging. also, david became a victim of his mother’s abuse around 1966. it was in the early sixties that child abuse was recognised as a social problem. in 1962 kemp and colleagues defined child abuse as a “clinical condition with diagnosable medical and physical symptoms resulting from deliberate physical assault” (kemp, 1962 as cited in barnett, 1997, p.7). it was not until 1974, the year after david had been taken into care that the child abuse prevention and treatment act was passed in america. this may go some way towards explaining why it allegedly took seven years for the authorities to intervene in david’s plight. it could have been that the claim-makers had not sufficiently brought the issue of child abuse into society’s awareness. when looking back into the history of childcare it shows that a child was perceived very much the property of the parent and subsequently parents would treat their children how they saw fit, as a being without any independent status or rights (walker, bonner & kaufman, 1988 as cited in barnett et al 1997, p.6). international journal of integrative psychotherapy, vol. 2, no. 2, 2011 76 sociologist yllo believes violence within the family cannot be fully understood unless gender and power are taken into account (yllo as cited in hansen et al 1998, p.609). she acknowledges that the feminist movement has not yet fully developed a distinctive framework for explaining domestic violence, but they are in good company because there is no single view in existence. hanmer believes that the field of sociology fails to consider adequately the role violence plays in maintaining male and female relations. like yllo, she raises the point that there is a lack of one over-arching theory about violence within the family unit. instead, researchers propose the cause to be explained be several theories addressing different areas. hanmer states “at crucial moments there seems to be a tendency to individualise and psychologise. the norms and values of violence are seen as deviant, affecting either sub-cultures or some individual families, while society as a whole remains unaffected” (hanmer as cited in littlejohn, 1978, p.222). the complexities that arise when trying to develop a framework or theory become apparent when consideration is given to the multiagency and multi-disciplinary approach that is evolving today. as nicky stanley and colleagues state “there is a potential structural problem which lies at the heart of responding appropriately to the needs of a child living with violence and abuse as well as to those of the adult victim who is usually also the child’s mother and primary carer” (stanley, as cited in humphreys, 2006, p.36). in response to the complexities encountered when trying to address the social problem of violence within the family, a domestic abuse intervention programme was founded in duluth, minnesota in 1980. it was formed as a result of the efforts of some innovative feminist activists who received the support of a progressive community. the main aim of the program was to shift the responsibility for the violence away from the victim and on to the state and the assailant. (dobash and dobash, 1992). the program was based on the theory that violence is used to control people’s behaviour and that individuals are socialized in a culture that values power. “the long patriarchal tradition…was explicitly established in the institutional practices of both the church and the state and supported by some of the most prominent political, legal, religious, philosophical, and literary figures in western society…they believed that men had the right to dominate and control women and that women were by their very nature subservient to men. this relationship was deemed natural, sacred and unproblematic and such beliefs resulted in long periods of disregard and/or denial of the husband’s abuses of his economic, political and physical power” (dobash & dobash, 1980, p. 7). in essence men are socialized to be dominant and women to be subordinate. men who assault women draw from cultural messages justifying their dominance within the home. for example they will make statements such as ‘someone has to be in charge’ or “‘this is my child, it is my responsibility to control him” (pence, international journal of integrative psychotherapy, vol. 2, no. 2, 2011 77 1993, as cited by dobash & dobash 1980, p.183). however, pence, a founder of the duluth project, does believe there has been an important shift in perspectives. “rather than seeing violence in the family as merely a ‘domestic’ problem arising from pathological individuals or dysfunctional families, battering is now seen as a criminal offence. (dobash & dobash, 1992, p.183). throughout the life of the duluth project, between 1982 and 1984 there was a 47 per cent reduction in reported domestic incidents received by the police. when examining the history of violence within the family and its apparent persistence, and lack of intervention, a proposed contribution towards an explanation by the historian demos is social isolation. many families in today’s society find themselves living in a neighbourhood where they do not know who their neighbours are. in the past, society reflected a more integrated existence; every day offered a density of human contact. just by carrying out daily essential duties guaranteed an encounter with the wider community. this in return ensured mutual support and mutual surveillance (demos, as cited in hansen, 1998, p.661). the studies carried out on the lives of abusers frequently found them to be friendless, isolated and, as demos phrases it, ‘rootless’. human animals are essentially social beings, and without a social outlet the abuser turns to the nearest available target. in the case of david, his mother had withdrawn from all social contact, spending the majority of her day in the house alone. in addition to the above, quantitative studies have shown that abusing parents have a disproportionate experience of ‘crisis’ as measured on a ‘social readadjustment scale’ (demos, as cited in hansen et al, 1998, p.662). demos argues that in this pre-modern setting, change occurs more frequently than a few generations ago. it appears that for many individuals the capacity to absorb change has diminished. demos states “we have no clear equivalent to the ‘providential’ worldview of our forebears – their belief that all things, no matter how surprising and inscrutable, must be attributed to god’s overarching will” (p. 662). in the beginning of the nineteenth century, this view was replaced by ‘individualism’, personal destiny was seen as something self-determined, but also dependent on one’s family. the family structure moved from the child contributing to the working of the household to the parents being charged with the responsibility to provide the best life prospects for their children. to return to the original question as to why society did not appear to respond to david’s and stuart’s sufferings. psychologist lerner believes one possible reason could be an individual’s tendency to find a reason to attribute blame towards the victims, stemming from their own need to believe in a just world (segal, 1986). kushner also states “blaming the victim is a way of reassuring ourselves that the world is not as bad a place as it may seem, and that there are good reasons for people’s suffering. it helps fortunate people international journal of integrative psychotherapy, vol. 2, no. 2, 2011 78 believe that their good fortune is deserved, rather than being a matter of luck” (segal, p.86). the next aspect of these case histories to be addressed is the fact that the victims did not inform the authorities outside the home of their plight. david attended school every day and was repeatedly asked how he had sustained his injuries. he would attempt to explain them away by fabricating accidental events around the home. stuart, whilst being repeatedly abused by his brother, did not immediately disclose to his mother or the school that abuse was taking place. the one emotion that is likely to have prevented them from doing so is shame. shame is an emotional response individuals experience when presented with a situation that does not reflect the cultural norms, either as the victim or the observer. examining ‘shame’ brings both sociology and psychology together, because shame is a psychological response to social expectation. yet to talk about shame is a social taboo. most other languages such as french and german have two words that describe two types of shame; ‘everyday shame’, which carries no offence and is necessary for daily interaction, and ‘disgrace shame’, which carries with it a social stigma. due to this lack of distinction within the english language it is not possible to discuss shame without risking offence (scheff, 2003, p.241). katz proposes one definition of shame: “an eerie revelation to self that isolates one in the face of a sacred community. what is revealed is a moral inferiority that makes one vulnerable to irresistible forces. as a state of feeling, shame is fearful, chaotic, holistic and humbling” (katz,1999 as cited in scheff, 2003, p.245). whilst reviewing the david and stuart stories it is evident that they experience shame. david, in his early years, experienced obsessive behaviour, periods of isolation and a deep feeling of worthlessness. stuart experienced the feeling of isolation when living on the street, always being on the outside looking in, and he managed his feeling by turning to drugs and alcohol. scheff (2003) states that shame is inherently a social emotion; unlike any other emotion it depends on specific aspects of social relationships. he believes there are two social sources that are common to shame: “first, most of one’s personal ideals are held in common with other members of one’s society. personal ideals are largely social ideals. second, and more subtly, the interior theatre of the self, in which both shame and embarrassment occur, is modelled on social interaction. one becomes ashamed by seeing one’s self in the eyes of the other” (p. 253). when trying to step back and uncover the possible reason why the society of their time did not intervene in david’s and stuart’s lives, and why they did not disclose their abuse to someone outside the family, the over-riding thread seems to be the influence of cultural norms. jung spoke of the ‘ordinary conformity of the goals and values of the mass culture’ (jung, 1933 as cited in crain, international journal of integrative psychotherapy, vol. 2, no. 2, 2011 79 1980p.341). bettleheim also addressed the intolerance of society when individuals fail to live up to what is culturally desirable (bettleheim, 1960). dobash and dobash (1992) reflected on the culture that surrounded a patriarchal society and where individuals were and still are socialized to value power. in addition, barnett also believes that the acceptability of violence within society is culturally led (barnett, 1997). even clearer is the way the emotion of shame is reacted to, in particular within english-speaking cultures. the issue of shame being an emotion that is aroused when individuals fail to meet the social or cultural ideals, which leads to the inhibition of the individual when there need is greatest, as demonstrated by david’s and stuart’s behaviours. summary placing the case studies side by side creates an opportunity to analyse what elements of the men’s lives influenced the outcomes. the first crucial difference took place in the first five years. david experienced a fairly stable environment, whereas stuart did not. this makes the application of bowlby’s attachment theory extremely relevant. it would appear that by experiencing this stable, consistent, nurturing, secure base, david managed to create a more robust internal working model and, as bowlby states, this affected how he interacted with others throughout his life. stuart was not so fortunate as he witnessed extreme violence during his first five years; bowlby believed a consequence of this would be to develop an extreme sensitivity towards the carer. this is evident during the initial conversation stuart had with the author of his book. he was trying to provoke someone into beating him to death, as he thought his mum would be less upset by murder that if he committed suicide. the next theory that was applied in more detail was that of fonagy and colleagues and the ‘interpersonal interpretive mechanism’ (iim). he compares this to the development of the ‘theory of mind’. fonagy and colleagues again place great importance on the first four years of a child’s life, and the development of a ‘psychic reality’. they believe a child will move from their ‘psychic equivalence and with the appropriate loving environment and effective mirroring, they will develop their psychic reality. they term it ‘playing with reality’, and it allows children to reflect themselves whilst being themselves. if they fail to experience this then their true sense of self is lost, and they will merely adopt the images that are around them. this weakened sense of self perpetuates the feeling of detachment and emptiness. david appeared to have an opportunity to gain a sense of self, even though evidence shows he did internalise his mother’s obsessive traits. stuart in contrast experienced a volatile existence; he continued throughout his life to have a deep sense of being worthless. the above theory clearly demonstrates how a child’s early development can be either hindered or helped by the care received. it can determine international journal of integrative psychotherapy, vol. 2, no. 2, 2011 80 psychological behaviour in the future, even though bowlby did believe that change was always possible, it does become more difficult with increasing age. fonagy and colleagues believe that it is never too late for an individual to ‘play with reality’ and possibly transform aspects of themselves from the ‘psychic equivalence’ to a ‘psychic reality’. the next crucial aspect of the case histories is how their paths held similarities when they were twelve years old. they both went into care, but while david went into loving and supportive foster care, stuart went into state care where his abuse continued. moursund and erskine (2004) believe that the longer a child is exposed to insufficient or inappropriate care, the more likely it is to development negative characteristics. what is also extremely relevant when applying this to stuart’s story is that they believe that what is more important than the exposure to abuse, is the absence of a healing and supportive relationship. if this is absent the experience will be transformed from a painful period to a scriptforming trauma; when considering stuart’s last recording before his death, the evidence of this is clear; the feeling of being dirty and disgusting, and wishing to die. in an attempt to look more closely into the meaning of an individual’s ‘psychic reality’, a term that is usually used to describe a subjective experience, consideration was given as to whether it emerges at birth as part of the self or is formed through interaction with others. analysis of these cases was an attempt to clarify whether or not david was born with a strong ‘psychic self’ which gave him the ability to survive the abuse. it was quickly realized that this is an unanswerable question; to break down someone’s subjectivity or consciousness into examinable pieces is not possible. it is as blackmore (2003) put it, ‘trying to look into the dark’. freud believed every human carries the history of human nature within the consciousness, a claim that could never be proved. the most plausible explanation is that there is no one single influence that creates the ‘psychic self’; it is a mesh of inputs, running parallel and interconnecting within the self. it is for this reason that individuals are unique within their own subjectivity. the final section of the paper addresses the sociological aspects of the case histories. it poses key questions as to why there was no intervention from the state into the boy’s plights and why the boys themselves did not ask for help. craib (1994) highlights how individuals within society live within an illusion that they can achieve everything they want to achieve, and therefore pull away from disappointment. bettleheim addresses the need for individuals to integrate their internal and external realities to permeate their surroundings with their personalities. bettelheim (1960) also addresses the intolerance society shows individuals when they fail to live up to the cultural norms. this intolerance could attribute to the social taboo that surrounded violence within the home for many years. international journal of integrative psychotherapy, vol. 2, no. 2, 2011 81 horley (2001) begins to bring the psychological and sociological factors together, stating that it is due to the imbalance of power between the sexes and society’s tolerance that has allowed domestic violence to flourish. by looking back into the history of family violence it reveals that when the men were being exposed to abuse the issue had only just been deemed a social problem that needed to be addressed. this could go some way into explaining why the intervention was slow or absent. it is also relevant to note that there is no one over arching theory when addressing violence within the home. the plethora of agencies that are needed when attempts are made to intervene is immense. such are the complexities when trying to deal with conflicting psychic realities and cultural norms. the project that took place in duluth achieved impressive results. it strived to coordinate all the agencies involved, but most importantly it moved the responsibility of prosecution away from the victim and back onto the assailant and the state. it recognised that the acceptance of violence within the home stemmed from the ingrained, patriarchal standpoint and, unless challenged, would continue to be tolerated. essentially there was present, within society, a cultural message justifying men’s dominance within the home. the consistent thread evident when examining the sociological aspects of violence within the home is the influence of cultural norms. demos highlights the changes that have occurred within modern society, the isolation that occurs as a direct result of the demise of daily interaction. as he states, at one time individuals had to interact within their community to ensure essential tasks were carried out. with this interaction came mutual support and mutual surveillance. however, social isolation can only be one of many contributing factors when considering the apparent social tolerance of family violence. the final area addressed is the individual’s and society’s experience of shame. shame was the possible reason for the men not disclosing their plight. it is also possible to apply the place of shame in a wider sociological context. social taboo surrounds the issue of shame and how it is not socially acceptable to admit suffering from it and how the english language is inadequate when trying to express different types of shame. it is a social emotion because it stems from the feeling of being outside the cultural norms and it is the individual’s perception of how they are seen through the eyes of the other. this leads this paper back to the issue that humans are social beings, and the sense of self is derived from how the individual is perceived in the eyes of the other. in conclusion, at the beginning of this research, i held the belief that there had to be one clear answer, such as the idea that survival of the individual was due to some innate, inner strength that they possessed. having researched this area it has become clear that there are no clear answers when addressing international journal of integrative psychotherapy, vol. 2, no. 2, 2011 82 violence within the family. a multi-facetted approach is necessary to intervene and develop a relationship to work closely with the other. author: deb davies-tutt, ba in psychosocial studies, pgce, is a sociologist and a member of the british sociological association. she mentors postgraduates and undergraduate students at the anglia ruskin university, cambridge, england. references barnett, o. w., miller-perrin, c. l. & perrin, r. d. (1997). family violence across the lifespan. london: sage publications. bettleheim, b. (1960). the informed heart: a study of the psychological consequences of living under extreme fear and terror. bungay: chaucer press. blackmore, s. (2003). consciousness: an introduction. london: hodder education. blackmore, s. (2005). the grand illusion of consciousness. paper given at the sceptics society annual conference: brain, mind and consciousness. [on line] retrieved july 9th 2009 from: http://video.google.com/videoplaydocid=6958873142520847424 bowlby, j. (1988). a secure base. abingdon: routledge. bowlby, j. (2005). the making and breaking of affectional bonds. abingdon: routledge. cassidy, j & shaver, p.r. (1999) handbook of attachment: theory, research, and clinical applications. new york: guilford press. craib, i (1994). the importance of disappointment. abingdon: routledge. crain, w. (1980). theories of development: concepts and applications (5th ed.), london: pearson education. dobash, r. e. & dobash r.p. (1992). women, violence and social change. london: routledge. fonagy, p., gergely, g., jurist, e. & target, m. (2004). affect regulation, mentalization, and the development of the self. new york: other press. gerhardt, s. (2004) why love matters: how affection shapes a baby’s brain. hove: routledge. goffman, e. (1963). stigma: notes on the management of spoiled identity. london: penguin books. hansen, k. v. & garey, a. i. (1998). families in the u.s : kinship and domestic politics. philadelphia: temple university press. horley, s. (monday march 12, 2001). ‘domestic violence: the issue explained’. the guardian (online newspaper) p.6. retrieved june 22, 2009 from world wide web: http://www.guardian.co.uk/society/2001/mar/12/6/print international journal of integrative psychotherapy, vol. 2, no. 2, 2011 83 http://video.google.com/videoplaydocid=6958873142520847424 http://www.guardian.co.uk/society/2001/mar/12/6/print international journal of integrative psychotherapy, vol. 2, no. 2, 2011 84 humphreys, c. & stanley, n. (eds.) (2006). domestic violence and child protection: directions for good practice. tyne and wear: athenaeum press. james, o. (2007), they f∗∗∗ you up: how to survive family life. bloomsbury publishing, london. littlejohn, g., smart, b., wakeford, j. & yuval-davis, n. (eds.) (1978). power and the state. london: billing & son ltd. masters, a. (2005) stuart: a life backwards. london: harper perennial. moursund, j.p. & erskine, r. g. (2004). integrative psychotherapy: the art and science of relationships. pacific grove, ca:brooks cole. pelzer, d. (1995). a child called ‘it’. london: orion books. rogers, c. r. (1967). on becoming a person: a therapist’s view of psychotherapy. london: constable & robinson ltd. segal, j. (1986). winning life’s toughest battles: roots of human resilience. new york: ballantine house. scrambler, g. (1987). sociological theory and medical sociology. london: tavistock publications. sceff, t. j. (2003). shame in self and society. symbolic interaction, 26, 239 262. siegal, d. j. (1999). the developing mind: how relationships and the brain interact to shape who we are. new york: guilford press. snowden, r. (2006). freud. london: hodder education. date of publication: 21.5.2012 part one: psychosocial selves part three: the sociological impact on the self to return to the original question as to why society did not appear to respond to david’s and stuart’s sufferings. psychologist lerner believes one possible reason could be an individual’s tendency to find a reason to attribute blame towards the victims, stemming from their own need to believe in a just world (segal, 1986). kushner also states “blaming the victim is a way of reassuring ourselves that the world is not as bad a place as it may seem, and that there are good reasons for people’s suffering. it helps fortunate people believe that their good fortune is deserved, rather than being a matter of luck” (segal, p.86). international journal of integrative psychotherapy, vol. 4, no. 2, 2013   10 an integrative psychotherapy approach to education: relational needs in the classroom thomas a. mcelfresh abstract: educators help meet the relational needs of students in ways that promote students' growth and development. powerful opportunities exist to increase effectiveness in the classroom by recognizing and responding to the relational needs of students. in this article, eight relational needs are described which, when satisfied, enhance human functioning. best practice in education focuses, in part, on the dynamics of the student/teacher relationship. key words: integrative psychotherapy, relational needs, education, student needs, relational pedagogy ______________________ in integrative psychotherapy, we understand and cherish the primacy of interpersonal relationships. we see harmful interpersonal relationships as one source of many personal and social problems. we also know the power of interpersonal relationships as curative agents for many of life‘s ills. valuing the client for his or her uniqueness and accepting the client regardless of life circumstances are key values in integrative psychotherapy (erskine, 2013). ever since the ground-breaking work of carl rogers (1951), the client-centered approach to psychotherapy has provided a solid foundation upon which all effective psychotherapies have been built. likewise, effective teachers adopt a student-centered perspective. educators recognize that teaching and learning is personal. students come to school with various academic goals and professional desires. they also bring a multitude of personal, cultural, emotional, and social needs. teachers interface with students on more than academic issues. educators who are prepared to engage students head-on and help them recognize their many personal needs make huge strides in educating the whole person. students’ emotional, psychological, and relational needs frequently become apparent in the classroom. observant teachers are quick to recognize students who demonstrate strong needs for attention and those who withdraw from attention, students with poor self-esteem, those experiencing fears of failure, and those showing the effects of bullying by classmates. much of the international journal of integrative psychotherapy, vol. 4, no. 2, 2013   11 workload of teachers is directed toward the non-academic dimensions in students' lives that affect their academic performance, such as issues of family, health, and poverty. a cornerstone of integrative psychotherapy is the emphasis placed on the dynamics of the client-counselor relationship. surely, issues of transference and counter-transference are recognized and commonly addressed when appropriate. similarly, from the student-centered perspective, one key element is the teacher-student relationship. who doubts the impact that teachers and classmates have on a student in the classroom? who does not have a story of a favorite teacher; a teacher who went out of his or her way to make a difference? student/teacher relationships in the book the ones we remember (pajares & urdan, 2008), educators reminisce about the teachers who changed their lives. story after story is told of teachers who influenced students' career choices and life-long pursuit of hobbies, and whom students continued to visit many years after leaving school. the powerful interactions between teachers and students have made for some of the world’s most inspiring and dramatic cinema. recall sidney poitier in to sir, with love, anne bancroft in the miracle worker, paolo villaggio in ciao, professore, isabelle adjani in la journee de la jupe, francois bégaudeau in the class, jon voight in conrack, gérard jugnot in les choristes, and even whoopi goldberg in sister act 2. keen sensitivity and focus on the non-academic needs of students certainly embodies best practices in education. the teacher who recognizes something special about a student, communicates this to the student, and then offers encouragement and support is one who will make a difference. the work of fouts & poulsen (2001) in attunement in the classroom and bergin & bergin (2009) in attachment in the classroom found that the quality of student-teacher relationships had a direct positive impact on the student‘s level of knowledge, test scores, and motivation, with positive relationships leading to fewer classroom and academic problems. these researchers also found that students who developed healthy attachments to teachers were better able to control their emotions, were more socially competent, and were more willing to explore new ideas in the classroom. they concluded that effective teachers connect with their students and care for them by providing necessary warmth, respect, and trust. young children whose teacher-child relationships are characterized by closeness show greater levels of overall school adjustment. children at risk for academic and behavioral difficulties are particularly well served by positive teacher-child relationships (birch & ladd, 1997). supportive, reciprocal relationships with teachers influence child development in multiple fashions and serve to promote positive emotional and academic outcomes, while protecting international journal of integrative psychotherapy, vol. 4, no. 2, 2013   12 children from a variety of potential educational, social, and emotional risks (pianta, steinberg, & rollins, 1995). salzberger-wittenberg, williams, & osborne (1999) in the emotional experience of learning and teaching concluded that a teacher‘s personality and interpersonal style are of supreme importance to the student‘s ability to perform inside and outside of the classroom. in other words, the personhood of the teacher was more critical in effecting lasting change than the subject matter or teaching method. a fast growing area in the field of education is called relational pedagogy. nel noddings, in her foreword to the book no education without relation (bingham & sidorkin, 2004/2010) discussed the reactions of students who developed close emotional connections with caring teachers. these students showed increased interest for the subject matter, enhanced self-esteem, and demonstrated respect and concern for others. in a published manifesto of relational pedagogy, pioneers in this field of education outlined the following principles: 1. the self is a knot in the web of multiple intersecting relationships. 2. a relationship is more real than the things it brings together. 3. knowledge and authority are not something one has, but relationships, which require others to enact. 4. human relationships exist in and through shared practices. 5. relationships are primary; actions are secondary. 6. human words and actions have no authentic meaning; they acquire meaning only in a context of specific relationships. 7. teaching is building educational relationships. learning outcomes are defined as specific forms of relationship: to oneself, people around the students, and the larger world. 8. educational relationships exist to include the student in a wider web of relationships beyond the limits of the classroom (bingham & sidorkin, 2004/2010, pp. 6-7). international journal of integrative psychotherapy, vol. 4, no. 2, 2013   13 classroom dynamics best practice in teaching may include raising students' awareness of the dynamics of the student-teacher relationship while also inviting students to recognize and examine their interactions with fellow students. certainly, transference phenomena occur in the classroom between students and teachers and among students themselves all the time. failure to recognize and respond effectively to the many personal needs that students bring to the classroom is to miss the student as a whole person and to produce graduates who may be intellectually prepared and technically proficient but who lack the essential characteristics of insight and empathy. students develop insight and empathy for others by recognizing and meeting their own needs (murphy & dillon, 2008). it is vital for teaching faculty to recognize students' emerging needs, whether subtle or obvious, and to respond in ethical and effective ways that foster student growth and development. relational needs a review of the psychotherapy literature reveals one constant and that is the paramount importance of the helping relationship. clinical theories and sophisticated intervention models abound, but one unifying factor is that of relationship. from buber (1958) to bowlby (1969), rogers (1951) to winnicott (1965), and sullivan (1968) to stern (1994), theorists, writers, and clinicians have emphasized that relationships, both early in life as well as throughout the lifespan, are the source of meaning and validation of the self (erskine, 1998). numerous theories of human motivation conclude that people will do just about anything for attention, affection, appreciation, and admiration from others (berne, 1964). people have all kinds of needs and maslow (1970) did an excellent job of naming and categorizing these various needs. relational needs, however, described by maslow as the need for love and belonging, are different than the needs for survival, physical comfort, and safety. relational needs are the needs for human contact and human interaction. relational needs are present at every age and stage of human development and we do not outgrow our need for relationship. when basic relational needs are met, the normal emotional and psychological growth process continues. when basic relational needs are not met regularly or sufficiently over time, especially during early development, the process of human growth and development is thwarted and psychological, emotional, and behavioral symptoms begin to appear (spitz, 1945). when relational needs are not met there is a tendency for the unmet needs to become stronger. as expected, a person whose relational needs are not being met will seek alternate ways of obtaining needed attention and contact. the absence of international journal of integrative psychotherapy, vol. 4, no. 2, 2013   14 need satisfaction may initially be manifested as a range of disruptive emotions and behaviors, such as irritability and frustration. when relational needs are not met over time, the lack of need satisfaction is experienced as a loss of energy, apathy, a lost sense of hope, and the development of a cynical attitude, as in “who cares?” or “what‘s the use?” (erskine & trautmann, 1996; moursund & erskine, 2004). erskine, moursund, and trautmann (1999) indicated that relational needs are met in interpersonal relationships characterized by the sustained “contactful presence of another person who is sensitive and attuned to our relational needs and who can respond to them in such a way that the need is satisfied” (p. 123). a lifetime of unmet relational needs leads to distorted relationships and skewed expectations later in life. sometimes, a person comes to realize that a relational need exists only as a result of the need not being met and the ensuing emotional distress that occurs. one example is the hurt one might experience when not receiving recognition in some desired way. there is no telling how many personal needs human beings have that are met in interpersonal relationships. erskine and trautmann (1996), however, identified eight universal relational needs that clients bring to the clinical situation and that, by extension, students bring to the classroom. these include the following: 1. emotional safety and security: personal safety and security are rooted in the belief and experience of having our physical and emotional vulnerabilities protected. it is living without fear of actual or anticipated danger. freedom from shaming, criticism, and ridicule and knowing that someone will block harmful judgments provides a basic sense of trust. 2. validation and affirmation as significant: when our thoughts, feelings, and experiences are validated as important to another person we learn to believe in ourselves. for healthy growth and development to occur it is necessary to believe that someone cares about us and considers our point of view to be important in some way. when others ask for our point of view and take our opinions and experiences seriously we come to believe in our basic worth. validation and affirmation from others, especially those whom we consider important to us, provides some of the essential building blocks of self-esteem and self-confidence. the classic example is the adult who praises a child‘s scribbled drawing. 3. acceptance by a stable and dependable other: throughout the lifespan, we need role models upon whom we can rely. the process of developing an accurate and stable personal identity is enhanced when we interact with others who are emotionally stable. a lack of permanence in the environment creates a shaky foundation for interpersonal relationships. rejection from others fosters hurt, fear, shame, and selfinternational journal of integrative psychotherapy, vol. 4, no. 2, 2013   15 rejection. we are free to grow and experiment with new behaviors when we know that we can return to the protection provided by steady and dependable others. 4. confirmation of personal experience: if we never meet anyone who is “just like me” in some way, it is easy to believe that we are the only ones to have a particular type of problem or a particular life circumstance. being in the presence of others who have or have had similar thoughts, ideas, feelings, and experiences provides a needed sense of normality and mutuality. yalom (1975) called this universality. the need to be believed and to have our experiences confirmed as real and genuine is a powerful dynamic. it means, “i‘m not the only one.” how valuable it is to our growth and development to be with others who have experienced what we are currently experiencing. 5. self-definition: the relational need of self-definition is described as knowing and expressing our own personal uniqueness and individuality and being acknowledged and accepted by others. when we communicate our self-chosen identity through the expression of our needs, interests, preferences, and points of view and we are accepted for who we are, the need for self-definition is met. self-definition means not being defined or labeled by others. rather than being told what we should think or feel, being asked to tell others about ourselves is one way the need for selfdefinition is met. when someone blocks labeling and name-calling we receive recognition and acceptance for our unique personhood. 6. to make an impact: there are many reasons why people help others. one motive is the need to make an impact on another person in some desired way. it is the desire to make a difference in the lives of others. sometimes this impact has a positive tone, as in giving someone a compliment. it can also be negative, as in imposing oneself on another in some way. we receive information about ourselves when we say or do something and then gauge others’ reactions. when others react to our comments, humor, and gestures we know we have been heard and received; a relationship has developed. not much of a relationship exists when we are ignored by others. 7. to have other people initiate: in infancy, we could not meet our own needs for food or comfort. we relied on the actions of others to receive nourishment and holding. we learned language because others spoke first. throughout the lifespan, we need others to initiate actions and activities so that learning can take place. we need people to reach out to us and to call us into relationship. how comforting is it to be sitting in a crowd of strangers when, finally, someone we know comes to sit next to us? at times, we may have an important point to add to a discussion and we need to be invited to participate because we are unlikely to participate international journal of integrative psychotherapy, vol. 4, no. 2, 2013   16 actively on our own. we need others to introduce new information and ideas all the time. clearly, there are times when we need to make the first move rather than wait for others. however, there are also numerous occasions when we require initiation into a new opportunity or way of being. 8. to express love and appreciation: the relational need to express appreciation, gratitude, and affection is seen when we do things for other people. it is heard when we tell others what we think about them and how we feel about them. our words of gratitude and acts of kindness must also be received by the other person. recall the hurt or frustration when someone rejects our compliment, refuses our gift, or does not acknowledge our love and affection. some may ask if the need to be loved by others might be a ninth relational need. in actuality, the vital relational need for receiving love from others is met when the eight relational needs described above are met on a sufficient basis. to have our relational needs met is to be loved by others (erskine, moursund, & trautmann, 1999). relational needs in the classroom how, then, are students’ relational needs expressed in the classroom? what situations and activities occur in academic settings that provide opportunities for relational needs to be addressed? in the classroom we see students of all age and grade levels exhibiting needs for excessive attention, social withdrawal, fears of conflict, rebellion and defiance, low self-esteem, lack of confidence, perfectionism, fears of making mistakes, and, of course, all manner of transference phenomena. some students distort the teacher-student relationship and attempt to get their archaic childhood relational needs met by the teacher and other students in the classroom in duplicitous ways (kaiser, 1965; miljkovic, 2010). consider the following conditions and scenarios regarding students’ relational needs in the classroom. security students whose physical and emotional vulnerabilities are protected are free to learn and grow normally. living without fear of actual or anticipated danger fosters basic trust and allows a necessary level of bonding to begin. being sensitive to and responsive to the insecurities of students by blocking harmful judgments by others in the classroom provides essential safety and security for students allowing them to open themselves to learning opportunities. a place where one‘s vulnerabilities are understood and honored rather than criticized or exploited makes for a powerful positive learning environment. a international journal of integrative psychotherapy, vol. 4, no. 2, 2013   17 nonjudgmental attitude and corresponding actions of faculty, staff, and administrators is an integral part of the educational process. valuing when students’ thoughts, feelings, and experiences are validated as important to others students learn to trust and believe in themselves. for positive learning to take hold it is necessary to believe that someone cares about us and considers our point of view to be important in some way. attributed to theodore roosevelt, the old saying, ― no one cares how much you know, until they know how much you care – is very much at the heart of informed teaching. skilled teachers help students find meaning in their experiences by taking students’ questions seriously. best practice in education includes the affective component, and skilled teachers are attuned to the emotions of their students and respond reciprocally. that is, students are taken seriously when angry, consoled in some way when they are sad, encouraged when afraid, and celebrated when they are happy. students may not be accustomed to having others show an interest in their ideas or experiences and they may be wary of and uncomfortable receiving such attention and positive feedback. students who have had little positive validation in life may display a lack of confidence, make poor eye contact, exhibit decreased participation in the classroom, and may question a teacher‘s motives for caring so much. at these times, it is incumbent on teachers to proceed slowly and to titrate the dosage of their attention and care so as to not overwhelm an insecure and fearful student (mcelfresh, 2007). this attunement to the student‘s unique pace, rhythm, and cadence is one way of conveying validation of the student‘s unique experience. acceptance students need role models to whom they can look as they discover and develop their identities. students cultivate a personal and social style by interacting with their teachers and other adults. the acceptance shown by teachers and mentors provides a solid rock of consistency and reliability that some students may have never experienced. as a result, students are free to experiment with new behavior when they know they can return to the protection provided by steady and dependable teachers. what about the student who idealizes the teacher? perhaps the student is conveying a true appreciation for what the teacher is providing or, maybe, the student is expressing, albeit indirectly, the relational need for acceptance by someone stable and secure. some students have had little acceptance in their lives and as a result may display dependency needs and clinging behaviors such as asking unnecessary questions, requesting out-of-class time, and seeking special assistance. at these moments, educators have an opportunity to demonstrate firm professional boundaries and caring confrontations. clarifying a student‘s need for acceptance and his or her maladaptive behavior is a way to international journal of integrative psychotherapy, vol. 4, no. 2, 2013   18 support the student in finding appropriate relationships to meet their relational needs. mutuality students may come to school believing that they are the only ones to have a particular type of problem or some unique life circumstance. by interacting with teachers and peers, students come to realize that many of life‘s challenges are, in fact, quite common. the relational need of mutuality, to be in the presence of someone “like me”, is tremendously important. for example, a shy gay male might have few peers in his own community but find support and encouragement in meeting a faculty member or fellow student who understands because he or she has “been there”. the opportunity for students to express themselves and learn about each other is enhanced when teachers utilize learning communities, team projects, service-learning activities, sharing exercises, and collaborative learning strategies. at times, teacher self-disclosure may help meet a student‘s relational need of having their thoughts, feelings, or experiences confirmed as real and important. naturally, appropriate professional boundaries apply. normalizing a student‘s experience goes a long way toward helping the student become less self-critical and more self-accepting. self-definition supporting students to identify and communicate their unique personal identities, through the expression of needs, interests, preferences, and points of view without rejection, helps meet the need for self-definition. in traditional educational settings there is a temptation for faculty to categorize students and for students to label and diagnose themselves and each other. effective teachers block this kind of labeling and name-calling in the classroom and demonstrate recognition and acceptance for individual differences. classroom activities and assignments that identify issues of cultural diversity help students meet the need for self-definition. course assignments that require self-reflection invite students to ask themselves the hard questions that may lead to greater self-awareness. making an impact some students may attempt to influence faculty by working extra hard, complimenting a professor, engaging the teacher in conversations about nonacademic topics like fashion, music, or sports, or by creating disturbances in the classroom. faculty who are intimidated or too easily distracted may actually reinforce a student‘s maladaptive style inadvertently by engaging in these tangential conversations. clearly, there is nothing wrong with talking to students about fashion, music, or sports. however, the mindful educator considers which relational needs the student may be expressing at the moment and then decides international journal of integrative psychotherapy, vol. 4, no. 2, 2013   19 whether or not to participate in the conversation or whether to bring the student‘s behavior to his or her attention. certainly, it may be necessary to caringly confront students who make a habit of following the teacher from the classroom to the office, request excessive out-of-class time, offer unnecessary gifts, or make inappropriate comments. some students help each other by organizing study groups, sharing resources and materials, and by mentoring or tutoring other students. inviting students to take leadership roles in the classroom helps them to maximize the positive impact they can make. having others initiate perhaps a student‘s quietness in the classroom is an expression of the need for someone to initiate contact. some students may have important points to add to class discussions and may need to be invited to participate because they are unlikely to participate actively on their own. there is a difference between students who do not participate because they are apathetic, unprepared, or tired and those who come to class prepared but need a push to become active and involved. teachers introduce new ideas and information that students have never considered. teachers initiate lines of thinking that lead to important learning for students. students come looking for education and training, and the program curriculum and course instructors prompt them to consider unknown aspects of themselves. effective education helps students do things they never imagined doing and things they have always imagined doing. expressing love and gratitude at times, students will express their appreciation and admiration to faculty and peers for their support. the giving of token end-of-the-year gifts, thank you notes, tearful hugs, and nominations for faculty teaching awards are all expressions of love and gratitude, and teachers must be mindful, while exercising good and ethical judgment, that this relational need is important to students. accepting students' compliments may be difficult for some faculty due to their humility or diminished self-esteem, yet it is important for faculty to accept that students are deeply grateful for all that they have learned and received in the training process. evaluation a process of formative assessment can help faculty and program administrators identify strategies that work well for managing issues affecting student success and those areas requiring change. by asking the following questions, teachers and educational administrators can assure that program international journal of integrative psychotherapy, vol. 4, no. 2, 2013   20 policies and classroom practices afford students the best opportunity to reach their personal and academic goals. individual teachers may ask: • what is the student really saying, at this moment, about their current relational needs? • what are my responsibilities, if any, for bringing the student‘s needs and behavior to his or her attention? • what are the likely consequences if i address these issues with the student? • what might happen if i do not address these issues with the student? • what issues of diversity need to be considered in this situation? • what ethical and professional standards come into play? • what supports are available to help me make effective choices? curriculum developers and program leadership might inquire: • what innovations can be made to provide students with opportunities to meet their relational needs? for example, service-learning activities or collaborative learning strategies might help. • what portions of the program curriculum have a potentially disturbing effect on students? a classroom assignment designed to unpack family of origin issues or a course in, say, domestic violence may stir long forgotten needs, memories, and emotions. • what supports are in place to help students maintain and enhance their personal growth and development, such as student counseling services, mentoring programs, and support groups? • does the demographic composition of the school empower students to address their relational needs? for example, is the school and classroom sufficiently diverse so that students feel safe and supported in their academic endeavors, free to form healthy attachments to faculty and peers, and able to discover positive role models? is a milieu of inclusion and respect apparent? international journal of integrative psychotherapy, vol. 4, no. 2, 2013   21 resources the potential is high for every classroom to be a place of safety and support so that the natural process of personal and academic growth is facilitated. currently, schools offering such engaged relational education include the worldwide systems of the reggio emilia approach based in italy [www.reggiochildren.it], germany’s waldorf education [www.freunde-waldorf.de], and the eton house schools in singapore [www.etonhouse.com.sg] to name a few. conclusion it is not the job of teachers to be psychotherapists to their students or to meet all of their students' relational needs. the contract is one of teaching and learning, not treatment. yet when educators are aware that students bring specific relational needs to the classroom, teachers can make prompt determinations about how to engage the student. teachers, too, have relational needs and these are frequently manifested in the classroom. educators dedicate themselves to making an impact on their students and in making the world a better place. some educators seek attention, admiration, and validation in the classroom. they feel proud when their students succeed and may define themselves, in some ways, in terms of the achievements and failures of their students. much of the influence that teachers and students have on each other is, of course, unconscious. that is, while teachers and students are about the daily work of teaching and learning they relate in ways that meet and frustrate deeper needs. academic and behavioral problems in the classroom can be traced, in part, to unmet relational needs and distorted expectations on the parts of teachers and students (zygouris-coe, 1999). therefore, best practice in education must include an awareness of and thoughtful response to students' relational needs. author: thomas a. mcelfresh, psy.d. is a clinical psychologist in private practice in dayton, ohio usa. he is also professor and department chairperson of the human services and behavioral health program at sinclair college. tom was a member of the dayton/indianapolis integrative psychotherapy professional development seminar with richard erskine from 1995 to 2003. email address: mcelfresh7071@yahoo.com mailto:mcelfresh7071@yahoo.com international journal of integrative psychotherapy, vol. 4, no. 2, 2013   22 references bergin, c., bergin, d. (2009). attachment in the classroom. education psychology review, 21, 141-170 berne, e. (1964). games people play. new york, ny: grove press. bingham, c., sidorkin, a. m. (2004/2010). manifesto of relational pedagogy: meeting to learn, learning to meet. in bingham, c., & sidorkin, a. m. (eds.), no education without relation (pp. 6-7). new york: peter lang. birch, s. h., ladd, g. w. (1997). the teacher-child relationship and children’s early school adjustment. journal of school psychology, 35(1): 61–79. bowlby, j. (1969). attachment (vol. 1 of attachment and loss). new york, ny: basic books. buber, m. (1958). i and thou. (r. g. smith, trans.). new york, ny: charles scribner‘s sons. erskine, r. g. (2013). vulnerability, authenticity, and inter-subjective contact: philosophical principles of integrative psychotherapy. international journal of integrative psychotherapy, 4 (2), 1-9. erskine, r. g. (1998). attunement and involvement: therapeutic responses to relational needs. international journal of psychotherapy, 3, 235-244. erskine. r. g., moursund, j. p., & trautmann, r. l. (1999). beyond empathy: a therapy of contact-in-relationship. philadelphia, pa: brunner/mazel. erskine, r. g., & trautmann, r. l. (1996). methods of an integrative psychotherapy. transactional analysis journal, 26(4), 316-328. fouts, g., poulsen, j. (2001). attunement in the classroom. alberta teachers’ association magazine, 81(3). retrieved from http://www.teachers.ab.ca/ publications/ata%20magazine/volume%2081/number%203/articles/pag es/attunement%20in%20the%20classroom.aspx kaiser, h. (1965). the universal symptom. in l. b. fierman (ed.), effective psychotherapy: the contributions of hellmuth kaiser. new york, ny: the free press. maslow, a. h. (1970). motivation and personality (2nd ed.). new york, ny: harper & row. mcelfresh, t. a. (2007). rhythmic attunement. voices: the art and science of psychotherapy, 43, 58-59. miljkovic, n. (2010, july). relational needs in educational contexts. international association of relational transactional analysis resources. retrieved from http://www.relationalta.com/resources.php moursund, j. p., erskine, r. g. (2004). integrative psychotherapy: the art and science of relationship. pacific grove, ca: brooks/cole thomson. murphy, b. c., dillon, c. (2008). interviewing in action in a multicultural world (3rd ed.). belmont, ca: brooks/cole thomson. noddings, n. (2004). foreword. in c. bingham and a. m. sidorkin (eds.), no education without relation (pp. vii-viii). new york: peter lang. pajares, f., urdan, t. (eds.). (2008). the ones we remember: scholars reflect on teachers who made a difference. charlotte, nc: information age. http://www.teachers.ab.ca/%20%09publications/%20ata%20magazine/volume%2081/number%203/articles/pages/%20%09attunement%20in%20the%20classroom.aspx http://www.teachers.ab.ca/%20%09publications/%20ata%20magazine/volume%2081/number%203/articles/pages/%20%09attunement%20in%20the%20classroom.aspx http://www.teachers.ab.ca/%20%09publications/%20ata%20magazine/volume%2081/number%203/articles/pages/%20%09attunement%20in%20the%20classroom.aspx http://www.relationalta.com/resources.php international journal of integrative psychotherapy, vol. 4, no. 2, 2013   23 pianta, r. c., steinberg, m. s., rollins, k. b. (1995). the first two years of school: teacher-child relationships and deflections in children’s classroom adjustment. development and psychopathology, 7(2): 297–312. rogers, c. r. (1951). client-centered therapy. boston, ma: houghton-mifflin. salzberger-wittenberg, i., williams, g., osborne, e. (1999). the emotional experience of learning and teaching. london, uk: karnac. retrieved from http://www.karnacbooks.com/productpreview.asp? pid=1650&match=1 spitz, r. (1945). hospitalism: an inquiry into the genesis of psychiatric conditions in early childhood, part i. psychoanalytic study of the child, 1, 53-74. stern, s. (1994). needed relationships and repeated relationships: an integrated relational perspective. psychoanalytic dialogues, 4(3), 317-346. sullivan, h. s. (1968). the interpersonal theory of psychiatry. new york, ny: w.w. norton. (original work published 1953). winnicott, d. w. (1965). the maturational processes and the facilitating environment: studies in the theory of emotional development. new york, ny: international universities press. yalom, i. d. (1975). the theory and practice of group psychotherapy (2nd ed.). new york, ny: basic books. zygouris-coe, v. i. (1999, january 21). uf researcher: teachers' nonverbal clues affect students' performance. university of florida news. retrieved from http://news.ufl.edu/1999/01/21/body-language/ date of publication: 24.2.2014 http://www.karnacbooks.com/productpreview.asp?%20pid=1650&match=1 http://news.ufl.edu/1999/01/21/body-language/ international journal of integrative psychotherapy, vol. 5, no. 1, 2014 53 integrative psychotherapy and mindfulness: the case of sara mihael černetič abstract: the article explores the relationship between integrative psychotherapy and mindfulness on a theoretical as well as practical level. although mindfulness is not an explicit constituent of integrative psychotherapy, the two are arguably a natural fit. mindfulness has the potential to enhance internal and external contact, a central concept in integrative psychotherapy, as well as strengthen a client’s adult ego state. this article presents a case study whereby integrative psychotherapy is analysed from the perspective of mindfulness. within the course of therapy, parallels were observed between the client's increased mindfulness, improved internal and external contact, strengthened adult ego state, mastery of introjections, as well as diminished feelings of guilt, improved mood, self care and ability to engage in appropriate separation and individuation. these gains support the conclusion that integrative psychotherapy and mindfulness are inherently related and that explicit incorporation of mindfulness may enhance the therapeutic process of integrative psychotherapy. key words: integrative psychotherapy, mindfulness, awareness, acceptance, contact ______________________ throughout human history, mindfulness has been used to lessen the sting of life's difficulties (germer, 2005). in this we can see a parallel to one of the main goals of psychotherapy, which is to alleviate mental suffering. the concept of mindfulness can be defined as a non-judgemental accepting awareness of one's own experience in the present moment (černetič, 2011a). in the last two decades, mindfulness has been integrated into psychotherapy in various ways. moreso, it has been identified as one of the common factors which has always been implicitly present in all psychotherapy orientations (martin, 1997). an example of mindfulness might be when one is sitting in a sunny window, taking a moment to become mindful and aware as in, “right now i feel the sun on my shoulders. i am thinking about the chores i have to do later, and fully tasting the warm tea i am drinking.” in a therapeutic encounter, the therapist may mindfully note, “my client seems anxious today, speaking quickly, and fidgeting with her scarf. i begin to wonder about this, and think of how to ask about her process.” international journal of integrative psychotherapy, vol. 5, no. 1, 2014 54 mindfulness can be incorporated into psychotherapeutic work in several ways. firstly, as a part of the fundamental therapeutic philosophy, which includes an understanding of pathogenesis and the process of healing and personal growth, with an emphasis on the client's awareness and acceptance of their experience. secondly, as a specific intervention package or therapeutic approach, intended to be the full focus of treatment, or as one of the major elements. thirdly, as the application of individual mindfulness interventions or techniques, and lastly as a tool for the psychotherapist for coping with their stress, catalyzing the therapeutic relationship, and/or for professional and personal growth (černetič, 2011a). mindfulness practice and research are very compatible with the framework of integrative psychotherapy (žvelc, 2009). theories and methods of integrative psychotherapy are based upon the philosophy of accepting awareness within an attuned therapeutic relationship. the main methods of integrative psychotherapy, inquiry, attunement, and involvement (erskine, moursund, & trautmann, 1998), invite the client into the state of awareness and acceptance of their internal experience – the main mechanism of mindfulness (žvelc, 2012). in this article, i present possibilities for the integration of mindfulness and integrative psychotherapy on a theoretical level, beyond what norcross (2005) termed technical eclecticism in psychotherapy integration. i focus on the exploration of how processes of integrative psychotherapy and mindfulness intertwine in the course of therapy and how they mutually enhance each other. in the presentation of the case study, theoretical findings are illustrated and further elaborated. mindfulness, contact and relationship the concept of contact plays a central role in integrative psychotherapy. according to erskine and trautmann (1997), contact takes place on an internal and external level within an individual and thus includes full awareness of sensations, feelings, needs, sensorimotor actions, thoughts and memories which occur within the individual, as well as full awareness of external events as they are registered by sensory organs. however, regaining full internal and external contact involves hard work and the client cannot do it alone, for it is based on the unfolding of awareness within a relationship with another (erskine et al., 1998). the therapist nurtures the therapeutic relationship with the client and that relationship becomes a vehicle for enhancing contact for the purpose of growth and healing. the contact between the therapist and the client promotes and supports the client's contactful experiences with others (erskine & moursund, 1998). whereas the therapeutic relationship is a key factor in integrative psychotherapy for increasing the client's contact, mindfulness can be of great help in promoting this awareness. as mindfulness is a type of awareness, the client's sense of mindfulness international journal of integrative psychotherapy, vol. 5, no. 1, 2014 55 promotes contact. the nature of mindful awareness is non-judgemental and therefore, non-criticizing and non-threatening. as such, it enables the client to open up to their experience, which further increases contact. mindfulness thus becomes a facilitator of internal and external contact, or of the client's relationship with themself, as well as with others. my experience as an integrative psychotherapist has led to an awareness of how mindfulness can help implement the core methods of attunement, inquiry, and involvement (erskine et al., 1998). a mindful therapist is fully present in the here and now of the on-going therapeutic process with the client. he or she is fully involved and available in the therapeutic relationship, accepting of the client and of whatever feelings and thoughts the client is experiencing. a mindful therapist is also attuned to the current state and processes of the client, and openly aware of the subtlest signals of the client's body language and para-verbal expressions, such as tempo of speaking, pauses, sighs and so on. consequently, a mindful therapist is better equipped for using the method of inquiry. when he or she is attuned to the client and involved in the therapeutic relationship, he or she is more prepared to properly implement inquiry (erskine et al., 1998). in addition, it seems that the therapist's mindfulness catalyses mindfulness in the client and, as previously noted, the client's mindfulness enhances their contact. the therapist's mindfulness may be helpful in the process of establishing and sustaining an optimal therapeutic relationship with a client. the two key elements of mindfulness are awareness and acceptance of one's experience (černetič, 2011b), and the same may apply to the therapeutic relationship. without an awareness of, and respect for another human being's experience (i.e. allowing that experience and accepting it), no interpersonal relationship can function well, let alone the therapeutic relationship, which is a particularly refined form of human relationship. in integrative psychotherapy, the three core methods – attunement, involvement, and inquiry – represent the foundation of the therapeutic relationship (erskine et al., 1998). in the course of psychotherapy, a mindful therapist – regardless of their psychotherapy orientation – becomes aware of (i.e. attuned to) the client's experience and accepts it (i.e. properly involved, validating and normalizing the client's experience). as curiosity is one of the characteristics of mindfulness (kabat-zinn, 1990), a mindful therapist inquires about the client with a sincere interest. the therapist's mindfulness can also be helpful in working with counter-transference, identifying counter-transference reactions and using them for diagnostic purposes (černetič, jančar, & vlašič tovornik, 2010), as well as for regulating such reactions. in addition, mindfulness facilitates the development of the therapist's empathy (morgan & morgan, 2005). siegel (2010) argued that the presence of the therapist, and how the therapist forges a connection with the client, are the most crucial factors affecting the healing process in the client. an engaged, committed and caring therapist who is mindful of their own self, and how that self relates to the client, is the key determinant of how well the client will international journal of integrative psychotherapy, vol. 5, no. 1, 2014 56 respond to therapy. similarly, surrey (2005) describes the therapist's application of mindfulness as a three-fold process of attention to themselves, the client, and the movement or flow of their relationship. the therapist is therefore attentive to the changes that are happening from moment to moment with regard to their own sensations, feelings, thoughts, and memories. as the client is describing their feelings, thoughts, perceptions, and sensations, the therapist is also attentive to the experience of the client. the therapist perceives the client's experience as the object of their awareness, and uses these perceptions to better navigate the course of their relationship. from moment to moment, the focus is on paying attention to the reality of the other – to the client's words, voice, feelings, expressions, body language, breathing and so on. furthermore, the therapist pays attention to the flow of the relationship with the client, to the changing qualities of contact and to its interruptions. for clients, mindful contact has proven to be a useful tool for coping with symptoms such as unpleasant thoughts (such as intrusions, ruminations, flashbacks), feelings (such as depression or excessive anxiety) and body sensations (such as muscle tension, trembling) (černetič, 2005, 2011b). for example, a client with generalized anxiety disorder would be invited to simply observe their worries instead of constantly dwelling and harping on them. when in the state of mindfulness, the client nonjudgementally observes, and thus tolerates, the ebb and flow of their anxiety and fear, without resorting to avoidance of their emotions through worrying, excessive safetyseeking behaviours, or other forms of experiential avoidance. they are aware that thoughts and feelings are not facts – they are merely sometimes unpleasant, but nevertheless interesting events in someone's mind and they do not necessarily reflect the real situation. when mindful, the client is able to de-center from their symptoms. a de-centered perspective is an important mechanism of mindfulness (teasdale, segal, & williams, 1995), which involves adopting the stance of an impartial observer or a witness to one’s experience. the client is in contact with their experience in the present moment, without over-identifying with the contents of that experience. mindfulness and ego states mindfulness can be readily integrated with the theory of ego states. being mindful has been associated with the adult ego state (žvelc, 2010; žvelc, černetič, & košak, 2011). in integrative psychotherapy and transactional analysis, the adult ego state is conceptualized as a person being in the here and now, being aware of and functioning in accordance with the present reality, and being autonomous from intrapsychic influences of rigid and outdated material which resides in the archeopsyche and exteropsyche (berne, 1961; erskine, 1991; tudor, 2003). being mindful is very similar to being in one’s adult ego state. a mindful person is in full internal and external contact, without suppressing or avoiding in other ways their own unpleasant thoughts, feelings and body sensations. correspondingly, a mindful person is clearly aware of the situation in the here and now. they are ready to act in accordance with that situation and do not international journal of integrative psychotherapy, vol. 5, no. 1, 2014 57 feel forcefully directed by the parent's introjections or the feeling and/or thinking of the child ego state. according to žvelc and colleagues (žvelc et al., 2011), mindfulness may be at the heart of the integration process of the adult ego state. observing one's current experience with de-centered awareness is not only a defining feature of being mindful, it is also an inherent characteristic of the adult ego state. both mindfulness and the adult ego state are focused on the here and now, being decentered from the material which pertains to the past or to the future, such as introjections in the parent ego state and traumatic experiences in the child ego state. when being mindful, an individual is able to observe and then let go of their pleasant or unpleasant thoughts and feelings. this cannot be achieved in the child or in the parent ego state due to the rigidity of these two ego states, which by definition lack awareness, because they have emerged as a consequence of contact interruptions (erskine et al., 1998). yet another parallel between mindfulness and the adult ego state can be observed on the neuropsychological level. it seems that being mindful and being in the adult ego state are both characterized by the engagement of an individual's executive functions. these functions, which include attention management and working memory, mental flexibility and task switching, initiation and monitoring of actions, have been associated with prefrontal cortex of the brain (miller & cohen, 2001). mindfulness and script according to berne (1964/1975), the final goal of psychotherapy for an individual is to achieve autonomy, which comprises awareness, spontaneity and the capacity for intimacy. to attain autonomy, a person must be "cured," as much as possible, of the intrapsychic control exerted by their script patterns. the script limits their spontaneity and flexibility in problem solving and relating to people, because the story of one's life, including the ending and all the major events, is already written, usually in early childhood (erskine & moursund, 1998). in letting go of the influences that a person's script exerts on their life, mindfulness may be of a great help. one of the key mechanisms of how mindfulness works is attenuating the automatic nature of a person's reactions. in the field of mindfulness, reacting in an automatic way is often called being on "automatic pilot." it means doing something with little or no awareness, in a way that is predetermined by old, rigid, often non-adaptive patterns of thinking, feeling and behaving. the concept of being on automatic pilot, or being mindless, and the concept of the script thus largely overlap. being mindless often involves reacting out of one's script. in both cases, the person lacks autonomy, as defined by berne (1964/1975), to be truly aware of things as they are, to be spontaneous in all forms of behaviour, and thus capable of real intimacy in relationships with other people. mindfulness, which is a process of de-automatization and of increasing awareness, can therefore help a person attain flexibility and freedom in responding. it helps them to think, feel and behave in a way that is relevant to the international journal of integrative psychotherapy, vol. 5, no. 1, 2014 58 specific situation in the here and now, free from "the old stuff," such as introjections and other materials from the parent and the child ego states. mindfulness is not related to the script only in the process of its dissolution, but also in the very development of script patterns. living mindfully means to be in contact, and if a person is in contact, there is no need for script formation. as erskine and moursund (1998) explain, the story of life scripts is the story of contact and contact distortion between an individual and the outside world of people and things. when contact is distorted or denied, needs are not met. since the experience is not closed naturally, it seeks an artificial closure. these artificial closures are the substance of childhood reactions and decisions that become fixated and may also create a situation where introjection of another person's personality is likely to occur (erskine & moursund, 1998). conversely, an individual’s needs are processed spontaneously and naturally when the person is in the state of mindfulness. being mindful of one's need and being in contact with it, enables a person to satisfy the need more easily, or at least close the gestalt through awareness that the need cannot be met for the time being. coming home – the case of sara sara, a primary school teacher and married mother in her early thirties with two pre-school children, came to psychotherapy due to several years of depression, and upon the recommendation of her psychiatrist. several months before the start of the psychotherapeutic process sara had stopped taking her antidepressant by her own decision. she did not like the side effects of her medication and wanted to overcome her depression without psycho-pharmaceutical assistance. at the beginning of the psychotherapeutic process, sara reported suffering from low selfesteem. she was dissatisfied with herself and often experienced feelings of guilt. she experienced an understanding relationship with her husband, with occasional conflicts that were due to her irritable outbursts. as a parent, she was caring and responsible. she was committed to her family and tried hard to be a good housekeeper. sara was not satisfied with her job. she wanted to do something else professionally, particularly because she experienced her pupils as naughty and exhausting. she perceived herself as not being competent enough to deal with them. sara grew up in a nuclear family of two children. she was the older child and her brother was several years younger. the parents were demanding towards sara and she was expected to help a lot in the household. they often criticized her help in the house, but did not expect so much from her brother. sara told me her brother was often praised for completing a chore, and in contrast, she would be criticized. sara’s developmental history was marked by strong criticism from her mother. sara told me that she was never good enough for her mother, who behaved towards her in a very demanding way. at school, sara was learning for her mother. she had excellent grades international journal of integrative psychotherapy, vol. 5, no. 1, 2014 59 in primary school, but felt that her mother took this for granted. sara was clearly trying hard to please her mother in order to avoid the mother's criticism and receive positive affection from her. such “mother-pleasing” behaviour persevered into sara's adult life. it is also important to note that while growing up, sara provided much emotional support to her mother. for example, when mother had a miscarriage, sara tried to help her emotionally, trying to comfort her. for a young child, the burden of this task was simply too heavy. as a child, sara had a somewhat better relationship with her father than with her mother. on occasions, sara and her father would cover up an event that mother could find embarrassing, for example a telephone call from grandmother, in order to avoid her angry acting out. unfortunately for sara, her father quite often failed to take her feelings seriously, and sometimes he ridiculed them. when sara was in high school, her psychological symptoms began to appear. she experienced feelings of meaninglessness and considered suicide. her headaches started in that period as well. they did not have a somatic cause, but frequently became worse when she relaxed. while attending university, about a decade before beginning psychotherapy, sara’s parents divorced. this triggered significant distress and marked the beginning of her depression. during the process of her parents' divorce, sara put herself on the side of her mother, even though her relationship with father had been better than her relationship with mother prior to the divorce. sara invested a lot of time and energy into providing emotional support to mother during and after the divorce. however, this support was not reciprocal. even though sara also needed emotional support at that time, she did not receive it from her parents. before the divorce her father was a source of support for sara, but as a consequence of the divorce, she felt abandoned by him and he moved out of their house. sara said she experienced the divorce as if she herself had divorced her father. in her early twenties, sara began to experience depressive symptoms. in the years that followed, she received two outpatient psychiatric treatments, which included taking the antidepressant medication sertraline. she was referred to psychotherapy by her psychiatrist. according to the dsm-iv-tr classification (american psychiatric association, 2000), sara’s diagnosis in the months preceding the beginning of the psychotherapy is consistent with an axis 1 disorder (296.32 major depressive disorder, recurrent, moderate), with two additional problems on axis 4; problems with primary support group (disruption of family due to parents' divorce) and occupational problems (job dissatisfaction). her gaf score (global assessment of functioning scale, axis 5) equalled 55. in integrative psychotherapy diagnosis, assessment of the client's ego states is an important element. at the beginning of the psychotherapeutic process, sara was frequently in her child ego state. such states were usually related to events with her mother and were most pronounced in the days following a quarrel. sara experienced a lot of guilt, sorrow and a feeling of being misunderstood by her mother. in the first months of our therapy, sara was very fragile in her child ego state and was very international journal of integrative psychotherapy, vol. 5, no. 1, 2014 60 sensitive to criticism by her mother. at the same time, she still tried hard to please the mother and meet her expectations through frequent housecleaning of her own home and manner of raising her children. in doing so, sara hoped to receive her mother's approval and positive affection, but mostly she did not. this stirred up old feelings of guilt, sadness and of being misunderstood. generally speaking, sara felt almost no anger, but especially not towards her mother. after about two months in therapy, sara's depression worsened to the degree that she needed a sick leave from her job. during a therapy session when she had been on sick leave for just a few days, she reported feeling better due to not working, but also thought that she ought to return back to work. even though her psychiatrist recommended three to four weeks of sick leave, sara – on her own initiative made an arrangement with her general physician to shorten her sick leave to only two weeks, and then stated at the beginning of this session that she was determined to go back to work after just one week of absence. to illustrate sara's structure of ego states and their typical dynamic, i present an example in figure 1. figure 1. an example of sara's ego states and conflict regarding the length of her sick leave. later in that session, with the help of chair work technique, two aspects of sara revealed themselves: "the wise ass" and "sara." the “wise ass” part represented sara’s parent ego state, which emphasized the disadvantages of her sick leave, such as the deprecating words of her co-workers and her work assignments piling up. her parent was trying to persuade her to return to work with statements such as "it is necessary to endure," "it is not so hard," "it is necessary to do [this and that]". these statements stemmed from the introjections, which sara acquired from her mother. the essence of international journal of integrative psychotherapy, vol. 5, no. 1, 2014 61 these introjections overemphasized "shoulds" and "musts" and underemphasized consideration of sara's own feelings and needs. the second part named "sara" represented her child ego state. this part told sara that returning to work at that time was simply too much for her and that she was unable to do that. perhaps even more importantly, this part told sara that she would have pulled herself together if she had the ability to do so. she told me that she was scared. "sara" also told me that she was, in a way, clinging to her depression because it enabled her to finally be "a small child" and have her parents take care of her. before, it was often sara who had been providing, or at least trying to provide, support to her mother, as in the previous example of mother’s miscarriage during sara’s early childhood. in contrast to her child and parent ego states, sara’s adult ego state was quite weak during this early stage of psychotherapy, and her daily experience was to a significant extent under the control of her child and parent ego states. her capacity to critically reflect on the content of her introjections and of her archeopsyche was quite limited at that time. a core model of integrative psychotherapy, also fundamental for making an integrative psychotherapy diagnosis, is the script system (erskine & moursund, 1998; o’reillyknapp & erskine, 2010). figure 2 illustrates sara’s script system. figure 2. the script system of sara. international journal of integrative psychotherapy, vol. 5, no. 1, 2014 62 sara held a core belief that she was not good enough. most of the time she felt guilty in one way or another. she believed that life was hard and that other people were demanding and hard to satisfy. consequently, she tried hard to meet the perceived expectations of others. however, often it was sara who perceived other people's expectations in an exaggerated way. when working with her colleagues, she was sometimes taken advantage of because she took upon herself an unfairly big amount of work. yet due to her script pattern, sara was constantly reminded, in one way or another, of her "insufficient" and "inadequate" performance. this perpetuated her scriptdriven vicious cycle. for example, when her mother came to look after sara’s children, she would sometimes comment on such things as dust being visible on the furniture, which made sara feel very bad about herself. sara had difficulty accepting that her mother might be overly critical. she would interpret her mother's comment as an indicator of her own faults and, as a consequence, she would feel guilty and sad. similarly, when she was having difficulties with the troubled kids at school, she would attribute the children's naughty behaviour to her professional incompetence. in general, sara was highly demanding of herself. in one of the initial therapy sessions, she said she usually expected a "120 per cent" performance from herself. old emotional memories reinforced sara's script system. for example, memories of being criticized by her mother, and memories of trying hard, yet still not being good enough, persisted. no matter how hard sara tried as a child, she could not prevent her mother's biting, painful comments. while talking about such situations in therapy, i expected at least some anger to occur in her. however, in the beginning of psychotherapy, sara's feelings of anger were repressed. sara's relational needs to be in a secure relationship where she was accepted, protected and valued the way she was were partly repressed as well. while growing up ridiculed for her feelings by her father and humiliated by her mother's frequent criticism, important relational needs were often unmet and, as a consequence, sara avoided the pressure of those needs by repressing them. sara also held a script belief that she was not important. while growing up, her feelings and needs were often not validated. as a result, she came to the conclusion that she did not matter. although in college when her parents divorced, sara nonetheless provided a lot of emotional support to her mother, whilst neglecting her own feelings. for example she had to suppress positive emotions towards father, and her needs to receive emotional support. in her adult life, it seemed that sara was not quite able to take enough time for herself. providing the necessary care to her family as a mother and a wife sometimes served as a rationalization for neglecting herself. sara's quiet voice during therapy sessions was one of the indicators of her belief that she was not important. international journal of integrative psychotherapy, vol. 5, no. 1, 2014 63 unsurprisingly, sara indulged in a fantasy of going somewhere far away. she said that, in her ideal life, she would be a manager of a hotel in an exotic tourist destination in asia, or a tourist worker in some other tourist destination in the south. doing that would make her feel happy and at ease. this fantasy, of a rather escapist nature, was valuable to me as her therapist, for it revealed the depth and significance of sara's distress. curiously, even in such an escapist fantasy, sara was taking care of other people – she was a tourist worker, but not a tourist herself. the self-in-relationship model (erskine & trautmann, 1997; o'reilly-knapp & erskine, 2003) shows how a client establishes contact with themselves internally and externally with others, on different dimensions of personality. sara was initially open to internal cognitive and behavioural contact, and partially open to physiological contact. she was able to think about her problems and understand them, and was quite receptive to behavioural interventions in the psychotherapeutic process. physiologically, she was able to report some of her body sensations related to her distress. however, she had very little contact with her emotions. on the one hand, she was often overwhelmed with some feelings, such as sorrow, but on the other hand, she repressed some other feelings such as anger. in the beginning of her therapy, i had to pace our work very carefully, otherwise the intensity of sara's emotional arousal in therapy sessions would quickly rise above her tolerance level. when it did, she would shut off and lose contact with her painful emotions. as the therapy progressed, she became more able to tolerate her feelings. in the beginning of therapy sara's external contact was also limited. she was often quite absorbed in her intrapsychic experiences and was less contactful in the interpersonal domain. several different contact interruptions (clarkson, 2004) such as introjection, retroflection and deflection were the most notable in sara's functioning. deflection corresponded to her feeling of being empty-headed, which was quite common in situations when sara was overwhelmed with negative emotions. in order to protect herself from feeling distress, she unconsciously broke off her awareness of these emotions. in sara's relationship with her mother, introjection was a characteristic contact interruption, also often tied to retroflection. the psychotherapeutic process from the perspective of mindfulness at the start of our therapy, sara and i made a therapeutic contract that we would work on the issues that were contributing to her depressive experiences and irritability. the goal was to gradually improve her general mood and make it more stable and positive. our work lasted for two years and four months, and followed the principles and methods of integrative psychotherapy. our work was not a mindfulness-based therapy. however, i used mindfulness as a therapeutic intervention, and we occasionally talked about mindfulness as an alternative way for her to approach her experiences. my clinical observation was that sara's level of state and trait mindfulness increased during the course of the psychotherapeutic process. in other words, sara was increasingly able international journal of integrative psychotherapy, vol. 5, no. 1, 2014 64 to experience the state of mindfulness in various situations, and mindfulness was also gradually gaining strength as a personality trait. in the first few months of therapy, sara was quite avoidant of her painful emotional experiences. it was hard for her to be mindful of unpleasant feelings, to be in contact with them as they were. when she could not tolerate an emotion, she interrupted internal contact. therefore, i had to pace the therapy carefully and not rush the process. my attunement to sara, or my mindfulness of what was going on with her in a given moment was crucial, for it ensured that my inquiry was not too intense for her. my therapeutic attunement, as well as involvement, also helped her to stay in contact with feelings despite their unpleasantness. consequently, she resorted to fewer contact interruptions. among the themes that sara avoided, her relationship with her mother was at the top of the list. this relationship was very painful for sara, yet at the same time it represented a topic of key importance for her psychotherapy. in her primary family, sara received a lot of criticism and was mocked for her feelings. in therapy, however, sara had a chance to experience a relationship that was different from her experiences in her developmental past. i tried to be attuned to sara's experience and take her feelings seriously. criticism, which had caused so much psychological harm to her in the past, was not present in our relationship. through the processes of attunement, involvement and inquiry, sara could feel understood. for this reason, our therapeutic relationship represented for sara what stern (1994) called the needed relationship, a place where her relational needs could be met to a greater extent than in her past. this different relationship also helped sara relate differently to herself, in a less critical way and with more acceptance, which weakened her internal critic. my attunement to sara, my acknowledgement and validation of her experience helped her to become aware of a wider spectrum of her feelings, instead of repressing them. her feelings were important and accepted in our therapeutic relationship, which helped her build her own awareness and accept her inner experience. awareness of one's own experience and acceptance of it are probably the two most pivotal elements of mindfulness (černetič, 2011b). the manner in which sara's feelings were approached in our therapeutic relationship helped her build a mindful stance towards them. strengthening sara's capacity for self-care was another important theme in our work. sara was learning to take better care of her important physiological needs, such as getting enough rest, as well as her psychological needs, such as the need to relax. becoming aware of a need is the necessary first step in ensuring that any need will be met. during our work, sara developed an increased mindful awareness of her various needs, such as the need for rest, relaxation and socializing, which enabled her to then take a proactive role in satisfying them. as a therapist, my efforts to be mindful helped me to implement the methods of integrative psychotherapy with greater skill. it enabled me to be involved in the international journal of integrative psychotherapy, vol. 5, no. 1, 2014 65 therapeutic relationship with greater presence, to be more attuned to what was going on with sara, either in the present or in the past, and which was being relived in the here and now of therapy. i was able to inquire in a more attuned manner. when i was mindful in a therapy session, i was more able to provide a calm presence and be completely present for sara, who was often suffering from painful feelings. i was able to psychologically hold her, calmly and strongly. my own mindfulness in a therapy session helped sara to be mindfully aware of her experience. it thus contributed to establishing the circumstances needed for the realization of her internal contact and processing of important material. in addition, i noted that being mindful as a therapist contributed to my awareness of counter-transference, and the impact of sara's depressive affect on me. when a therapy session was over, i often felt somewhat melancholic compared to my mood before the session. this usually happened for no reason that i could attribute to my personal circumstances. it was interesting, though, that i was often simultaneously aware of another feeling in myself that could be described as a release from melancholy and sadness. when sara came to a resolution and diminution of her painful emotions in the therapy session, her relief was probably often reflected in my counter-transference. being mindful of counter-transference widened the scope of my attunement to sara, deepened our therapeutic relationship, and provided valuable information about her ongoing process. this information was often related to the material which sara was not yet ready to explore on the conscious level, warding it off instead. yet, due to the mechanism of projective identification, the material became observable through my counter-transference. being mindful of my counter-transference reactions also enabled me to put these reactions into the right perspective and deal with them in an appropriate manner. as our work progressed, and sara became more contactful internally and externally. she was less avoidant of her unpleasant emotions and came more easily in contact with them. she used interruptions of contact less frequently and became more mindful. increased mindfulness helped her therapy to run more smoothly and progress faster. sara was more able to talk about her core issues, particularly her relationship with her mother. although the unpleasant events in this relationship still hurt her, and the two were still quarrelling occasionally, sara changed her inner relationship to the problem. she now perceived those events and circumstances more mindfully, from a decentred perspective, with more equanimity and calmness. consequently, mother's critical remarks and their now less frequent quarrels, did not, in her words, "completely crush her,” as they previously had. the first months of therapy were marked with sara's frequent, intensive, and often overwhelming, depressive symptoms. sara was frequently in her child ego state, feeling sad and hopeless, reliving her past, instead of being present and mindfully in the here and now. international journal of integrative psychotherapy, vol. 5, no. 1, 2014 66 when sara was in her child ego state, our therapeutic work, especially during the first year, was often centred around attuning to the child and processing the child material. part of this work included exploring the child's unmet relational needs for security, validation and acceptance. in addition to focusing on the child, we also worked on strengthening sara's adult ego state to enable "dual awareness" (rothschild, 2000). the aim of this was to help sara calmly observe and reflect upon her own experiences of distress when they were happening. it is important to note that enhancing sara's capacity for reflective self-observation also strengthened her capacity for mindfulness, and developed what žvelc (2009, 2010) named the mindful adult. it helped sara in her efforts to merely observe, with equanimity, whatever was going on inside her, without getting overwhelmed by distressful experiences so characteristic of child ego states. during the course of therapy, sara gradually became less vulnerable to her mother's criticism, and her behaviour and feelings during these difficult situations with her mother changed, as she became more able to stay in her adult ego state. her previously strong child ego state reactions diminished. she was able to view the mother's behaviour more objectively and less as a threat to her very self. such decentred, mindful perspective is reflected in sara's statement, "i do not only say this to myself now, i really feel in this way, more and more, that this is all that mother is capable of, that it is the best she can give me." in another statement sara reflects on her non-reactive, mindful stance towards mother. "well, she just has to say that. […] that's the way it is, she cannot do differently. and i try to make it go in at one ear and out at the other, and not react at all. it is easier." in this period of therapy, sara cried less, her mood was more stable, and she remained more balanced when faced with challenges. sara’s strengthened adult ego state enabled her to be more mindful of other aspects of her present experience, which did not comply with her life script. in addition to having negative, unpleasant feelings, she could be simultaneously aware of positive feelings. for example, in one session, after sixteen months in therapy, sara felt trapped, unfree, unworthy and guilty. however, she was aware that this only applied to the situations at home and at work, because when she was in town that day, running errands, she felt self-confident. when experiencing negative, unpleasant affect and cognitions, sara did not become so overwhelmed with them in comparison to when she first came into psychotherapy. instead, she was more able to stay in her adult ego state and tolerate, as well as regulate, such unpleasant feelings and thoughts. she managed her sadness, tension, anger and frustrations more efficiently and in ways that were more adaptive and healthy for her. for example, in stressful moments she ate less sweets and less frequently resorted to cuticle biting, compared to the past, when her fingers would often bleed as a result. it is important to note that, especially from the perspective of mindfulness, tolerating negative affect, without interrupting contact, in fact means regulating them. staying mindful with unpleasant feelings, in a non-judgemental and accepting manner, international journal of integrative psychotherapy, vol. 5, no. 1, 2014 67 usually brings a surge of relief. with the development of a stronger adult ego state, sara's affective tolerance markedly increased. in our work, it was necessary to decontaminate sara’s adult ego state in regard to her parents. in this process, sara learned that respecting parents does not mean one needs to be submissive, self-belittling, or even self-humiliating. on the contrary, real respect of parents implies respecting oneself, too. for sara, this realization was the necessary prerequisite for developing the real freedom that she had been longing for so much – the inner freedom from the tyranny of the introjected parent. in the process of establishing this psychological freedom, sara developed a new way of coming home. her own family and her mother lived in separate apartments in the same building. before therapy, she felt obliged to first visit her mother when she came home, even though she would have preferred to go to her own apartment first and then, sometimes, visit mother. sara did not feel free to do what she wanted to do. instead, she felt an inner compulsion to first say hello to her mother. it even seemed to her that she would have betrayed her mother if she had gone straight to her own apartment. sara did not feel adult in what she was doing. as we worked on a behavioural change regarding this issue, i suggested to sara, and she agreed, to try something different. after coming home, she was to go to her own apartment first and then, if she wished to, visit her mother. at first, it was quite a challenge for sara to carry out our agreement. i encouraged her to be present in the here and now when she came home, to be in that very moment with awareness, and then to mindfully ask herself, "now, what do i want to do? where exactly do i want to go?" after a while, she mastered a new way of coming home, and it strengthened her feelings of freedom, independence, and of being an adult. she lived more in the present, in accordance with what she was an adult woman. she was no longer chained by her past, no longer a child trying to please her mother and avoid her critique. being more mindful in crucial, decisive moments was helpful for her in transcending a part of her script and developing new, more mature and more adaptive patterns of behaviour. coming home in a different way also bore an important symbolical meaning sara managed to "come home" – to get a bit closer to her true self. the aforementioned tyranny of the introjected parent is probably the single most suitable phrase to describe sara's script system. a prototype of her script dynamics is demonstrated in the previous description of her dilemma of how long should she stay on sick leave (see figure 1). these dynamics also became part of sara's personality structure which contained a demanding, low-empathic parent acting out towards the sad, helpless, but struggling child who is trying hard to please the parent in order to gain the parent's recognition and possibly, love. although the psychiatrist recommended about a month of sick leave, sara felt a lot of guilt for staying at home, and she wanted to go back to work after just a week. working on this dilemma was an opportunity for us to deepen contact with the vulnerable part of sara – the part that needed the sick leave international journal of integrative psychotherapy, vol. 5, no. 1, 2014 68 – and to become more aware of her needs. as a consequence, she remained on sick leave longer, despite her feelings of guilt. she said that such a "long" sick leave – two weeks – was a success for her and she attributed it to our therapeutic work. she was becoming better at acknowledging her own needs and taking proper care of them. another important part of sara’s work was related to her repressed and retroflected anger. i often wondered where her anger towards mother was hiding. even though mother was often unkind to her, i noticed that sara did not feel much anger towards her. instead, she would "feel broken," very sad, desperate, not understood, and with bad feelings about herself. she retroflected angry feelings that were originally directed towards her mother and less often towards other people. her anger was often overcontrolled, but sometimes under-controlled, as when she acted out in irritable outbursts directed at her family members. for sara, our work on anger was important for several reasons. first, being mindfully in contact with anger lessened the need for retroflection. consequently, depressive symptoms, which to a certain extent represented retroflected material resurfacing, were less likely to occur. secondly, anger as such was oriented against the script beliefs sara held, such as "i'm not important" or "i'm not good enough." due to the unique characteristics of the emotion of anger, it is less likely for an angry person to feel that they are not important or not acceptable to others. thirdly, anger became a helpful resource to sara in regulating relationships. often, sara had only limited success in setting efficient boundaries in relationships and saying "no" to others. through her therapy, she was learning to use the progressive energy of anger to be more assertive with others, and especially with her mother. sara needed this constructive aspect of anger to transform her relationship with mother, and in her words, "build her independence." feeling anger mindfully, instead of retroflecting or repressing it, supported sara in her process of separation and individuation. it was also helpful in her journey from an anxious-avoidant attachment style towards an active and authentic engagement in relationships. at the end of the psychotherapeutic process, sara's relationship with herself was considerably improved in comparison to the beginning of therapy. she was less critical and demanding of herself, more lenient and self-compassionate. she also became more able and willing to take care of herself than before. she actively took time for herself and engaged in recreational activities that were beneficial for her. she was more relaxed, satisfied and calm. in contrast to her previous script beliefs, therapy helped sara develop an increased sense of self-respect and self-worth. she also became more able to set boundaries in her relationships at home and at work. importantly, her psychological well being became significantly less dependent on the dynamics of the relationship with her mother. sara's sensitivity to her mother's criticism decreased considerably. at the end of therapy, she was psychologically more separated and more independent from her mother, and she was able to manage this relationship more effectively and mindfully. international journal of integrative psychotherapy, vol. 5, no. 1, 2014 69 conclusion this theoretical presentation of the integration of integrative psychotherapy and mindfulness, supported with a case presentation, demonstrates that integrative psychotherapy and mindfulness are not only mutually compatible, but also implicitly intertwined on theoretical and on practical level. the process of integrative psychotherapy may enhance mindfulness in clients, just as increased mindfulness may enhance a client’s process of integrative psychotherapy. therefore, we can hypothesize that encouraging and introducing mindfulness more explicitly in the process of integrative psychotherapy will bring even more benefit to our clients. in further investigations of the relationship between integrative psychotherapy and mindfulness, it would be helpful to explore in greater depth how various elements of integrative psychotherapy might be related to mindfulness. finally, a closer examination of changes in state and trait mindfulness during the process of integrative psychotherapy is an important topic for further research. author: mihael černetič, phd is a psychologist and certified integrative psychotherapist in private practice in maribor, slovenia. dr. černetič is on the faculty of the psychotherapy science of sigmund freud university, ljubljana, slovenia, and doba faculty of applied business and social studies http://www.dobafaculty.com/en/home/, maribor, slovenia. his special interest is in integrating mindfulness into psychotherapy. author’s note: i would like to thank my supervisor, gregor žvelc, phd, for helping me with this case study. i am also very grateful to carol merle-fishman, co-editor of the international journal for integrative psychotherapy for her editorial assistance during the writing of this article. references american psychiatric association. (2000). diagnostic and statistical manual of mental disorders, fourth edition, text revision: dsm-iv-tr. washington, dc: american psychiatric association. berne, e. (1961). transactional analysis in psychotherapy. a systematic individual and social psychiatry. new york: grove press. berne, e. (1964/1975). games people play: the psychology of human relationships. middlesex: penguin books. clarkson, p. (2004). gestalt counselling in action. london: sage publications. international journal of integrative psychotherapy, vol. 5, no. 1, 2014 70 černetič, m. (2005). biti tukaj in zdaj: čuječnost, njena uporabnost in mehanizmi delovanja [being here and now: mindfulness, its applicability, and mechanisms of action]. psihološka obzorja, 14(2), 73–92. černetič, m. (2011a). kjer je bil id, tam naj bo... čuječnost – nepresojajoče zavedanje in psihoterapija [where id was, there shall... mindfulness be – nonjudgmental awareness and psychotherapy]. kairos, 5(3–4), 23–34. černetič, m. (2011b). odnos med anksioznostjo in čuječnostjo [relationship between anxiety and mindfulness] (unpublished doctoral dissertation). univerza v ljubljani, filozofska fakulteta, oddelek za psihologijo. černetič, m., jančar, v., & vlašič tovornik, a. (2010). kontratransfer kot diagnostično sredstvo v psihoterapiji: tri študije primera [countertransference as a diagnostic tool in psychotherapy: three case studies] (unpublished manuscript). erskine, r. g. (1991). transference and transactions: critique from an intrapsychic and integrative perspective. transactional analysis journal, 21, 63–76. erskine, r., & moursund, j. (1998). integrative psychotherapy in action. highland, ny: the gestalt journal press. erskine, r. g., moursund, j. p., & trautmann, r. l. (1998). beyond empathy: a therapy of contact-in-relationship. new york: routledge. erskine, r. g., & trautmann, r. l. (1997). the process of integrative psychotherapy. in r. g. erskine (ed.), theories and methods of an integrative transactional analysis: a volume of selected articles (pp. 79–95). san francisco: ta press. germer, c. k. (2005). mindfulness – what is it? what does it matter? in c. k. germer, r. d. siegel, & p. r. fulton (eds.), mindfulness and psychotherapy (pp. 3–27). new york: guilford press. kabat-zinn, j. (1990). full catastrophe living: using the wisdom of your body and mind to face stress, pain, and illness. new york: dell publishing. martin, j. r. (1997). mindfulness: a proposed common factor. journal of psychotherapy integration, 7, 291–312. miller, e. k., & cohen, j. d. (2001). an integrative theory of prefrontal cortex function. annual review of neuroscience, 24, 167–202. morgan, w. d., & morgan, s. t. (2005). cultivating attention and empathy. in c. k. germer, r. d. siegel & p. r. fulton (eds.), mindfulness and psychotherapy (pp. 73–90). new york: guilford press. norcross, j. c. (2005). a primer on psychotherapy integration. in j. c. norcross & m. r. goldfried (eds.), handbook of psychotherapy integration (2nd edition) (pp. 3–23). cary, nc: oxford university press. o'reilly-knapp, m., & erskine, r. g. (2003). core concepts of an integrative transactional analysis. transactional analysis journal, 33, 168–177. o’reilly-knapp, m., & erskine, r. g. (2010). the script system: an unconscious organization of experience. international journal of integrative psychotherapy, 1(2), 13–28. rothschild, b. (2000). the body remembers: the psychophysiology of trauma and trauma treatment. new york: w. w. norton & company. international journal of integrative psychotherapy, vol. 5, no. 1, 2014 71 siegel, d. j. (2010). the mindful therapist: a clinician's guide to mindsight and neural integration. new york: w. w. norton & company. stern, s. (1994). needed relationships and repeated relationships: an integrated relational perspective. psychoanalytic dialogues, 4, 317–345. surrey, j. l. (2005). relational psychotherapy, relational mindfulness. in c. k. germer, r. d. siegel & p. r. fulton (eds.), mindfulness and psychotherapy (pp. 91–110). new york: guilford press. teasdale, j. d., segal, z. v., & williams, j. m. g. (1995). how does cognitive therapy prevent depressive relapse and why should attentional control (mindfulness) training help? behavior research and therapy, 33, 25–39. tudor, k. (2003). the neopsyche: the integrating adult ego state. in c. sills & h. hargaden (eds.), ego states (pp. 201–231). london: worth publishing. žvelc, g. (2009, april). present moment in integrative psychotherapy. keynote speech delivered at the 4th international integrative psychotherapy conference, bled, slovenia. žvelc, g. (2010). relational schemas theory and transactional analysis. transactional analysis journal, 40, 8–22. žvelc, g. (2012). mindful processing in psychotherapy – facilitating natural healing process within attuned therapeutic relationship. international journal of integrative psychotherapy, 3(1), 42–58. žvelc, g., černetič, m., & košak, m. (2011). mindfulness-based transactional analysis. transactional analysis journal, 41, 241–254. integrative psychotherapy and mindfulness: the case of sara international journal of integrative psychotherapy, vol.6, 2015 63 the impact of hope in mediating psychotherapy expectations and outcomes: a study of brazilian clients nicki l. aubuchon-endsley, jennifer l. callahan, david a. gonzález, camilo j. ruggero, & charles i. abramson abstract: client treatment expectations and hope are robustly associated with treatment outcome. despite this, no known studies have examined client hope as a mediator to the relationship between expectancies and psychotherapy session outcomes. in addition, recent literature also supports cross-cultural differences in relations between treatment expectancies and outcomes. this article presents a cross-sectional study with a sample of brazilian psychotherapy clients collected via referral sampling, in which existing clients referred potential participants. participants were asked about their symptomatology and expectations of psychotherapy. the current study found that, within this brazilian sample, trait hope partially mediated relations between expectancies and treatment session outcomes. further studies are needed to investigate these effects and session outcomes in a culturally competent manner. key words: psychotherapy, expectancies, hope, session outcomes, brazil, cross-cultural ____________________________ psychotherapy expectancies client psychotherapy expectancies have been categorized into role, process, control, and outcome/effectiveness expectations (cyr, bouchard, & lecomte, 1990; delsignore & schnyder, 2007; dew & bickman, 2005). a seminal review article (kirsch, 1997) defines role expectancies as the clients’ expectations of their own behavior as well as the behavior of their therapists during treatment. four components of client expectancies of their providers’ roles have been supported in the research literature, including “nurturant” (guidance and support from provider), “critical” (constructive feedback), “model” (providing instruction so that clients can help themselves), and “cooperative” (equality of client and provider) expectations (bleyen, vertommen, vander steene, & van audenhove, 2001). early theoretical work in this area resulted in construction of international journal of integrative psychotherapy, vol.6, 2015 64 the psychotherapy expectancies inventory-revised (pei-r), which has been used with good sensitivity and specificity in predicting treatment outcomes, including attrition, length of treatment, development of therapeutic alliance, and symptom reduction (ackerman & hilsenroth, 2003; aubuchon-endsley & callahan, 2009; constantino, ametrano, & greenberg, 2012). in contrast, outcome expectancies have been described as prognostic expectancies, which may include expectations of improvement in presenting symptoms, acquiring of particular skills or competencies following treatment, or other benefits of treatment derived from the institution and/or provider (kirsch, 1997). additionally, process expectancies are related to the client’s beliefs about therapeutic session content and general subjective experience of therapy (constantino, ametrano, & greenberg, 2012). the milwaukee psychotherapy expectations questionnaire (mpeq) was created to capture these additional expectancies pertaining to process and outcome, while also assessing clients’ role expectations (norberg, wetterneck, sass, & kanter, 2011). similar to the pei-r, the mpeq has been used to demonstrate significant relations between clients’ expectancies and therapy attendance, treatment length, well-being, and symptomatic distress. despite the developing literature on the influence of client expectations on psychotherapy treatment outcomes, several notable gaps remain. specifically, the vast majority of studies examine samples of predominantly european american clients, utilize end of therapy outcomes while failing to consider session outcomes during a course of treatment, and have not adequately investigated potential mediators to relations between expectancies and outcomes (bhugra, 2006). the need to include international samples is supported by recent findings that psychotherapy process and outcomes may differ by culture, and may yield differential effects on treatment outcomes (bhugra, 2006). in the most recent empirical study informing this issue, associations among treatment expectancies and end of treatment outcomes were explored in a sample of osage nation native american clients (aubuchon-endsley et al., 2014). results revealed that greater pre-treatment expectations of receiving advice and approval in therapy led to poorer treatment outcomes in osage nation clients. in contrast, lower scores on pre-treatment expectations of receiving advice and approval led to diminished treatment outcomes among caucasian clients (the opposite of osage nation clients) seen in the same clinic and within the same socioeconomic status. this study, like many others, did not consider therapeutic change associated with sessions during treatment, or examine potential mediators between early expectancies and end of treatment outcomes. consideration of ongoing session outcomes, rather than end of treatment outcomes, could provide a more nuanced understanding of the link between expectancies and outcomes. furthermore, examination of important mediators of this link may inform intervention selection for efficacious practice. international journal of integrative psychotherapy, vol.6, 2015 65 client hope a compelling potential mediator is client hope. client hope has been defined extensively by snyder and colleagues (2002), and is thought to reflect “a goal-directed thinking process in which people believe that they can produce the routes to desired goals (pathways thought), along with motivations to use those routes (agency thought)” (snyder et al., 1996, p. 289). hope theory has informed specific therapy modalities to utilize this non-specific factor in order to enhance treatment outcomes (cheavens, feldman, gum, michael, & snyder, 2006; michael, taylor, & cheavens, 2000). similar to psychotherapy expectancies, client hope regarding treatment has been found to be associated with greater well-being, coping, emotional regulation and functioning, and fewer psychopathological symptoms at the beginning and later phases of psychotherapy (irving et al., 2004). hope as mediator of expectancies-outcome link the terms “hope” and “expectations” are often used interchangeably within the treatment outcome literature and are not always well defined. although lambert (2004) has conceptualized expectancies as including hope, dew and bickman (2005) made distinctions between the two constructs. in particular, they noted that (1) hope can only exist when there are concurrent positive expectations of treatment, (2) negative expectations may exist in the absence of hope, and (3) a client may hope for positive treatment outcomes, but not expect them to occur (dew & bickman, 2005). in this conceptualization, there is interdependency between the two constructs, but they remain distinguishable. subsequent research supported this conceptualization and found significant, though incomplete, associations between expectancies and hope. for example, swift, whipple, & sandberg (2012) reported correlations between outcome expectancies and state hope between .35-.59. there appear to be robust associations of both treatment expectancies and client hope with end of treatment outcomes (ackerman & hilsenroth, 2003; aubuchonendsley & callahan, 2009; cheavens, feldman, gum, michael, & snyder, 2006; constantino, ametrano, & greenberg, 2012; irving et al., 2004; michael, taylor, & cheavens, 2000; norberg, wetterneck, sass, & kanter, 2011) as well as recent evidence of the interrelatedness between hope and treatment expectancies (swift et al., 2012). while there remains ambiguity regarding the unique contributions of each construct to client outcomes, there may be an indirect effect of expectancies on outcomes mediated by other client or therapist factors (joyce, ogrodniczuk, piper, & mccallum, 2003), which may include client hopefulness. international journal of integrative psychotherapy, vol.6, 2015 66 importance to integrative psychotherapy empirically elucidating the connection among hope, expectancies, and client outcomes is of critical importance to a common factors route to integrative psychotherapy. as described by norcross and goldfried (2005), there are four main routes established for attaining psychotherapy integration: assimilative integration, whereby the therapist is grounded in a primary orientation but assimilates elements of other theoretical orientations in a deliberate manner, theoretical integration whereby multiple therapies are combined and synthesized, technical eclecticism whereby interventions that have been found to work for others are selected and drawn from a range of theoretical orientations, as well as a common factors approach. the common factors approach focuses on variables that are common to many different therapies and associated with treatment effectiveness (miller, duncan, & hubble, 2005; wampold, 2001). both hope and expectancies may be conceptualized as common factors. for example, in a formative meta-analysis, howard, lueger, maling, and martinovich (1993) studied the process of effective treatment, irrespective of orientation or intervention and found that clients’ progress through three sequential phases. these phases include remoralization (inculcation of hope), remediation (reduction in symptom distress), and rehabilitation (sustained improvements in functioning). importantly, they noted that treatment effectiveness was associated with moving through these phases sequentially with instillation of hope providing the grounding for positive treatment outcomes. in more recent years, the phase model has held up well to replications ( callahan, swift, & hynan, 2006). the extant literature also points to expectancies as being an important common factor. lambert (2004) summarized this body of literature and concluded that client expectancies account for a robust 15% of treatment outcomes. unfortunately, a more recent review (constantino, ametrano, & greenberg, 2012) reported that expectancies remain one of the most understudied of the common factors. thus, this study tested the hypothesis that client hope mediates relations between pre-treatment psychotherapy expectancies and ongoing session outcomes, specifically within a brazilian sample. the goals of the study include examination of role, outcome, and process treatment expectancies. this included exploration of within-session outcomes such as subjective well-being, symptom severity, and interpersonal distress. as well, client hope was examined as a mediator between treatment expectancies and within-session outcomes. if client hope was found to be a significant mediator of relations between treatment expectancies and within-session outcomes, this would support the assessment of important common factors to treatment outcome, namely client expectancies and hope. additionally, to the degree that hope mediates relations between client expectancies and treatment outcome, it should be assessed regularly and findings should be integrated into psychotherapy to inform clinical international journal of integrative psychotherapy, vol.6, 2015 67 decision-making. for example, clinical decisions such as whether to focus on techniques to bolster hope, or focus on interventions consistent with other diverse theoretical orientations/approaches, could potentially influence treatment outcome. assessment of hope via therapist inquiry, particularly as it relates to a long-term absence of satisfaction of relational needs, has been noted by integrative psychotherapy authors (erskine & trautmann, 1996). they suggest interventions that include engaging the client in the expression of hope, in order to assist with processing of past instances of hopefulness and validation of personal experience, which is one of the eight principal relational needs delineated in integrative psychotherapy theory (erskine & trautmann, 1996). thus, hope has been shown to be an important aspect of co-created, relationally based psychotherapy and working within an integrative, relationship-based model, assessment and interventions targeting clients’ hope become important elements in shaping positive treatment outcomes. method procedures data were obtained directly from brazilian researchers who previously gathered information consistent with institutional procedures and in compliance with ethical standards. the collected data had not been previously analyzed and consisted of participants who were currently engaged in psychotherapy within any of the surrounding community clinics. cross-sectional data were collected at a single time point via participant questionnaires, given by the researchers, regarding current expectations and symptomatology. participants beginning with students attending a brazilian university, participants were recruited by referral sampling from existing participants. participation did not require student status however; students were only the starting point for recruitment. participants (n = 112) consisted of 68 women (60.7%) and 43 (38.4%) men, who were primarily not married or partnered (83%). the age of participants ranged from 17 to 51 years, with a mean age of 23 years (sd = 6.05). unfortunately, no information regarding psychotherapy orientation was available from treating clinicians. measures data were gathered via paper questionnaires, which were presented in portuguese. all measures were first translated and back-translated by a team of bilingual (english/portuguese) brazilian colleagues in the field of psychology with prior experience translating measures for research purposes. in addition to providing brief demographic information, participants completed the following measures. international journal of integrative psychotherapy, vol.6, 2015 68 psychotherapy expectancy inventory-revised (pei-r). the pei-r is a 24-item self-report inventory of client’s role expectancies of the therapist (berzins, herron, & seidman, 1971; bleyen, vertommen, vander steene, & van audenhove, 2001). this includes approval seeking, advice seeking, audience seeking (i.e., genuine listening), and relationship seeking scales. an example of an approval seeking item is, “how strongly do you expect your therapist to be gentle in phrasing his/her opinions about an important topic?” an example of an advice seeking item is, “how strongly do you expect to get definite advice from your therapist?” an example of an audience seeking item is, “how strongly do you expect to ‘carry the ball’ conversationally?” an example of a relationship seeking item is, “how strongly do you expect to be comfortable in expressing your feelings toward the therapist?” respondents rate items using a likert scale from 1 (not at all) to 7 (very strongly). higher scores correspond to greater client expectations of the therapist. the pei-r has high internal consistency (reported alpha coefficients of .75 .87 and falling from.74 .85 in the current sample) and 1-week test–retest reliability (rs = .54 .68) across its scales (berzins, herron, & seidman, 1971). the pei-r also has good internal construct validity, supported by exploratory and confirmatory factor analyses (bleyen, vertommen, vander steene, & van audenhove, 2001), in addition to concurrent validity with other measures of expectancies (aubuchon-endsley & callahan, 2014). milwaukee psychotherapy expectations questionnaire (mpeq) the mpeq is a 28-item self-report measure of several forms of treatment expectancies, including role, outcome, and process expectancies (norberg, wetterneck, sass, & kanter, 2011). a recent validation of the instrument, including exploratory and confirmatory factor analyses, supported the measure’s five-factor structure which includes expectations of therapeutic activities, self in therapy, improvement after therapy, therapist/alliance, and personal improvement (aubuchon-endsley & callahan, 2014). an example of a therapeutic activities item is, “i will be taught new skills in therapy.” an example of a self in therapy item is “i will be able to express my true thoughts and feelings.” an example of an improvement after therapy item is, “at the end of the therapy period, how much improvement in your problem(s) do you think will occur?” an example of a therapist/alliance item is “my therapist will be interested in what i have to say.” an example of a personal improvement item is, “after therapy, i will have the strength needed to avoid feelings of distress in the future.” items 1 – 24 are rated using a likert scale from 0 (not at all) to 10 (very much so), whereas items 25 – 27 are rated from 0% to 100% (scored as 0 10) corresponding to the frequency of expectations and item 28 is scored using a likert rating scale ranging from 0 (i expect to feel worse) to 10 (i expect to feel completely better). higher scores correspond to greater client expectations on each respective factor. the mpeq has good internal consistency (reported α international journal of integrative psychotherapy, vol.6, 2015 69 coefficients = .81 .95; obtained α coefficients = .85 .93) and 2-week test–retest reliability (rs = .73 .85; aubuchon-endsley & callahan, 2014). the mpeq has also demonstrated good divergent validity with measures of self-efficacy, hope, subjective well-being, and symptom severity and good convergent validity with other measures of role expectancies (aubuchon-endsley & callahan, 2014). state and trait hope scales the state and trait hope scales (shs and ths, respectively; snyder et al., 1991) were created to measure one’s current and dispositional hope. for each scale, participants were asked to rate three agency and three pathways items on a likert scale ranging from 0 (strongly disagree) to 8 (strongly agree). the shs has a stable two-factor structure with agency factor loadings ranging from .83 .89 and pathways factor loadings ranging from .69 .88 (snyder et al., 1996). the shs also has high internal consistency with reported α coefficients ranging from .82 .95 and an observed α coefficient in the current study of .86. similarly, the shs evidences adequate to good convergent (rs = .78) and concurrent validity (rs = .49) with other hope measures as well as discriminant validity after partialling out variance from another dispositional hope measure (feldman & snyder, 2000; snyder et al., 1996). the ths also has a stable two-factor (agency and pathway) structure and high internal consistency with reported α coefficients ranging from .74 .84 and an observed α coefficient in the current study of .78). the ths has a 3-week test-retest reliability of r = .85 and adequate to good convergent validity with other hope measures (rs = .50 .75). the ths also has adequate to good discriminant validity with measures of self-esteem, hopelessness, expectancies for success, problem-solving, and symptom severity (carifio & rhodes, 2002; tong, fredrickson, weining, & zi xing, 2010). subjective well-being (swb) the swb measure is a four-item client report questionnaire which was expanded from two items used in howard and colleagues’ (1986) phase model study (callahan, swift, & hynan, 2006). items address subjective distress, energy level, emotional functioning, and level of satisfaction with life on a five-point scale. the swb has adequate internal consistency (reported α = .71; observed α = .73), 1week test-retest reliability (r = .63), and convergent validity with other measures of well-being (r = .79; callahan et al., 2006). this instrument has been found to perform well in clinical research applications (swift, callahan, heath, herbert, & levine, 2010). outcome questionnaire-abbreviated (oq-abbreviated) the outcome questionnaire-45.2 (oq-45.2; lambert et al., 1996) is a self-report measure that consists of 45 items inquiring about the client’s feelings and functioning in the preceding week with responses provided on a scale ranging from never to almost always. back translation of the full oq-45.2 indicated that international journal of integrative psychotherapy, vol.6, 2015 70 some items might be problematic from the standpoint of construct invariance. thus, for this study an abbreviated version of the measure was developed. the oq-abbreviated consists of 13 oq-45.2 items that raised no concerns during the translation process. factor analysis of the oq-abbreviated identified two factors: the first factor is thought to reflect symptom severity (items 9, 10, 23, 28, 33, 36, 40, and 42 of the original measure), while the second factor is conceptualized as indicative of interpersonal distress (items 19, 30, 37, 39, and 43 of the original measure). the internal consistency (α = .72) was found to be acceptable in the current sample. results descriptive statistics for the measures used are reported in table 1 and zeroorder pearson correlations among measures are reported in table 2. table 1 descriptive statistics for the study measures (n = 112) mean (sd) α mpeq total 197.29(50.93) .86 mpeq therapeutic activities 63.63 (16.66) .91 mpeq self in therapy 52.42 (14.89) .92 mpeq improvement after therapy 24.57 (7.11) .85 mpeq therapist/alliance 27.56 (9.54) .91 mpeq personal improvement 29.10 (9.36) .93 pei-r total 107.05(23.55) .90 pei-r approval seeking 26.38 (7.42) .74 pei-r advice seeking 28.21 (7.86) .84 pei-r audience seeking 23.79 (7.16) .76 pei-r relationship seeking 28.67 (7.89) .85 trait hope total 25.55 (3.42) .77 state hope total 36.68 (7.91) .86 oq-abbreviated total 19.49 (6.43) .72 swb total 13.77 (2.75) .73 note. mpeq = milwaukee psychotherapy expectations questionnaire; pei-r = psychotherapy expectancy inventory-revised; oq-abbreviated = outcome questionnaire-abbreviated; swb = subjective well-being. kolmogorov-smirnov (k-s) tests of normality were non-significant for each measure. international journal of integrative psychotherapy, vol.6, 2015 71 table 2 zero-order correlations among study measures (n = 112) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 1. mpeq total 2. mpeq therapeutic activities .89* 3. mpeq self in therapy .90* .70* 4. mpeq improvement after therapy .87* .69* .80* 5. mpeq therapist/alliance .83* .63* .69* .68* 6. mpeq personal improvement .92* .78* .79* .77* .76* 7. pei-r total .71* .58* .69* .59* .62* .62* 8. pei-r approval seeking .63* .58* .56* .52* .50* .60* .80* 9. pei-r advice seeking .62* .59* .55* .46* .52* .58* .78* .61* 10. pei-r audience seeking .38* .25 .38* .34* .42* .34* .76* .47* .42* 11. pei-r relationship seeking .54* .37* .63* .49* .47* .43* .74* .40* .37* .50* 12. trait hope total .33* .25 .36* .24 .36* .22 .36* .27 .24 .32* .27 13. state hope total .35* .28 .35* .23 .36* .32 .33* .35* .19 .26 .22 .65* 14. oq-abbreviated total -.19 -.08 -.28 -.19 -.18 -.14 -.22 -.15 -.12 -.22 -20 -.39* -.40* 15. swb total .27 .14 .32 .29 .24 .23 .24 .24 .10 .26 .14 .44* .54* -.61* notes. all correlations in bold were significant at p ≤ .05. those with * were significant at bonferroni corrected critical value of p ≤ .001. mpeq = milwaukee psychotherapy expectations questionnaire; pei-r = psychotherapy expectations inventoryrevised; oq-abbreviated = outcome questionnaire-abbreviated; swb = subjective well-being. international journal of integrative psychotherapy, vol.6, 2015 72 as noted in the introduction, it was hypothesized that the effect of client expectancies on session outcomes would be mediated by client hopefulness. mediation models were tested using the product of coefficients approach outlined by mackinnon and fairchild (2009). this technique is more sensitive than traditional causal steps approaches (baron & kenny, 1986) and allows for the calculation of confidence intervals around the mediated effect (tofighi & mackinnon, 2011). a product of coefficients was calculated by estimating a regression coefficient between the predictor and mediator (a path), estimating a regression coefficient between the mediator and outcome variable controlling for the predictor variable (b path), and multiplying the two. if the subsequent confidence interval did not include 0, then a statistically significant mediation effect was said to exist. furthermore, if the relation between the predictor and outcome variable controlling for the predictor (c' path) was still significant, partial mediation was deemed present. there is no standard measure of effect size for the mediation effect that statisticians agree upon. nevertheless, the zero-order correlation for the a path and the partial correlation for the b path has been suggested for this purpose and were therefore used in the current study (mackinnon, fairchild, & fritz, 2007). mediation was found to be present in all models, which are summarized in table 3. international journal of integrative psychotherapy, vol.6, 2015 73 table 3 product of coefficients and partial correlations for mediated effects ab σ ci partial r for b partial r for c' trait hope total mpeq total → oq 13 -.01 .01 [-.03, -.01] -.35 -.19† mpeq activities → oq 13 -.04 .02 [-.08, -.01] -.38 .02 mpeq self → oq 13 -.05 .02 [-.09, -.01] -.32 -.17† mpeq improve after → oq 13 -.08 .04 [-.16, -.02] -.36 -.10 mpeq therapist → oq 13 -.08 .03 [-.15, -.03] -.35 -.05 mpeq improve personal → oq 13 -.05 .03 [-.11, -.004] -.37 -.06 mpeq total → swb .01 .002 [.002, .01] .38 .15† mpeq activities → swb .02 .01 [.01, .03] .42 .02 mpeq self → swb .02 .01 [.01, .04] .37 .20† mpeq improve after → swb .04 .02 [.01, .07] .39 .21† mpeq therapist → swb .04 .01 [.01, .07] .38 .13† mpeq improve personal → swb .02 .01 [.002, .05] .40 .15† pei-r total → oq 13 -.03 .01 [-.06, -.01] -.34 -.09† pei-r approval → oq 13 -.09 .04 [-.17, -.02] -.36 -.04 pei-r advice → oq 13 -.07 .04 [-.15, -.02] -.37 -.03 pei-r audience → oq 13 -.10 .04 [-.19, -.03] -.34 -.11† pei-r relationship → oq 13 -.08 .04 [-.16, -.02] -.35 -.10† pei-r total → swb .012 .01 [.01, .03] .38 .10† pei-r approval → swb .04 .02 [.01, .07] .39 .16† pei-r advice→ swb .04 .02 [.01, .07] .42 -.01 pei-r audience → swb .05 .02 [.02, .09] .38 .14† pei-r relationship → swb .04 .02 [.01, .08] .42 .01 note. mpeq = milwaukee psychotherapy expectations questionnaire; pei-r = psychotherapy expectancy inventory-revised; oq 13 = outcome questionnaireabbreviated; swb = subjective well-being. bolded values in table 3 have a p < .05. †= zero-order r, p < .05. ab = product of regression coefficient (a) between expectancies and mediator (hope), and regression coefficient (b) between mediator and outcome (distress/well-being), controlling for expectancies. σ = sd of ab. ci = 95% confidence interval. c' = relation between expectancies and outcome, controlling for mediator. the partial r for b is used as a measure of effect size, while the partial r for c is used as a criterion for evaluating the statistical significance of mediation utilizing the product of coefficients approach. with two exceptions, effects were in the anticipated direction. in particular, for the international journal of integrative psychotherapy, vol.6, 2015 74 majority of models, elevated client hope accounted for relations between greater treatment expectations and (1) more subjective well-being, (2) reduced symptom severity, and (3) less interpersonal distress. for the two models in which the direction of effects deviated from hypotheses (i.e., mpeq activities → oq 13 and pei-r advice→ swb), the sign of the ab path was opposite the c’ path, suggesting that there is an unidentified direct effect. to allow for comparisons among the literature, a traditional causal steps approach (i.e., comparing c zero-order to c' partial correlation) to mediation was also used. all mediation models were still significant; the relation between predictor and outcome changed from statistically significant to non-significant when controlling for the mediator. the size of all mediated effects was medium. data were further analyzed to explore which specific types of expectancies were mediated by client hope. five different expectancies measured by the mpeq were used as predictors, including: (1) expectations of therapeutic activities, (2) self in therapy, (3) improvement after therapy, (4) therapist/alliance, and (5) personal improvement. moreover, four types of role expectancies measured by the pei-r were used, including: (1) approval seeking, (2) advice seeking, (3) audience seeking, and (4) relationship seeking. as a more stable construct, only the trait related hope scale (i.e., ths) was used as a mediator to contain the number of analyses and reduce family-wise error. utilizing the product of coefficients approach with measures’ total scores, relations between the pei-r and mpeq and swb and oq-13 were partially mediated by trait hope, though relations between the mpeq and the oq-13 remained significant after controlling for hope. analyses by scale also suggested that trait hope mediated (medium effect sizes) relations between the mpeq and swb (expectancies of therapist and personal improvement) and oq-13 (expectancies of self) with scales initially significantly related to respective outcomes. the same was true of the pei-r and swb (approval and audience seeking expectancies) and oq-13 (audience and relationship seeking expectancies). discussion within this sample of brazilian clients, the means and standard deviations for the study measures largely mirrored those found in previous samples (aubuchon-endsley & callahan, 2014; aubuchon-endsley & callahan, 2009; bleyen et al., 2001; callahan et al., 2006), suggesting ample variability in this study’s constructs. one notable exception was the ths. in particular, the mean in our sample (m = 25.55) was much lower than the typical mean of 49 found in other samples (snyder, 2002). however, none of the samples reported by snyder (2002) were derived internationally. therefore, study findings highlight the possibility that trait hope may be lower in populations of clients within developing countries. despite this, hope still significantly mediated relations international journal of integrative psychotherapy, vol.6, 2015 75 between greater expectancies and positive session outcomes. one possible implication of this observation is that the threshold or level of hope needed to enhance treatment outcomes may be lower within such populations. as in previous samples, internal consistency was adequate for all measures used, which were also normally distributed without major outliers. this further supports the appropriateness of the use of these measures within brazilian samples and suggests that follow-up studies within other international populations may also benefit from their utilization. similarly, as in prior studies, both expectancies measures (pei-r and mpeq) were significantly correlated. they were also found to be significantly associated with measures of both state and trait hope in this sample. results further suggest that hope partially mediates relations between treatment expectancies and session outcomes. although hopefulness partially accounts for relations between process, role, and outcome expectancies and subjective well-being, only process and role expectancies were mediated by hope in relation to symptom severity/client distress. this suggests that hopefulness does not explain relations between treatment outcome expectancies and symptom severity/client distress following psychotherapy sessions. this may be because outcome expectancies are more robustly associated with end of treatment outcomes rather than session outcomes. future studies should measure and compare session and treatment outcomes in reference to expectancies and hope in order to evaluate this hypothesis. additionally, two models (i.e., mpeq activities → oq 13 and pei-r advice→ swb) contained opposite signs for paths ab and c’, suggesting that there are additional mediators that should be considered for relations between expectancies and outcome. while previous studies have highlighted the mediational role of the therapeutic alliance (joyce et al., 2003), additional client and therapist characteristics might also be important to consider in future research. overall, because hope partially mediates relations between expectancies and session outcomes, treatment providers may wish to evaluate both. if treatment expectancies are low, interventions to augment hope could be combined with expectancies interventions to foster positive session outcomes. specifically, interventions and techniques which may promote hope may include a greater focus on the client’s strengths and resiliency factors, as opposed to pathology/symptomatology, when explaining case conceptualization and treatment rationale (cheavens et al., 2006). additionally, setting reasonably attainable early goals for treatment may enhance clients’ probability of reaching their goals, leading to positive affect and enhanced hope of accomplishing future treatment goals. highlighting and monitoring clear, tangible pathways or plans for obtaining these goals may also be important to enhance client confidence in treatment. moreover, identification of variables that increase motivation for treatment may also be beneficial. additional expectancies interventions have been recently outlined by several authors (constantino et al., 2012; defife & hilsenroth, 2011; swift et al., 2012). this may include the therapist modeling international journal of integrative psychotherapy, vol.6, 2015 76 positive expectations of treatment process and outcome, emphasizing treatment initiation as a positive first step toward therapeutic efficacy, establishing rapport and a collaborative treatment process early, working toward a mutual understanding and explanation of client concerns and treatment rationale, and normalizing client concerns with appropriate empathy and realistic expectations regarding treatment. future studies should evaluate the efficacy of these combined treatment interventions with dismantling designs recommended to parse out the most efficacious elements. despite the promising implications for clinical practice and beneficial lines of future research, results should be interpreted within the context of existing study limitations. specifically, the convenience, medium-sized sample had relatively homogeneous sociodemographic characteristics, which carries the potential of limiting external validity of current findings. however, when placed within the larger context of the developing expectancies literature, this study seems to lend strong support to the previously identified expectancies-outcomes association as also salient to international populations. additional international studies are strongly encouraged to examine the generalizability of these findings. further, the archival data did not contain information about how many sessions participants had completed thus far in their course of treatment. despite this lack of information, a moderate mediation effect was still observed. however, had that data been available, a more nuanced picture might have emerged. in particular, the effect of expectancies on session outcomes might be dose-dependent. future research examining the possibility of a dose-dependent expectancies effect is strongly encouraged. in sum, the current study supports the use of the aforementioned measures to conduct important and much-needed investigation of psychotherapy process and outcomes in diverse populations. although results suggest that expectations in brazilian samples are similar to those found in other samples, there may be less client hopefulness in brazilian samples. nevertheless, hope still significantly explains associations between treatment expectations and outcomes. therefore, treatment techniques that bolster hope should be considered within such populations when clients are experiencing low treatment expectations. because these associations were found throughout treatment and not just at the end of psychotherapy, the assessment of expectations and application of hope interventions should be considered at any stage of treatment. despite the fact that results support hope as a mediator between several forms of treatment expectancies and within-session outcomes, they also highlight the need for further research to examine why these models are not unanimously significant. specifically, future research should focus on whether there are particular types of expectancies or treatment outcomes for which this mediation hypothesis does not hold true. additionally, other salient potential mediators to relations between client treatment expectancies and within-session outcomes should be examined. international journal of integrative psychotherapy, vol.6, 2015 77 authors: nicki aubuchon-endsley, ph.d., is the clinic director and an assistant professor in the department of psychology at idaho state university. she completed graduate school at oklahoma state university, a pre-doctoral internship at the durham, nc vamc, and an nih postdoctoral research fellowship at the alpert medical school of brown university. she is a licensed psychologist who currently has two lines of research examining (1) treatment efficacy and the development of clinical competencies within psychology training clinics and (2) biopsychosocial mechanisms underlying the influence of maternal perinatal health on offspring neurobehavioral and cardiometabolic outcomes. jennifer l. callahan earned her ph.d. in clinical psychology from the university of wisconsin-milwaukee, completed her internship and postdoctoral training at yale university, and holds board certification in clinical psychology. she is currently associate professor and director of clinical training for the clinical psychology program at the university of north texas (denton tx) where she directs the evidence-based training and competencies research lab. address: jennifer l. callahan, department of psychology, university of north texas, 1155 union circle #311280, denton, tx 76203-5017, usa. e-mail: jennifer.callahan@unt.edu. david andrés gonzález is completing a postdoctoral fellowship in clinical neuropsychology at the south texas veterans health care system where he also completed his internship; he earned a ph.d. in clinical psychology from the university of north texas. in addition to clinical work with low-income and minority individuals, he maintains a line of research aimed at improving the assessment of emotion and cognition in individuals with neurologic and psychiatric disorders. camilo j. ruggero is associate professor of psychology at the university of north texas. he completed his ph.d. at the university of miami and his pre-doctoral internship and nimh-sponsored f32 postdoctoral fellowship at the alpert medical school of brown university. his research explores phenomenology and risk factors related to psychopathology in general and mood disorders in particular. charles i. abramson earned his ph.d. in experimental psychology from boston university. he is currently regents professor of psychology and lawrence boger professor of international studies at oklahoma state university. his area of research is the comparative analysis of behavior where he is director of the laboratory of comparative psychology and behavioral biology. mailto:jennifer.callahan@unt.edu international journal of integrative psychotherapy, vol.6, 2015 78 references ackerman, s. j., & hilsenroth, m. j. (2003). a review of therapist characteristics and techniques positively impacting the therapeutic alliance. clinical psychology review, 23, 1-33. doi: 10.1016/s0272-7358(02)00146-0 aubuchon-endsley, n. l. & callahan, j. l. (2009). the hour of departure: predicting attrition in the training clinic from role expectancies. training and education in professional psychology, 3, 120-126. doi: 10.1037/a0014455 aubuchon-endsley, n. l., & callahan, j. l. (2014). exploring pretreatment expectancies in a campus mental health setting. journal of college counseling, 17, 64-79. doi: 10.1002/j.2161-1882.2014.00048.x aubuchon-endsley, n., callahan, j. l., & scott, s. (2014). role expectancies, race, and treatment outcome in rural mental health. american journal of psychotherapy, 68, 339-354. baron, r. m., & kenny, d. a. (1986). the moderator-mediator variable distinction in social psychological research: conceptual, strategic, and statistical considerations. journal of personality and social psychology, 51, 11731182. doi: 10.1037/0022-3514.51.6.1173 berzins, j. i., herron, e., & seidman, e. (1971). patients’ role behaviors as seen by therapists: a factor analytic study. psychotherapy: theory, research, and practice, 8, 127-130. doi: 10.1037/h00866638 bleyen, k., vertommen, h., vander steene, g., & van audenhove, c. (2001). psychometric properties of the psychotherapy expectancy inventory revised (pei-r). psychotherapy research, 11, 69-83. doi: 10.1080/713663853 callahan, j. l., swift, j. k., & hynan, m. t. (2006). test of the phase model of psychotherapy in a training clinic. psychological services, 3, 129-136. doi: 10.1037/1541-1559.3.2.129 carifio, j., & rhodes, l. (2002). construct validities and the empirical relationships between optimism, hope, self-efficacy, and locus of control. work, 19, 125-136. cheavens, j. s., feldman, d. b., gum, a., michael, s. t., & snyder, c. r. (2006). hope therapy in a community sample: a pilot investigation. social indicators research, 77, 61-78. doi: 10.1007/s11205-005-5553-0 constantino, m. j., ametrano, r. m., & greenberg, r. p. (2012). clinician interventions and participant characteristics that foster adaptive patient expectations for psychotherapy and psychotherapeutic change. psychotherapy, 49, 557-569. doi: 10.1037/a0029440 cyr, m., & bouchard, m-a., & lecomte, c. (1990). self-consciousness and theoretical orientation as mediators of therapist expectancies in psychotherapy. counselling psychology quarterly, 3, 125-132. doi: 10.1080/09515079008254241 defife, j. a., & hilsenroth, m. j. (2011). starting off on the right foot: common factor elements in early psychotherapy process. journal of psychotherapy integration, 21, 172-191. doi: 10.1037/a0023889 international journal of integrative psychotherapy, vol.6, 2015 79 delsignore, a., & schnyder, u. (2007). control expectancies as predictors of psychotherapy outcome: a systematic review. british journal of clinical psychology, 46, 467-483. doi: 10.1348/014466507x226953 dew, s. e., & bickman, l. (2005). client expectancies about therapy. mental health services research, 7, 21-33. doi: 10.1007/s11020-005-1963-5 erskine, r. g., & trautmann, r. l. (1996). methods of an integrative psychotherapy. transactional analysis journal, 26(4), 316-328. feldman, d. b., & snyder, c. r. (2000). the state hope scale. in: j. maltby, c. a. lewis, & a. hill (eds.) a handbook of psychological tests. lampeter, wales: edwin mellen press (pp. 240-245). howard, k. i., kopta, s. m., krause, m. s., & orlinsky, d. e. (1986). the doseeffect relationship in psychotherapy. american psychologist, 41, 159-164. doi: 10.1037/0003-066x.41.2.159 howard, k. i., leuger, r. j., maling, m. s., & martinovich, z. (1993). a phase model of psychotherapy outcome: causal mediation of change. journal of consulting and clinical psychology, 61, 678-685. doi: 10.1037/0003066x.51.10.1059 irving, l. m., snyder, c. r., cheavens, j., gravel, l., hanke, j., hilberg, p., & nelson, n. (2004). the relationships between hope and outcomes at the pretreatment, beginning, and later phases of psychotherapy. journal of psychotherapy integration, 14, 419-443. doi: 10.1037/1053-0479.14.4.419 joyce, a. s., ogrodniczuk, j. s., piper, w. e., & mccallum, m. (2003). the alliance as mediator of expectancy effects in short-term individual therapy. journal of consulting and clinical psychology, 71, 672-679. doi: 10.1037/1089-2699.8.1.3 kirsch, i. (1997). response expectancy theory and application: a decennial review. applied and preventive psychology, 6, 69-79. doi: 10/1016/s0962-1849(05)80012-5 lambert, m. j. (2004). bergin and garfield’s handbook of psychotherapy and behavior change (5th ed.). new york: john wiley & sons, inc. lambert, m. j., hansen, n. b., umpress, v., lunnen, k., okiishi, j., & burlingame, g. m. (1996). administration and scoring manual for the oq45.2. stevenson, md: american professional credentialing services llc. mackinnon, d. p. & fairchild, a. j. (2009). current directions in mediation analysis. current directions in psychological science, 18, 16-20. doi: 10.1111/j.1467-8721.2009.01598.x mackinnon, d. p., fairchild, a. j., & fritz, m. s. (2007). mediation analysis. annual review of psychology, 58, 593-614. doi: 10.1146/annurev.psych.58.110405.085542 michael, s. t., taylor, j. d., & cheavens, j. (2000). handbook of hope: theory, measures, and applications. san diego, ca us: academic press. miller, s. d., duncan, b. l., & hubble, m. a. (2005). outcome-informed clinical work. in j. c. norcross & m. r. goldfried, (eds.), handbook of psychotherapy integration (2nd ed., pp. 84-102). new york: oxford. norberg, m. m., wetterneck, c. t., sass, d. a., & kanter, j. w. (2011). development and psychometric evaluation of the milwaukee international journal of integrative psychotherapy, vol.6, 2015 80 psychotherapy expectations questionnaire. journal of clinical psychology, 67, 574-590. doi: 10.1002/jclp.20781 norcross, j. c. & goldfried, m. r. (eds.) (2005). handbook of psychotherapy integration (2nd ed.). new york: oxford. snyder, c. r. (2002). hope theory: rainbows in the mind. psychological inquiry, 13, 249-275. article stable url: http://www.jstor.org/stable/1448867 snyder, c. r., harris, c., anderson, j. r., holleran, s. a., irving, l. m., sigmon, s. t.,…harney, p. (1991). the will and the ways: development and validation of an individual-differences measure of hope. journal of personality and social psychology, 60, 570-585. doi: 10.1037/00223514.60.4.570 snyder, c. r., sympson, s. c., ybasco, f. c., borders, t. f., babyak, m. a. & higgins, r. l. (1996). development and validation of the state hope scale. journal of personality and social psychology, 70, 321-335. doi: 10.1037/0022-3514.70.2.321 swift, j. k., whipple, j. l., & sandberg, p. (2012). a prediction of initial appointment attendance and initial outcome expectations. psychotherapy, 49, 549-556. doi: 10.1037/a0029441 tofighi, d. & mackinnon, d. p. (2011). rmediation: an r package for mediation analysis confidence intervals. behavior research methods, 43, 692-700. doi: 10.3758/s13428-011-0076-x tong, e. w., fredrickson, b. l., weining, c., & zi xing, l. (2010). re-examining hope: the roles of agency thinking and pathways thinking. cognition and emotion, 24, 1207-1215. doi: 10.1080/02699930903138865 vermeersch, d., lambert, m., & burlingame, g. (2000). outcome questionnaire: item sensitivity to change. journal of personality assessment, 74, 242261. doi: 10.1207/s15327752jpa7402_6 wampold, b. e. (2001). the great psychotherapy debate: models, methods, and findings. mahwah, n.j.: lawrence erlbaum. date of publication: 22.12.2015 international journal of integrative psychotherapy, vol. 12, 2021 163 reflexively exploring the “therapeutic use of self:” a response to richard erskine’s five-chapter case study of allan linda finlay abstract this commentary seeks to open up dialogue and debate about the therapeutic use of self in integrative psychotherapy. reflexively responding to richard erskine’s (2021a, b, c, d, e) touching and inspiring five-chapter case study of allan, i examine some of the key processes that occur at each phase of longterm therapy, from the initial stage of assessing and engaging the client in therapy, to making contact, building deeper integrative connections (with self and the therapist), and eventually entering the final ending phase. while my model of integrative psychotherapy mirrors that of richard erskine, the probing undertaken here raises questions around our respective commitment to existentialphenomenological ways of working over approaches drawn from other theoretical frameworks. but while our stances may be subtly different, i salute erskine’s exquisitely artful use of self, as revealed in the titrated choice and timing of his interventions. keywords: therapeutic use of self, integrative psychotherapy, therapy process, phenomenological inquiry, reflexive dialogue i sit down with anticipation to read the five chapters comprising richard erskine’s latest writings about his work with allan (erskine, 2021a, b, c, d, e). his abstract explains how this case study explores depression as a “presenting symptom that reflects an isolated attachment pattern, a core feature in the personality of psychotherapy clients who rely on schizoid process as a form of emotional stabilization.” i am aware of my sense of curiosity and excitement. richard’s case studies always inspire; engaging with his text will be a stimulating challenge. a distant self-critical voice calls out warnings. richard has invited me to use the work as a “springboard” and share my ideas around psychotherapeutic international journal of integrative psychotherapy, vol. 12, 2021 164 process. this invitation is a huge honor. but what if i can’t make sense of the process? worse, what if i have nothing to say, nothing to contribute? ah. i smile to myself and find my ground once more. this feels a familiar place—a parallel process. that cocktail of assured curiosity and excitement, blended with a touch of (reasonable) professional self-doubt and (less reasonable) personal shame, is exactly my experience every time i sit down with a new client and prepare to go on a journey with them. this time, i’m readying myself to go on a journey with richard and his client allan. i don’t know where we’re going, or what new vistas will be revealed. but i am eager to step aboard, keen to embrace this opportunity to reflect deeply on psychotherapy process and practice. i reflect momentarily on my current grounded place which parallels my stance at the beginning of every therapy encounter. the key ingredient here is to grasp and hold a phenomenological attitude. yes, i think to myself, that is something immediate and specific that i want to talk about. my own approach to relational integrative psychotherapy is similar to richard’s—this is not surprising since he was one of my early teachers. but there are also points where we subtly diverge—mainly concerning his use of psychoanalytic concepts (against my own strong leanings towards existential phenomenological theory and practice). this lens of focusing on richard’s therapeutic use of self (rather than commenting on allan’s process) with the emphasis on phenomenological insights feels right. i feel an easing in my body, my excitement builds. i have no idea where this journey will take us, but, just like the start of therapy, i have opened myself to embracing and exploring whatever should unfold. in this paper, i seek to open up dialogue and debate—both with richard erskine and with our psychotherapy community—about the therapeutic use of self in integrative psychotherapy. the commentary that follows is a response to erskine’s (2021a, b, c, d, e) five-part account of his therapy with a client called allan. i’ve structured my narrative in terms of four phases (the ones typically engaged in longterm therapy). first, there is the initial stage of assessing and engaging the client in therapy. then the focus is on making contact (where the client contacts both the therapist and themself). as therapy proceeds, the process of making connections and integration becomes figural; then therapy can then proceed towards endings. assessing and engaging the client richard’s first impression of allan is of a shy, pleasant man who is either withholding responses or slow to respond. through gentle questioning, richard learns that allan is a 50-year-old, “diligent” bookkeeper who has lived in the same apartment international journal of integrative psychotherapy, vol. 12, 2021 165 since he was a child. his father had died when allan was in kindergarten. allan has never married and has lived with his mother until her death (from cancer) four years previously. although he attends church every sunday, he remains socially isolated. mostly flat in his presentation, he comes to life when talking about his hiking and camping vacations in the wilderness (erskine, 2021a). reading richard’s initial evaluation of allan, i experience a mixture of reactions. there is so much that calls out for attention in just these few evocatively crafted pages. not only do we meet allan, but richard also models a phenomenological attitude (of attunement, openness, and descriptive inquiry). he also engages clinical reasoning and demonstrates how to be reflexively present. all these processes, which i discuss below, underpin this initial assessing-engaging phase, where both client and therapist commit to the work. phenomenological attitude the phenomenological attitude is open, non-judgmental, and filled with wonder and curiosity about the world. it seeks to hold prior assumptions apart. for therapists seeking to infuse their work with such an attitude, the immediate challenge when entering a therapeutic encounter is to remain open to new understandings: to be present and empathically open to the client, ready to attune to them and to simply go exploring. it’s important to “bracket” (husserl, 1936/1970) knowledge and assumptions. taking its cue from phenomenological philosophy, this bracketing is best understood as non-judgmental focused openness, where we are trying to see clients and their lives with “fresh eyes” (finlay, 2008, p. 29, 2016a, 2022). it’s about bracketing in order to be present, while resonating to what is emerging relationally in the here-and-now (finlay, 2013, 2021). in his first three assessment sessions with allan, richard reveals this ready-toreceive, non-judgmental approach, even if he does not explicitly call it a phenomenological attitude. he is busy opening himself to his client and attuning to allan’s being. “i did not understand his internal processes,” richard says, “but i listened for the covert meaning in his stories. i needed to be patient, attentive, and attune myself (the best i could) to his indistinct and subtle affects” (erskine, 2021a, p. 30). richard favors phenomenological inquiry, and we see this throughout the therapy and his other writings (erskine, 2015). for me, phenomenological inquiry is a part of a broader, sustained phenomenological attitude that goes beyond asking questions to being an attempt to describe the “is-ness” of self-states that are emerging (finlay, 2021). novice therapists can all too easily see phenomenological inquiry as simply a technique of asking questions about the client’s experiencing in the here-and-now, missing its broader philosophical significance. i suspect richard has his own philosophical commitments, ones which probably go beyond my preferred humanistic, international journal of integrative psychotherapy, vol. 12, 2021 166 existential framework. however, based on his previous writings, i believe he privileges phenomenological inquiry over historical inquiry (erskine, 2015, 2020b). phenomenological inquiry aims to raise the client’s moment-to-moment awareness of their intersubjective experience, meanings, issues, and needs (current and archaic)—all aspects that may have been pushed down or defensively disowned. through the therapist’s respectful questioning and listening, the client can become curious about their own self and gain new insight: the first step towards self-acceptance and growth. for me, the key here is how the questions are posed. especially when working so delicately at the contact boundary with individuals with anxious, avoidant, or isolating attachment patterns, any questioning needs to be done with care and curiosity, ideally with both therapist and client working together on the answers. richard notes that with many depressed clients he relies on phenomenological inquiry to focus attention on the client’s experience, rather than on their observable behavior. in previous writings, he has explained how to use questions or statements that focus on bodily (“what’s happening in your body just now?”), cognitive (“what sense do you make of that?”), affective (“what are you feeling?”), and/or relational dimensions (“what’s it like to be sitting here telling me that story?”) (erskine, 2020a). through his exquisitely patient inquiry, richard slowly builds a picture of allan’s life. at work, allan diligently applies himself while being disapproving of his “timewasting” co-workers. when not at work or attending church on sundays, allan takes to the streets of new york city, spending his evenings walking through neighborhoods and observing people from a distance. saturdays, he sets off alone to hike nature trails. his life is devoid of family, friends, and the warmth of human contact. like richard, i feel sad as allan’s story unfurls. “i felt an emptiness, like a vacuum, in my belly when i imagined that allan’s world was deprived of intimate contact with people,” is how richard describes his feelings. but richard does not seem to find it easy to tune into allan’s experience. he ruefully acknowledges that in the first three evaluation sessions, his phenomenological inquiry mostly elicited evasion or a non-response. this causes him to wonder if such inquiry might be “more of a hinderance than a help” (erskine, 2021a, p. 30). i feel some sympathy for him. those early sessions, marked by allan’s deflections or silent responses, must have been challenging. richard keeps reminding himself to be patient. could there be some irritation and frustration lying beneath the surface—reactions he has not expressed or perhaps does not want to show? he sounds admirably calm. i know from my own work that i can get frustrated and irritated in similar situations and need to redouble my effort to hold on to some compassion and patience. what helps me is supervision or consultation where i can have some space with a valued peer colleague in which international journal of integrative psychotherapy, vol. 12, 2021 167 to vent and regroup, reminding myself to focus compassionately on the likely terror that lies behind the withdrawal rather than reacting to it. but there is more here. is richard indicating that for some clients (allan among them) phenomenological inquiry simply does not work? if so, i am not sure i would agree. after all, if richard had not asked all those vital questions, would he not already be giving up on allan? i think there is value in showing allan some of the routes they might take over time, even if the questions look too unappealing or treacherous at that moment. even if allan is not responding, the questions are being posed and they can be held in the space, in anticipation of a time when he is ready to take them up. i agree, of course, that care must be taken to not be invasive with the questioning. part of my version of phenomenological inquiry would be simply to reflect back: “is it difficult to say what you’re feeling just now?” equally, i might engage phenomenological description (what richard calls “therapeutic description”) to begin to raise awareness of the client’s process, initially providing some words for the client that they don’t yet have, for example, “i sense it is difficult for you to speak about feelings just now” or “i’m sensing there is some scare here. is that possible?” i would argue that phenomenological inquiry engaged by a therapist with genuine non-judgmental openness, interest, curiosity, and empathy (i.e., the phenomenological attitude), is an invaluable core stance at all times, even as other therapeutic techniques may be employed. the manner of delivery will emerge and evolve within the specific relationship—over time—as we adapt to the client’s needs and the relational context, and as they adapt to us (finlay, 2022). it is hard to tell from richard’s selective narrative, but i would say the bits of inquiry he has already engaged will prove extremely valuable. richard’s account suggests that he (appropriately) experimented with different kinds of interventions including how he worked towards making more directive suggestions about how allan might change his behavior or do things differently. allan’s silent responses and/or defensive deflections were in their own way an effective form of communication. richard evidently heard the message allan was conveying through his silences, as he changed course and returned (for the time being at least) to gentler, non-invasive phenomenological inquiry: i increased my use of phenomenological inquiry, particularly my inquiry about his affect and body sensations. although he was slow to answer, he usually identified tension in his neck and chest. somehow that led us to talking about his difficulty in expressing any emotion to people. he said, “i want to remain private. i don’t want anyone poking their nose into my business.” i asked if that included me. allan answered, “yeah, sometimes your questions are too damn invasive.” i responded, “what happens inside you when i ask such questions?” allan shrugged his shoulders and remained silent for the remainder of the session. during the next couple of sessions, he struggled to describe how he international journal of integrative psychotherapy, vol. 12, 2021 168 became physically tense, expecting me to criticize whatever he said, and how he quickly searched “for the right answer.” (erskine, 2021a, p. 33) i am struck by this passage—it feels relationally significant. not only is allan’s difficulty with expressing emotion apparent, but allan also tells of being primed and alert to the slightest whiff of criticism. recognizing this watchfulness, richard grasps the importance of not suggesting any behavioral change that might imply a judgement of sorts. his strategy of simply engaging more inquiry strikes me as helpful since it shows acceptance of allan’s being and choices. as richard notes, psychotherapy is not happening if the client is simply giving what they perceive to be the “right” or expected answers. i appreciate richard’s flexibility here. he is responding relationally—titrating his therapeutic use of self to mesh with what allan is ready to tolerate (finlay, 2022). research consistently underlines the importance of tailoring therapy to the individual (norcross & wampold, 2018). in addition to the way richard is adapting to allan, i hugely respect his humility and openness to learning. i like the way he allows his client to take on the role of teacher: i often overlooked the significance of these subtle signs of the schizoid process. it has taken me a number of years to become sensitive to the unspoken story of such clients, a story replete with fear, shame, disavowed loneliness, selfcriticism, and a compulsion to isolate. allan was one of the clients who taught me to listen for the therapeutically significant story encoded in what such individuals do not say. (erskine, 2021a, p. 37) clinical reasoning richard notes that allan fits the picture of a “schizoid” client. i appreciate richard’s rejection of the diagnosis of “depressive disorder.” like other existentially oriented therapists, i resist reductionist, dehumanizing medical model categories, preferring instead more intuitive, phenomenological ways of seeing the client in the context of their relational world (finlay, 2016a). while diagnosis can be informative, it’s important to ask what we might miss if we view just through that lens. the lens of “depressive disorder” may lead us simply to peer within the person and thereby miss viewing them in the context of their depressing life circumstances. and is there a risk of unduly pathologizing allan rather than acknowledging it’s his way of being and/or our way of seeing him? “when we totalize others, when we reduce them to objects of our knowledge, i.e., to easily labelled categories and stereotypes, we have violated their inherent worth as good in themselves” (sayre & kunz, 2005, p. 227). international journal of integrative psychotherapy, vol. 12, 2021 169 george atwood and robert stolorow (2016, p. 104) also wade into this debate: the features of experience and conduct formerly regarded as symptoms of reified psychiatric categorizations or as expressions of decontextualized psychoanalytic character types then become understood as inseparable from the multifaceted relational fields linking the patient to other people, which includes the participating presence of the observing clinician. instead of diagnosis, richard offers a formulation of allan’s situation, namely that encoded in allan’s self-descriptions and behaviors are “unconscious relational patterns” that are being lived out in his daily life (flatness, avoidance, and disavowed affect). apparently devoid of intimacy, these relational patterns are leading him to “despair” and a longing for “peace and quiet.” richard senses that something vital is missing from allan’s life. but he’s not yet sure what it is other than appreciating the schizoid process is one of splitting off from the vital and vulnerable child self (erskine, 2001, 2020b). for my part, i want to hold lightly to this initial formulation (interpretation?). with my reservations about the extent to which anyone can know another, i also want to try to see allan without reducing and fixing him as a “schizoid patient” who might be treated by pre-set therapeutic formulae. as yalom (2001) states, taking diagnostic systems and protocols too seriously may “threaten the human, the spontaneous, the creative and uncertain nature of the therapeutic venture” (p. 5). knowing richard’s work, i know that he too is reluctant to label another and would work against applying prefabricated protocols. when he uses terms like “schizoid,” he is talking about a protective withdrawal process arising as part of a style or pattern of behavior rather than a fixed and pathological “disorder.” at the same time, i’m aware of richard’s north american cultural context, where diagnosis is needed for insurance purposes and is often the starting point of framing clinical needs. there is a clear contrast here with my british context and my own experience of private practice. it seems richard lives more comfortably with psychodiagnostic labels than i do. richard also turns away from taking a fuller phenomenological attitude in his reflections about “schizoid process” and his formulation of what might constitute allan’s “unconscious relational patterns.” i suspect i might have done the same— although i would have been working harder to bracket the idea that allan had a schizoid process. it is here that the difference between theory and the practice reveals itself. it is virtually impossible to completely hold back our assumptions or understandings—a point phenomenological philosophers (e.g., merleau-ponty, 1962) stress (finlay, 2021). there is a balance to be struck between employing our presence, power, judgement, and expertise as therapists while holding on to unknowing. it takes discipline and courage to sit with uncertainty and not-knowing; it is not easy to let go of power and control towards trusting the process of the therapy encounter (finlay & evans, international journal of integrative psychotherapy, vol. 12, 2021 170 2009). richard reveals this in his sincere wish to let allan’s story unfold in the way that it needed to: i was curious about allan, but my inquiries were only partially effective. he answered my questions but often with reticence. i wanted to know him, to know the depth and extent of what he felt, what he had lived as a boy, and how he managed his life. it was necessary to continually remind myself to be patient, to just let his story unfold. (erskine, 2021a, p. 33) i agree with richard that seeking to lift allan’s (so-called) “depression” was unlikely to be a particularly fruitful approach. however, richard seems to have further concerns about allan’s engagement and their lack of a mutual, affect connection. i, too, wonder about this. it is often the case that some kind of therapeutic alliance is in place by the end of the third session of therapy. indeed, research indicates that this is necessary for positive outcomes (norcross & lambert, 2019). that richard agreed to carry on with the therapy suggests that he sensed some element of hope, even if it remained vague and intuitive: a sense of the possibility of something positive emerging from the collaboration. and, importantly, allan himself seemed more than prepared to commit to weekly therapy for a year. it was essential that he made this commitment. it was an implicit acknowledgement that he was not intending to commit suicide (a lurking risk factor richard rightly checked out). without mutual commitment on both sides, it would not have been ethical to proceed (finlay, 2019). richard does not say it explicitly, but i have a sense that allan would not be an easy client to work with. i am reminded that therapy can be hard work—for both client and therapist. therapy with a client who is flat and lifeless in presentation and who dismissively avoids talking about emotion poses particular challenges where it is hard to keep present and engaged. i am touched by richard’s care and the way he reflects deeply as he makes an “emotional commitment” to meet allan weekly for a year: i wanted our psychotherapy to enhance the quality of his life and provide him with a desire to live. i walked home from the office that night questioning myself: “was i wanting more for allan than he wanted or was willing to do?” i knew what was possible in an in-depth psychotherapy, but i had no evidence that allan knew the commitment, perseverance, and time that would be required to make some fundamental changes in his life. (erskine, 2021a, p. 32) the power of this commitment, along with richard’s candor, uncertainty, and doubts, should not be underestimated. international journal of integrative psychotherapy, vol. 12, 2021 171 being reflexively present erskine (2015; moursund & erskine, 2003/2004) notes there is a duality to the therapist’s presence: a simultaneous attending to client and to self (in terms of being emotionally available and self-aware). the therapist de-centers from their own needs, making the client’s process the primary focus. here the therapist is mindful of the client’s experience, watching every little gesture, listening to each word, and being with the client’s silence. at the same time, the therapist’s history, relational needs and sensitivities, theoretical stance and professional experience all enter into building therapeutic presence (erskine, 2011; erskine et al., 1999). more than a duality, however, i would argue that the best relational work in psychotherapy is characterized by a triality (or, to apply my preferred metaphor, seeing with three eyes). as richard has indicated, one eye is focused firmly on observing-sensing the client; the second eye is engaged with reflexively observingsensing oneself. the new third eye element is an explicit monitoring of what is happening “between,” concerned with the emerging relationship. here, i follow hycner’s (2017) dialogic gestalt approach, which underscores the need to be present to all these three points of focus. sometimes we are deeply immersed in holding a client’s story; then we switch our attention to our own embodied experience and also towards reflexively monitoring what is happening in the relationship. we focus on ourselves and the relationship, not out of narcissistic motives, but reflexively as a way of furthering our appreciation of the client’s process. i believe that richard engages this three-way focus when he makes his regular, explicit sensorial searches of his own internal process while monitoring the moment-to-moment dynamics of the relationship with allan. at these times he recognizes the importance of maintaining his own vitality and curiosity (particularly in the face of any deadening deflections from allan). being present in this way involves being grounded in one’s own embodied self in order to receive the client’s experience (geller & greenberg, 2002). opening ourselves to whatever is emerging moment-to-moment in the therapeutic encounter in open, alive, curious ways is central to our work as therapists (mcwilliams, 2017; schneider, 2008). it is about being present to new possibilities, ready to be awed and surprised as we touch—and are touched by—the other. placing our trust in the therapeutic process, we strive to be energetically present, inviting, alive to creative possibilities, and ready to share ourselves as we join with our client and go exploring (finlay, 2016b). richard’s “relational needs” work (and i include here his writing colleagues) (see erskine, 2020a; erskine et al., 1999) attests to the importance of being focused on the therapeutic relationship while being solidly grounded, attuned, aware, and responsive in order for the client to feel adequately held and attended to. it can also be powerful for the client to see they have impacted the therapist. the less the therapist is present, the more anxiety-provoking the situation is likely to be international journal of integrative psychotherapy, vol. 12, 2021 172 for the client, who may feel shame and/or abandonment in the face of therapist withdrawal or perceived lack of interest. in turn, the client is likely to want to withdraw and/or dissociate. in other words, “the presence of the therapist invites the client to be present” (finlay, 2022, p. 39). richard has written elsewhere (2001, 2020b) about being the security-in-therelationship and engendering a sense of security in the client so that they do not need their self-created withdrawal defense. the point i would stress here is that this is a co-created—relational—process. the therapist does not just create a “safe space.” instead, somehow the therapist needs to involve and negotiate with the client, trying to work out together what would be a safe space. with allan initially struggling to be fully present to himself and his therapist, richard’s presence becomes more important. he needs to be present as a safe presence in order to invite allan to be present. he does this by holding a welcoming therapeutic space where allan can feel accepted, respected, and empathized with. in a way, richard is like a welcoming, gracious host who offers a special kind of spacious hospitality (finlay, 2022): the guest… client comes seeking sanctuary, a safe place of protection where wounds can be carefully cleansed and healed. but where is the sanctuary, if not fundamentally in the heart of the host or therapist who is willing to face this living encounter and courageously open to it? (kapitan, 2003, p. 74) making contact the challenge to the therapist is to meet the client at that point of contact in a manner that encompasses that resistance, rather than threatens it. it is to genuinely see the resistance as a point of contact between rather than as merely an oppositional force. (hycner, 1991/1993, pp. 151–152) over the course of the first year or so, the therapeutic alliance between richard and allan builds. as the two men explore allan’s world together, their contact deepens. they are engaged in something of a dance at the contact boundary as they explore the space between intimacy and distance, insight, and resistance. at first, their dance is stiff, the steps uncertain. but then their ease with the movement builds. richard glides through a series of improvised steps with allan, movements whose sharp shifts of focus and rhythm are more reminiscent of a tango than a graceful waltz. at times they move together; at other times allan pulls away and then is gently brought back. a question lies between them: just how close is it safe to be? would their tenuous interpersonal connection prove sufficient to prevent allan reverting to his old isolated/isolating patterns? richard recognizes that allan’s avoidant withdrawing pattern is part of his survival strategy in the face of an unresponsive, critical mother. international journal of integrative psychotherapy, vol. 12, 2021 173 with this compassionate empathy to the fore, richard takes care to be patient and respectful; he strives to lessen the likelihood of allan closing down. i applaud this approach: honoring allan’s defenses is, paradoxically, likely to result in him relinquishing them. in this critical dance-of-contact phase, four dimensions of the therapeutic use of self stands out for me: dwelling, resisting contact, transference, and titration. dwelling the art of engaging a proper phenomenological attitude and inquiry involves a special attentiveness that dwells with the situations the client describes and attends to (even magnifies) details (wertz, 2005; finlay, 2021). the aim is to focus on the implicit meaning of the situation as it presents to the client. at the same time, the therapist takes a slowed, savoring approach which involves intuitively sensing, moving with, empathizing, responding, and resonating with their whole body-self. george atwood and robert stolorow (2016, p. 103), both phenomenologically oriented psychoanalysts, characterize dwelling as an “active, relationally engaged form of therapeutic comportment” geared towards healing emotional wounds. in dwelling, they say, we don’t just seek to understand the other’s world. instead, “one leans into the other’s experience and participates in it, with the aid of one’s own analogous experiences” (p. 103). time and again through the case study, i see richard sensitively embodying this dwelling approach (though he may not use that word or see it, as i do, as being linked to the phenomenological attitude). for instance, i really appreciate the way that richard engages allan’s dreams (over the years). he does this in a layered way, excavating meanings when it seems allan is ready to face them. these dream analysis sequences are powerful, and i suspect pivotal, as allan learns about the richness of his internal world. early on in therapy, whenever allan mentions a dream, richard invites him to find his own meanings. allan appreciates this; as he notes later on in therapy, “you allowed it to be my dream, my meaning” (erskine, 2021b, p. 44). in his account, richard suggests that he might have offered interpretations about allan’s intrapsychic life had he had more information. my view is that interpretation would be an unnecessary embellishment and that working phenomenologically is sufficient at any stage. interpretations, i feel, take away from the very dwelling inquiry which was now beginning to bear fruit. as richard acknowledges, what is important is the client’s meaning and growing awareness. international journal of integrative psychotherapy, vol. 12, 2021 174 allan’s tortured inner world is further revealed in his disclosure that when he leaves the therapy session, the volume of his self-criticism rises. richard makes a point of working with such insights, showing that he is resonating with allan’s affect or unarticulated relational needs: i encouraged him to let me hear what was happening inside him, even to shout the criticisms out loud. when he finally spoke, the forcefulness of his words was lethal: “i’m useless,” “i’m a weakling,” “no one’s interested in me.” (erskine, 2021b, p. 48) this gestalt technique of amplifying inner dialogue, richard notes, is effective precisely because intrapsychic conflict is diminished when it is externalized (baumgardner & perls, 1975; perls, 1973). in time, the source of those shamed/shaming judgements is traced to allan’s disdainful, fault-finding mother. this insight emerges as allan acknowledges that his trust in richard is precarious; it seems that allan has expected richard to criticize him. richard explains how allan is transferring emotional memories of his mother’s responses onto his therapist and is perhaps compensating for the damaging effects of his mother’s criticisms by imagining richard’s criticism. however, we do not learn how exactly this is communicated to allan. i find such interpretations are best delivered cautiously rather than authoritatively and best posed as an open question for exploration. resisting contact? allan’s reluctance to talk about his relationship with his mother speaks loudly to richard. but given the intensity of allan’s pain and anger, it is crucial that richard continues to be patient while persistently trying to access allan’s feelings. in the initial stages of therapy, allan remains reticent, unwilling to modify his behavior or talk about his feelings and early life experiences. weekly therapy sessions seem to follow the same pattern, one in which allan simply shares his stories about his irritations at work, night treks in the neighborhood or his nature hiking. it seems that it was important to him was to stay with the familiar and safe—his routines helped to stabilize and protect him. it is not clear from the narrative if richard made attempts to bring the functions of allan’s repetitions to his awareness. unlike many therapists, richard notably avoids the term “resistance” when he talks about allan and his response to therapy. the fact that he does not critically label allan as resistant is significant. the concept of resistance in psychotherapy has been hotly contested, with different schools having different understandings of what it is and how to work with it. since its introduction to the psychoanalytic field, there is general agreement that resistance can be understood as a defensive, protective response to threat. international journal of integrative psychotherapy, vol. 12, 2021 175 however, if we take a humanistic-relational perspective, we understand that interpersonal contact is always a co-creation (erskine, 2015). this being the case, resistance cannot be understood just as a refusal by one person to engage. i would challenge this pathologizing characterization of the client as the “problem.” rather than seeing resistance as unidirectional, negative and an oppositional move by a recalcitrant client, i prefer the gestalt approach to seeing resistance as a potentially wonderful creative adjustment that needs to be respected, honored, and even celebrated. then, it can be gently managed (mcferran & finlay, 2018). the relational therapist will want to create a safe-enough space where client selfprotection is met with non-judgmental compassion. by naming, not judging, the battle between avoidance and self-insight, therapists can establish themselves as able to contain expressions of the subjective life of the client, which then allows these expressions to emerge more freely (atwood & stolorow, 2014; mcferran & finlay, 2018). i am interested in richard’s observation that initially he did not attend to the sarcastic swipes allan aimed in his direction. i see this as evidence of richard’s experience (and robustness) coming into play. while we all have a need to feel helpful (we may even yearn to be needed or appreciated), usually experience helps us to avoid taking criticisms too personally. it’s likely that any negativity or rupture has arisen out of a relational process to which both client and therapist are contributing. reflexively exploring underlying dynamics more deeply will help enrich the work and strengthen the awareness or choices of both therapist and client. richard rightly starts to probe the function of allan’s habitual criticism of both himself and others. do allan’s projections offer momentary relief from his own raucous self-criticisms? are his criticisms the active outward expression of all that he has introjected from his mother and sister? exploring these questions explicitly in therapy results in allan having a profound insight: that his self-criticism is a way of drowning out his mother’s voice: we talked about how his self-criticism became more prevalent and vociferous than his mother’s and a distraction from the emotional pain of a mother’s words. his posture changed, and the tension in his face and shoulders relaxed as he cried. (erskine, 2021b, p. 52) transferential responses from his previous writings, i recognize that richard’s therapy model of contact-inrelationship (erskine et al., 1999) is in play. it is a model that draws on transactional analysis, behaviorism, gestalt therapy, systemic, relational psychoanalysis, and developmental-attachment theory. perhaps the biggest challenge for any integrative psychotherapist is how to blend competing—even contradictory—perspectives (finlay, 2016a). one international journal of integrative psychotherapy, vol. 12, 2021 176 potential contradiction in richard’s model is the place of psychoanalytic understandings of unconscious processes and transference. humanistically inclined therapists reject the idea that unconscious, irrational, instinctive forces determine human behavior. some even deny the existence of an unconscious as such, preferring instead to talk about material that is not yet in conscious awareness. i wonder where richard sits in this debate as he attempts to straddle psychoanalytic and humanistic assumptions. perhaps he manages to avoid the problem of contradiction by his use of transactional analysis, since that theory is implicitly integrative and smoothly blends interventions that works with both archaic and here-and-now needs. from his other writings (erskine, 1991), i understand that he follows berne’s (1961) early ta formulation, seeing transferential transactions as “externalized expressions of internal ego conflicts between exteropsychic and archeopsychic ego states” (p. 66). more specifically, transferential transactions may be both a projection of child needs and intrapsychic conflict, and an overt transaction from either exteropsychic or archeopsychic ego states. i do not disagree with richard here as my model of working draws heavily on his model and the use of transactional analytic concepts and processes. however, it can be problematic when practitioners inadvertently misuse the model by naively claiming to be simultaneously psychoanalytic, behavioral, and humanistic in their approach. more critical discussion is needed about precisely how competing theories, with their contradictory underpinning philosophies and assumptions, can or should be integrated (finlay, 2016a). i like lynne jacobs’ dialogic gestalt approach where she finesses apparent contradictions in her concept of “enduring relational themes” (jacobs, 2017). here, she highlights how clients’ patterns of relating derived from historical experience can become embodied-emotional perspectives on the world. she embraces a thorough-going humanistic focus on the intersubjective here-and-now without assuming that past relationships somehow get unconsciously displaced onto the present. transference and countertransference are reframed as a co-created relationship of mutual responding where the histories of both therapist and client shape our hopes, longings, or dreaded expectations. this position, focusing more on the relationship as opposed to an individual’s intrapsychic world, would probably find acceptance with many contemporary relational psychoanalysts and relational integrative psychotherapists more generally. i suspect richard would feel comfortable enough with jacobs’ position. at the same time, he is explicit about his work with transference and his psychodynamic interests. in this case study, i’m interested in the way richard usefully and clearly categorizes his countertransferential responses as reactive, responsive, and international journal of integrative psychotherapy, vol. 12, 2021 177 identifying (erskine, 2012, 2013a, 2013b). that he deeply and reflexively challenged himself to explore his internal experience is significant, and i appreciate his honesty in recognizing his own unrequited relational-needs and identifications, as well as his desire to offer relational healing. allan’s developmental attachment history is palpably present, both in his own responses and in those of richard. richard treads carefully, given the way inquiries about allan’s childhood have been largely rebuffed (“i don’t remember my childhood”). he is forced to fall back on his own observations and “intuitive sensings” of possible unconscious relational patterns from childhood. in session after session, as he listens to allan’s detailed stories of his nature hikes or nightly “low-down” treks, it seems that richard gets the message that he needs to show a “fatherly” interest. “i began to form a developmental image of allan as a 6to 8year-old boy, a child without a father to take an interest in his adventures” (erskine, 2021a, p. 34). this developmental image, richard says, evoked feelings of compassion within him and increased his interest in allan’s stories. he took care to ask factual questions about allan’s hiking and to use his face and body gestures to indicate that he was present and attentively engaged. i feel touched when i hear that richard wants to go hiking with allan, to smell the forest, to see the woodland trail, to be a companion. i appreciate his care in listening so intently. i feel happy for allan that he has finally found someone who can mirror, witness, and validate him—and be the companion he has never had. i am aware of my own powerful developmental image of a caring father and (no longer lonely) little boy walking hand-in-hand through the woods. i recognize that my own enduring relational themes have become figural, and that in a parallel process this could be understood as my own reactive and identifying countertransference. titration the somatic therapist peter levine (2011) has developed a systematic approach to working bodily with trauma which involves helping clients progressively access bodily energies and sensations a little bit at a time to build up their tolerance. borrowing from the field of chemistry, he calls this process “titration.” we can observe titration in action in the way psychotherapists constantly adapt their therapeutic use of self, making subtle adjustments (finlay, 2022). research consistently emphasizes the importance of adapting therapy to the individual. “the clinical reality is that no single psychotherapy is effective for all patients and situations no matter how good it is for some” (norcross & wampold, 2018, p. 1893). international journal of integrative psychotherapy, vol. 12, 2021 178 “as therapists, we make deliberate choices about how and when to intervene. we continuously adapt and pace the levels of tenderness, formality, spontaneity, emotionality, challenge, support, self-disclosure, intimacy, and directiveness we offer” (finlay, 2022, p. 3). early in the therapeutic relationship, we might choose to engage more phenomenological inquiry and/or description, and simply listen in a reserved, slow, quiet, empathic way. a client’s withdrawal (to self-stabilize) might be supported and even encouraged. as therapy unfolds, we may become more present, animated and/or inject more challenge or self-disclosure (finlay, 2022). throughout the case study, we see richard making subtle adjustments in his approach, adapting to what allan can tolerate. when even phenomenological inquiry proves too much, richard eases back to be simply an appreciative listeningwitnessing ear for all of allan’s stories. when allan experiences richard as too invasive or critical, richard again backs off and is respectful of allan’s silent withdrawal. of course, it is not always that easy to attune to the precise level of tenderness, silence, empathy, challenge, directiveness, and so on that the client can handle. some clients can find too much attentiveness overwhelming and invasive; feeling unworthy themselves, they become uncomfortable with too much warm appreciation (finlay, 2022). allan, it seems, found any inquiry about his affect uncomfortable (or confusing?), which resulted in him deflecting by changing the topic. it seems that richard got the balance about right. he helps allan begin to express himself by accepting the deflections or silences in a non-judgmental way. i suspect any other approach (e.g., being more directive or challenging) would have resulted in allan disengaging (although perhaps a cognitive-behavioral therapist would disagree with me). as the months and years of therapy go by, i again appreciate richard’s artful titrating of his therapeutic use of self where he invites relational connection and makes contact with allan’s vulnerable parts. sometimes he leans in and offers challenge, and at other times he pulls back to give more space to allan. he continuously adjusts his responses—relationally. we can see richard regularly and reflexively monitoring his use of self. this is particularly evident at times when he realizes his intervention may be a mistake. importantly he does not beat himself up: i was disappointed in myself because i had missed the significance of his various criticizing comments. but, unlike allan, i did not chastise myself. instead, i wondered what was happening within allan, what was unexpressed, and the functions of his criticisms of others. (erskine, 2021b, p. 51) i am struck by this passage where richard states he does not chastise himself (unlike allan). i suspect this more self-accepting stance grows with experience. we all make mistakes. it is part of the process—possibly even a necessary part. it is international journal of integrative psychotherapy, vol. 12, 2021 179 best to view our so-called mistakes with curiosity and compassion and see them as potential opportunities. many arise out of therapists’ genuine concern; if at times we try too hard it is because we care. ideally, we catch any errors, repair any ruptures, and manage arising wounds over time. both therapist and client have the opportunity to learn and grow (finlay, 2022). making connections the client is becoming whole. contact with the self, with all its complexities and capacities, so long split and fragmented, is being re-established. feelings and thoughts and perceptions rush in, often with surprising intensity. and each of those long-repressed, long-hidden parts of self has a kind of fragility, like a flower bud freshly opened or a butterfly newly escaped from its hard cocoon. (erskine et al., 1999, p. 172) integrative psychotherapy aims to facilitate a sense of wholeness in a person’s being and functioning at intrapsychic, mind-body, relational, societal, and transpersonal levels (finlay, 2016b). we strive to enable our clients to gain insight into their experience and to have a sense of feeling at home with self and ease with others (i.e., both internal and relational integration). there are, of course, limits to the extent to which any of us can be deemed “whole,” but integration remains the driving spirit of our project—particularly so in the case of longer-term work. relationally oriented therapists believe that healing integration occurs through relationships (with the therapist and with others). the therapeutic relationship acts as a particular catalyst, enabling a client’s growth. it is the unfamiliar experience of being deeply connected in a relationship that allows previous ways of being to be understood and laid to rest, enabling new ways of being to be brought to life. in latter stages of therapy, the focus goes towards helping the client own previously disowned parts, find ways to emotionally self-stabilize, and become aware of new possibilities and life choices. the case study demonstrates this theory beautifully. over the years that follow, trust, intimacy and connection between richard and allan deepen, just as allan’s connection with himself solidifies. for me this distinguishes the most artful level of relational integrative work: where the client’s connections both externally and internally are enabled (finlay, 2016a). richard and allan begin to more closely examine and work through the effects of allan’s mother’s disapproval at each developmental age and his efforts to hide from her. using the relationship with richard as a microcosm of his world, allan is able to allow the surfacing of issues around trust, shame, and feeling criticized. as allan connects with his archaic experience, his self-criticism becomes louder. at international journal of integrative psychotherapy, vol. 12, 2021 180 last, he can acknowledge his shame and the harsh intense grip of self-criticism is loosened. the work richard and allan engage in is so profound that there is much to comment on and explore further. i would like to open up two aspects: working creatively and with multiple parts of self. working creatively the flow of therapy should be spontaneous, forever following unanticipated riverbeds; it is grotesquely distorted by being packaged into a formula that enables inexperienced, inadequately trained therapists (or computers) to deliver a uniform course of therapy. (yalom, 2001, p. 34) curiosity, warmth, passion, permissiveness, courage, and heart-and-soul commitment are among the qualities that often animate the best relational work. it is important to remain creative rather than follow therapy recipes. we need to engage our own vitality if we are to help enable another’s to come forth. being mechanical or formulaic in our work stultifies the dynamic, growth-enhancing potential of therapy (finlay, 2022). as yalom (2001) advises, we should create a new therapy for each patient, one tailored to their needs. richard shows this creativity again and again. i would like to highlight three instances shown in the way he: 1) challenges allan to talk about his relationship with his mother, 2) works with another dream, and 3) encourages allan to withdraw to a safe internal space. being challenging. firstly, i appreciate the way richard makes a few deliberate inquiries about allan’s relationship with his mother in each session. that deliberately provocative challenge of his brought a smile to my face. although richard does not openly liken their relationship to a battle, there is certainly a battle of sorts (a battle for allan’s soul?) at work. richard’s persistence eventually pays off—allan shares more about his early life; his awareness of the impact of his mother’s abusiveness grows. i continued to inquire about his body sensations, and it became evident that each time he held his breath for a moment and then sighed that he had heard an internal criticism such as “you can’t do that” or “people don’t want you bothering them.” with several phenomenological inquiries, allan was able to tell me that it sounded just like his mother’s disapproving voice. we talked about how discouraging it was to constantly relive his mother’s criticism. i asked him to make those comments again, and loudly, like he was talking to little allan. he repeatedly yelled his mother’s words, then he lowered his head and was silent international journal of integrative psychotherapy, vol. 12, 2021 181 for several minutes. when he again looked at me he had tears in his eyes. (erskine, 2021b, p. 52) in this quotation, the embodied creativity of richard’s interventions is revealed where he makes direct contact with allan’s vital, vulnerable child self (erskine, 2001, 2020b). he has shown some courage in bringing that somewhat scary mother into the room. but the intervention has poignant results. at last, little allan has a witness for his mother’s abuse. allan now feels safe enough with richard and sufficiently protected to let his mother appear. in richard’s place i might have considered engaging psychotherapy with his introjected mother, perhaps as a future possibility when the solidity of the therapeutic relationship is more firmly established. otherwise referred to in the literature as a “parent interview” (erskine, 2015; moursund & erskine, 2003/2004), this technique offers a way of giving in-depth therapy to the introjected other (e.g., internalized parent ego state) with the aim being for the client to experience a resolution of the intrapsychic conflict. i wonder if this also was richard’s thinking. such carefully calibrated timing of interventions is characteristic of the work of “master” practitioners. dream work. secondly, richard’s creative approach is demonstrated when he works with another of allan’s dreams. when allan explicitly asks richard for his interpretation of one particular dream, it seems important for richard to try to respond to this request. richard hears a young boy ask his father, “what does it mean?” somewhat challenged, richard tries to find a heart-to-heart way to offer a “duplex transaction” (berne, 1961), where the therapist talks simultaneously to the client’s child and adult ego states. this is not easy to do, and i’m reminded once more of richard’s considerable sensitivity and skills. i am touched by his intuitive spontaneous empathetic approach where he reflected back the story of the young boy (taking the form of a locomotive train) who carried a heavy load and was stopped in its tracks by a threateningly “large faceless woman” (possibly representing his “mother”). that richard and allan dwell with this dream over several sessions is important. i appreciate richard’s decision to properly record the dream as allan was telling it so that details can be pulled out in subsequent sessions. eventually, allan is ready to hear the message of the dream more directly: i said, “it must have been impossible for you as a young boy to have a real face-to-face contact with your mother, particularly if she was criticizing and misdefining you. it seems that your mother could not face your uniqueness and vitality. nor was she sensitive to your vulnerability… but she was able to stop your locomotion. just like in the dream where the faceless woman stopped the steam locomotive.” (erskine, 2021c, p. 64) international journal of integrative psychotherapy, vol. 12, 2021 182 as allan’s trust in richard and connection to himself slowly grow (i.e., external and internal relational connections made), he is able to face his shame and demons and begin to find his uniqueness and vitality. up to this point allan discloses he had held back a shameful secret: that on his night-time neighborhood treks he follows women. the story that eventually unfolds over several sessions is thoroughly heartrending. it turns out that spotting a woman, and following her, allows allan a few moments of fantasy: the make-belief that she might be kind to him. the question he has repeatedly asked into the silence is “can you love me?” over time, richard and allan come to interpret the mantra of “can you love me?” as a lament. through this question, allan has been facing the reality and grief of being an unloved, neglected yet controlled child who yearned to be loved. initially hearing about allan’s stalking behavior, i could feel my alarm stirring. richard was clearly also concerned and confronted a huge ethical dilemma. weighing up the risks, he made a choice to stay with patient empathic listening rather than being more directive, critical or challenging (finlay, 2019). while i feel uncomfortable about this decision (like it seemed richard did), i agree with richard’s therapeutic response given the women were not—it would appear—being actively damaged. and i wonder if, in richard’s place, i would have been able to contain my judgements and aversion to allan’s potentially threatening obsessive behavior with women. i would be interested to hear more about richard’s process of navigating this delicate and tricky ethical dilemma. encouraging withdrawal to a safe internal space. thirdly, i value the way richard employs a special creative strategy of actively encouraging allan to withdraw to a safe internal space during sessions. then, he shows a touching attunement to allan’s silence. this is perhaps the most significant and powerful technique richard uses when working with schizoid processes (see also erskine, 2001, 2020b). richard becomes aware that in highly charged emotional moments during therapy, allan seemed to withdraw, automatically returning to a private internal place. by inviting a deliberate withdrawal, he raises allan’s awareness of this approach to emotional self-stabilization and regulation. recognizing the safety of this space, richard encourages allan to withdraw at will during the therapy sessions. it seems that richard saw this process as a way for allan to internally hide and keep himself safe lest someone damage his soul once again—a vital ingredient when working with schizoid process. together, they make the discovery that, watched over by a caring, attentive (but non-invasive) presence, allan could safely get in touch with many painful and suppressed memories. they also discover that, after being replenished by his private space, he is more relationally contactful and spontaneously vital. i appreciate the way a therapeutic space has been opened up through richard’s attunement to silence, allowing allan’s memories to surface in their own time. international journal of integrative psychotherapy, vol. 12, 2021 183 allan has also been given a new resource: a space where, rather than engaging in defensive withdrawal, he can explore his past in more positive and helpful ways. multiple parts of self during the fourth year of therapy, allan is beginning to feel less depressed and self-critical. is it now time to wrap up the narrative and celebrate the progress? or is there more work to be done? what is in allan’s best interests? such are the questions richard now confronts. but at this point he discovers that allan is hearing his mother’s critically harsh voice ever more loudly. for this reason, richard suggests one further year of work. it could be beneficial, he thinks, to begin working explicitly with that introjected parent. many of us routinely refer to different metaphorical selves within us (such as our “inner critic” or “rebellious adolescent”). sometimes it can feel like different parts within us are at war with each other (such as the conflict between the “industrious student” part of self and the “playboy” who just wants to have fun). for some people, the internal splits are more extreme and disturbing, for instance, when a suicidal part acts out in self-destructive ways. sometimes an individual might embody different personas in dissociative ways without conscious memory of their actions (as in dissociative identity disorder) (finlay, 2022). in the field of trauma work, different theories that embrace multiplicity of “selves” tend to subscribe to the idea that people who have a history of trauma show evidence of internal fragmentation (e.g., splitting or dissociation), even if they have perfectly crafted, adaptive social selves which they show the world or do not have an actual dissociative identity disorder. here, we might include theories such as: transactional analysis and ego state theory (berne, 1961; watkins & watkins, 1997), internal family systems (schwartz, 2001), self-pluralistic perspectives of person-centered and experiential psychotherapies (cooper et al., 2004), and parts work in gestalt therapy. the metaphorical representation of selves or parts-of-self in these therapies can be a useful way of containing the fragmentation and exploring problematic aspects (which may or may not be owned) towards integration (finlay, 2022). in the case study, richard doesn’t talk explicitly about using the metaphor of parts of self, other than mentioning “little allan,” and then latterly in the in-depth way he engages allan’s internalized “mother” therapeutically. his version of working with parts here is thus to think in terms of transactional analytic ego states. (see erskine, 1991, for an in-depth elaboration which applies berne’s [1961] original definitions to integrative psychotherapy.) while it is difficult to spot clear differences between what i can see of richard’s practice and my own, i suspect that, with allan, i would have done more to engage international journal of integrative psychotherapy, vol. 12, 2021 184 parts work early on and more explicitly, beyond thinking in terms of ego-states. parts-work figures regularly in my own relational integrative practice (finlay, 2016a, 2022) when i work somatically and existentially with longer-term clients, particularly when shame and trauma are involved. the question for me is which parts of the client (and myself!) are coming forward. who is talking to whom? our relational connections are usually multiple with different attachment and relating styles between us being revealed. “the theory makes sense to me as it mirrors my internal landscape and my own therapeutic journey” (finlay, 2022, p. 135). i see parts in myself and perhaps that sensitizes me to see them (or look for them?) in others. “i appreciate the way that parts work calls forth an integrating, self-compassionate, creative energy. when a new part comes forward (and is recognized by my client or myself), the moment of insight can resemble an inspirational epiphany” (finlay, 2022, p. 135). with this integrating awareness the client becomes aware of the possibility of choice, change, and escape from habitual ways of responding. the ability to turn down the volume on cacophonous choruses of strident voices becomes a realizable goal (finlay, 2022). deyoung (2015) has highlighted the role of relationally validating connections based in “right-brain-to-right-brain communication” when working with clients who experience chronic shame. highlighting the role of respect and compassion when working with chronic shame, deyoung recommends engaging multiple parts of self: bringing shame to light often illuminates a needy part of self who is despised by a tough, independent part of self. listening respectfully to both parts and helping each to find compassion for what drives the other brings better balance and harmony to the whole self system.… parts of self can find space to speak the unspeakable about need, longing, and humiliation, and in their speaking and being heard, integration happens. (2015, pp. 132–133) work with the parts which represent internalized others is potentially the most powerful, transformative, imaginal technique we have at our disposal. i know from his previous work that richard is a master when it comes to this way of working (erskine, 2015; erskine & moursund, 1988/2011; moursund & erskine, 2003/2004). while hugely aware of the healing promise of therapy with internalized others, i’m also mindful of its potential to be intense, stirring, disorientating, and unsettling. this is not an intervention to be used superficially as a technique or gimmick. it needs to be handled carefully so that plentiful time and space are given to processing the material. i know from my own experience how terrifying it can be to have the problematic internalized other come into the therapy space. the therapist needs to ensure the client feels safe and supported while the internalized other is being worked with. at the same time, the “parent”/other needs to be acknowledged international journal of integrative psychotherapy, vol. 12, 2021 185 and respected for their own struggles while being challenged to take responsibility for the impact of their behavior. richard did all these things—of course. but i am struck afresh at the care he took initially to explain the process; then again, during the work he took care with his sensitive, tactful handling of both allan and his “mother;” and after, he gave plenty of time to explore the revelations. in particular, richard worked with allan’s child’s response to work with this “mother,” enabling him to express what had not been previously expressed, helping to free his child confusion and the old attachment bonds. that the work was layered, and carried on over several sessions, is particularly interesting to me. most of my previous experience with this sort of work has been as a one-off “parent interview” and i am now intrigued about the possibilities of engaging in-depth psychotherapy with the introjected other and discovering how this way of working may unfold when engaged long-term on an ongoing basis. i also appreciate richard’s evident skills in helping allan work through some of his relational trauma, his sense of betrayal and anger at the neglect and disparagement he received. i particularly like the empty chair work where, first, allan’s “mother” was invited to explain her treatment of allan and challenged to take responsibility for it. then allan was invited to take cathartic step of sitting in the chair and replying to his mother. richard’s summary shows something of the extraordinary, completed gestalt that was achieved: in sessions that followed, allan and i went over each conversation i had with his introjected mother. he talked about how her coldness and criticism had permeated his life. he went into detail about his mother’s voice being “consistent and insistent.” we again examined how his self-criticisms had been a way to block out his mother’s voice. i talked to allan about “the loyalty of a little boy” and how he stayed attached to his mother by disavowing his anger and believing her definitions of him. allan was happy that he seldom heard her critical voice in his head now. (erskine, 2021e, p. 84) endings the decision about when to end long-term therapy is never easy. then a further layer of difficulty must be worked through to ensure the end is handled in a constructive, healing way. clients and therapists alike face the challenge of separation and the grief that results from severing a special bond. ending therapy can also trigger a re-experiencing of past loss, rejections, and unresolved grief (finlay, 2016a, 2019). it is not surprising there are sometimes missteps along the way. either therapist or client may begin to think it is time to end. then suddenly it isn’t. they may disagree, tussle, or find a way to compromise. richard and allan also had to face this negotiation. international journal of integrative psychotherapy, vol. 12, 2021 186 the key process in this ending phase involves enabling a client to work through any arising pain. in strategic terms, it is about allowing the client to deal with unfinished business. therapy should not add to the list of client’s experiences of problematic endings (finlay, 2016a). i am intrigued to learn that richard builds in a summer break vacation when doing long-term work—something i have never done (choosing instead to take a week or so off periodically). i now see that having a formal, built-in break offers interesting grist for the mill. for one thing, there is an opportunity to practice the eventual ending process, which could otherwise be avoided or resisted. this happens, for example, when clients ask, “can we keep in touch?” or—worse—when a therapist says, “come back if it doesn’t work out.” any ending, says romanyshyn (2006, p. 31) is “always a petit mort.” even if we don’t go as far as thinking in terms of death and grief, at the very least, having a summer break can offer time for reflection and therapy can be re-set accordingly. perhaps helped by their formal breaks, both allan and richard seem well prepared when the end of therapy eventually occurs. that allan was leaving therapy because he was moving away to fulfil a dream helped with the positive forwardlooking momentum. i am not sure i can say the same about being prepared for the ending myself; i am aware that i want to find out more about allan. is he enjoying his new life? has his photography taken off? has he found some nice nature trails nearby? has he made some new friends or supportive acquaintances? ruefully, i acknowledge to myself that i am not quite ready to let them go. (and, yes, this is another parallel process—i often feel something similar at the end of therapy.) richard does not expand on what the loss of allan means to him personally. he does not mention if part of him was reluctant to let allan go, or whether he was tempted to invite a continued correspondence. maybe i project my own difficulties with endings here. after all, richard had many months in which to work through the ending. yet at the end of his writing richard strikes me as retreating a little abruptly into theory. i wonder if that intellectualization helped him move away from the loss and grief he might have been experiencing. perhaps, too, the act of writing up his case study was another way to “let go” while also celebrating allan’s growthful journey. i respect richard for ensuring what sounds like a good (relationally connected) ending with allan. as he says of the last few sessions: in each session he cried as he expressed his gratitude for the quality of our relationship. during those final sessions i was sad and glad: glad that allan was creating a new life and sad to be saying good-bye to both the man and the neglected little boy, both of whom i had come to love. (erskine, 2021e, p. 85) international journal of integrative psychotherapy, vol. 12, 2021 187 i find it almost unbearably poignant to hear richard say he had come to “love” allan. i appreciate his authentic honesty and the way he both owns and gives voice to the special kind of love we can feel in the therapy room—one that we do not often talk about publicly. that love stands as a testament to their profound relational work. i wonder if allan was eventually able to feel he was truly loved by richard—both the man and the little boy. as therapists, we carry the privilege and the responsibility associated with endings. our role is to help clients face the pain of the goodbye as part of embracing life. we celebrate the client’s growth with them as they take their new discoveries into the rest of their lives. and then we need to let go with grace (finlay, 2016b, 2019). i am honored by this opportunity to work with this story of allan’s therapy. like others, perhaps, i feel privileged and humbled to have been given such an intimate glimpse into allan’s trauma and to have witnessed the healing process, in which the accumulated impact of his neglect is healed through the therapeutic relationship with richard. dwelling with their story has helped me identify both with richard and with allan. i had a strange sense of being a part of their relationship where tendrils of vicarious healing unfolded for me as well. i started this project of dialoguing with richard’s writing with excitement and curiosity, and yes, some uncertainty. i believe i have managed to unfurl some interesting aspects of their journey and learned more about the therapy process (a lifelong quest!). there is much more, had space allowed, that i might have said, but i hope i have conveyed the deep respect i feel for richard’s work. it’s not just that he engaged some wonderfully attuned and care-full therapeutic interventions with the right balance (for allan) between inquiry and challenge; it’s the artfulness of his exquisitely sensitive choice and timing of those interventions and the way he uses himself therapeutically, in service of allan’s growth. their work has touched me deeply and, although i leave it now with some sadness, i remain grateful for and enriched by richard’s gift. references atwood, g. e., & stolorow, r. d. (2014). undergoing the situation: emotional dwelling is more than empathic understanding. international journal of psychoanalytic self psychology, 9(1), 80–83. https://doi.org/10.1080/15551024.2014.857750 https://doi.org/10.1080/15551024.2014.857750 international journal of integrative psychotherapy, vol. 12, 2021 188 atwood, g. e., & stolorow, r. d. (2016). walking the tightrope of emotional dwelling. psychoanalytic dialogues, 26(1), 103–108. https://doi.org/10.1080/10481885.2016.1123525 baumgardner, p., & perls, f. (1975). legacy from fritz: gifts from lake cowichan. science and behavior books. berne, e. (1961). transactional analysis in psychotherapy: a systematic individual and social psychiatry. grove press. cooper, m., mearns, d., stiles, w. b., warner, m., & elliott, r. (2004). developing self-pluralistic perspectives within the person-centered and experiential approaches: a round-table dialogue. person-centered and experiential psychotherapies, 3(3), 176–191. https://doi.org/10.1080/14779757.2004.9688345 deyoung, p. a. (2015). understanding and treating chronic shame: a relational and neurobiological approach. routledge. erskine, r. g. (1991). transference and transactions: critique from an intrapsychic and integrative perspective. transactional analysis journal, 21(2), 63– 76. https://doi.org/10.1177/036215379102100202 erskine, r. g. (2001) the schizoid process. international journal of integrative psychotherapy, 31(1), 1–6. https://doi.org/10.1177/036215370103100102 erskine, r. g. (2011, april 21). attachment, relational-needs, and psychotherapeutic presence [keynote address]. international integrative psychotherapy association conference, vichy, france. https://www.integrativetherapy.com/en/articles.php?id=73 erskine, r. g. (2012). early affect-confusion: the “borderline” between despair and rage. (part 1 of a case study trilogy). international journal of integrative psychotherapy, 3(2), 3–14. erskine, r. g. (2013a). balancing on the “borderline” of early affect-confusion. (part 2 of a case study trilogy). international journal of integrative psychotherapy, 4(1), 3–9. erskine, r. g. (2013b). relational healing of early affect-confusion. (part 3 of a case study trilogy). international journal of integrative psychotherapy. 4(1), 31–40. erskine, r. g. (2015). relational patterns, therapeutic presence: concepts and practice of integrative psychotherapy. karnac. erskine, r. g. (2020a). a healing relationship: commentary on therapeutic dialogues. phoenix. https://doi.org/10.1080/10481885.2016.1123525 https://doi.org/10.1080/14779757.2004.9688345 https://doi.org/10.1177/036215379102100202 https://doi.org/10.1177/036215370103100102 https://www.integrativetherapy.com/en/articles.php?id=73 https://www.integrativetherapy.com/en/articles.php?id=73 international journal of integrative psychotherapy, vol. 12, 2021 189 erskine, r. g. (2020b). relational withdrawal, attunement to silence: psychotherapy of the schizoid process. international journal of integrative psychotherapy, 11, 14–29. https://www.integrative-journal.com/index.php/ijip/article/view/161/104 erskine, r. g. (2021a). depression or isolated attachment? part 1 of a 5-part case study of the psychotherapy of the schizoid process. international journal of integrative psychotherapy, 12, 28–40. https://www.integrative-journal.com/index.php/ijip/article/view/207/113 erskine, r. g. (2021b). internal criticism and shame, physical sensations, and affect: part 2 of a 5-part case study of the psychotherapy of the schizoid process. international journal of integrative psychotherapy, 12, 41–55. https://www.integrative-journal.com/index.php/ijip/article/view/208/114 erskine, r. g. (2021c). isolation, loneliness, and a need to be loved: part 3 of a 5-part case study of the psychotherapy of the schizoid process. international journal of integrative psychotherapy, 12, 56–65. https://www.integrative-journal.com/index.php/ijip/article/view/209/115 erskine, r. g. (2021d). therapeutic withdrawal and painful memories: part 4 of a 5-part case study of the psychotherapy of the schizoid process. international journal of integrative psychotherapy, 12, 66–74. https://www.integrative-journal.com/index.php/ijip/article/view/210/116 erskine, r. g. (2021e). my mother’s voice: psychotherapy of introjection: part 5 of a 5-part case study of the psychotherapy of the schizoid process. international journal of integrative psychotherapy, 12, 75–88. https://www.integrative-journal.com/index.php/ijip/article/view/211/117 erskine, r. g., & moursund, j. p. (2011). integrative psychotherapy in action. karnac. (original work published 1988) erskine, r. g., moursund, j. p., & trautmann, r. l. (1999). beyond empathy: a therapy of contact-in-relationship. brunner/mazel. finlay, l. (2008). a dance between the reduction and reflexivity: explicating the “phenomenological psychological attitude.” journal of phenomenological psychology, 39(1), 1–32. https://doi.org/10.1163/156916208x311601 finlay, l. (2013). unfolding the phenomenological research process: iterative stages of “seeing afresh.” journal of humanistic psychology, 53(2), 172–201. https://doi.org/10.1177/0022167812453877 finlay, l. (2016a). relational integrative psychotherapy: engaging process and theory in practice. wiley. https://www.integrative-journal.com/index.php/ijip/article/view/207/113 https://www.integrative-journal.com/index.php/ijip/article/view/207/113 https://www.integrative-journal.com/index.php/ijip/article/view/208/114 https://www.integrative-journal.com/index.php/ijip/article/view/209/115 https://www.integrative-journal.com/index.php/ijip/article/view/209/115 https://www.integrative-journal.com/index.php/ijip/article/view/210/116 https://www.integrative-journal.com/index.php/ijip/article/view/210/116 https://www.integrative-journal.com/index.php/ijip/article/view/211/117 https://www.integrative-journal.com/index.php/ijip/article/view/211/117 https://doi.org/10.1163/156916208x311601 https://psycnet.apa.org/doi/10.1177/0022167812453877 international journal of integrative psychotherapy, vol. 12, 2021 190 finlay, l. (2016b). ‘therapeutic presence’ as embodied, relational ‘being.’ international journal of psychotherapy, 20(2), 17–30. finlay, l. (2019). practical ethics in counselling and psychotherapy: a relational approach. sage. finlay, l. (2021). the phenomenological use of self in integrative psychotherapy: applying philosophy to practice. international journal of integrative psychotherapy, 12, 114–141. https://www.integrative-journal.com/index.php/ijip/article/view/167/123 finlay, l. (2022). the therapeutic use of self in counselling and psychotherapy. sage. finlay, l., & evans, k. (2009). relational-centred research for psychotherapists: exploring meanings and experience. wiley-blackwell. geller, s. m., & greenberg, l. s. (2002). therapeutic presence: therapists’ experience of presence in the psychotherapy encounter. person-centered and experiential psychotherapies, 1(1-2), 71– 86. https://doi.org/10.1080/14779757.2002.9688279 husserl, e. (1970). the crisis of european sciences and transcendental phenomenology. northwestern university press. (original work published 1936) hycner, r. (1993). between person and person: toward a dialogical psychotherapy. gestalt journal press. (original work published 1991) hycner, r. (2017, september 8). what does it mean to be a relational psychotherapist? [lecture]. scarborough counselling and psychotherapy institute, scarborough, united kingdom. jacobs, l. (2017). hopes, fears, and enduring relational themes. british gestalt journal, 26(1), 7–16. kapitan, l. (2003). re-enchanting art therapy: transformational practices for restoring creative vitality. charles c thomas. levine, p. a. (2011). waking the tiger-healing trauma: the innate capacity to transform overwhelming experiences. north atlantic books. mcferran, k. s., & finlay, l. (2018). resistance as a ‘dance’ between client and therapist. body, movement and dance in psychotherapy, 13(2), 114–127. https://doi.org/10.1080/17432979.2018.1448302 mcwilliams, n. (2017). core competency two: therapeutic stance/attitude. in r. e. barsness (ed.), core competencies of relational psychoanalysis: a guide to practice, study, and research (pp. 87–104). routledge. https://www.integrative-journal.com/index.php/ijip/article/view/167/123 https://www.integrative-journal.com/index.php/ijip/article/view/167/123 https://psycnet.apa.org/doi/10.1080/14779757.2002.9688279 https://doi.org/10.1080/17432979.2018.1448302 international journal of integrative psychotherapy, vol. 12, 2021 191 merleau-ponty, m. (1962). phenomenology of perception (c. smith, trans.). routledge & kegan paul. (original work published 1945) moursund, j. p., & erskine, r. g. (2004). integrative psychotherapy: the art and science of relationship. brooks/cole. (original work published 2003) norcross, j. c., & lambert, m. j. (eds.). (2019). psychotherapy relationships that work: volume 1: evidence-based therapist contributions (3rd edition). oxford university press. norcross, j. c., & wampold, b. e. (2018). a new therapy for each patient: evidence-based relationships and responsiveness. journal of clinical psychology, 74(11), 1889–1906. https://doi.org/10.1002/jclp.22678 perls, f. (1973). the gestalt approach & eye witness to therapy. science & behavior books. romanyshyn, r. d. (2006, february 23–26). therapy and the theater of soul: the drama of performance [keynote address]. new zealand association of psychotherapy. sayre, g., & kunz, g. (2005). enduring intimate relationships as ethical and more than ethical: inspired by emmanuel levinas and martin buber. journal of theoretical and philosophical psychology, 25(2), 224– 237. https://doi.org/10.1037/h0091260 schneider, k. j. (ed.). (2008). existential‐integrative psychotherapy: guideposts to the core of practice. routledge. schwartz, r. c. (2001). introduction to the internal family systems model. trailhead publishers. watkins, j. g., & watkins, h. h. (1997). ego states: theory and therapy. w. w. norton. wertz, f. (2005). phenomenological research methods for counseling psychology. journal of counseling psychology, 52(2), 167–177. https:doi.org/10.1037/0022-0167.52.2.167 yalom, i. d. (2001). the gift of therapy: an open letter to a new generation of therapists and their patients (revised and updated ed.). piatkus. https://doi.org/10.1002/jclp.22678 https://psycnet.apa.org/doi/10.1037/h0091260 https://doi.apa.org/doi/10.1037/0022-0167.52.2.167 international journal of integrative psychotherapy, vol. 8, 2017 40 nested hierarchy for therapy integration: integrating the integrative valery krupnik abstract: several well-established psychotherapies have seen a proliferation of their derivatives. among notable examples are truncated forms of psychoanalysis, such as psychoanalytic psychotherapy and brief psychodynamic therapy; a variety of cognitive behavioral therapies (cbt) including cbt-i (cbt for insomnia), cbt-d (cbt for depression), and cpt (a trauma-focused cbt). despite its relatively young age emdr has also produced multiple modifications like ego states emdr, emdr for addiction, and emdr for somatic conditions. the majority of modifications are developed by integrating new interventions with the original protocols. however, there is no commonly accepted ad hoc methodology or standard for such integration. this article suggests a “nested hierarchy” as a methodology for psychotherapy integration, exploring its ramifications for practice and research. keywords: nested hierarchy, psychotherapy integration, emdr, tdd, evolution. _____________________ integrative therapies have become a mainstay in contemporary practice (norcross, karpiak, & lister, 2005), indicating the presence of significant factors driving psychotherapy integration. some of them are extrinsic, such as market forces of competition between different therapies, whereby integration is another way of creating a new marketable product. other factors are intrinsic and follow the natural trends in psychotherapy evolution (norcross, 2005). the latter include the search to increase the efficacy of existing therapies, as well as their applicability to wider and more diverse client populations and therapeutic settings. whether therapy integration often or ever results in increased efficacy is an open question that, to our knowledge, no study has conclusively answered. international journal of integrative psychotherapy, vol. 8, 2017 41 however, doubts have been raised (schottenbauer, glass, & arnkoff, 2005). that may not be surprising considering that therapy integration comes with both presumed advantages and real challenges. integrative treatment combines more therapeutic tools, potentially leading to a greater versatility, but that comes with the challenge of modifying the original therapies that have been refined in practice and may have developed to their maximal potential. therefore, in designing an integrative therapy it is imperative to understand the reason for such undertaking and to choose the right strategy for the integration. to date, however, there is no commonly accepted methodology for psychotherapy integration, leaving it mostly to personal preference and experimentation. there are four commonly identified strategies for psychotherapy integration: technical eclecticism, common factors integration, principle-based assimilative integration, and theoretical integration (norcross, 2005). in short, technical eclecticism refers to a systematic combining of techniques from different therapies without concern for the therapies’ theoretical compatibility. common factors integration builds a treatment based on a theory of universal principles of change common to different brands of therapy. for example, an empathic disposition and collaborative approach are common to most therapies and have significant effects on outcomes (laska, gurman, & wampold, 2014). a system of interventions built around such common factors is then expected to result in an effective therapy beyond the list of original existing brands. principlebased assimilative integration proceeds from a certain theoretical orientation, assimilating techniques from other therapies in line with that theoretical frame. theoretical integration refers to integration of different theoretical traditions into a unified theory of psychotherapy. there have also been proposals for transtheoretical integration meant to transcend individual integrative models. for example, systematic treatment selection approach (beutler & clarkin, 2014) proposes to construct a treatment by matching interventions to the contextual parameters of a therapeutic encounter based on empirical evidence for the effectiveness of such match. those parameters include characteristics of the patient, the therapeutic relationship, and the process of change. in multitheoretical therapy, brooks-harris (2008) suggests approaching therapy integration from multiple theoretical levels including psychobiological, experiential, behavioral, cognitive, psychodynamic, systemic, and multicultural. integration of these levels in application to a particular therapeutic encounter helps identify the most salient targets for intervention and instructs the therapist’s choice of interventions. in yet another multi-theoretical integrative model, the primary focus is on integrating the client’s self through a therapeutic process that also relies on a multi-level theoretical understanding of the client. such international journal of integrative psychotherapy, vol. 8, 2017 42 understanding instructs the development of a therapeutic relationship to facilitate that integration (erskine & moursund, 2011; erskine & trautmann, 1996). regardless of the strategy, therapy integration is rife with contradictions. a new integrative treatment combines interventions from already internally consistent therapeutic systems. these interventions are bound to impose mutual constraints that may differ from the ones placed on them in their original therapies. for example, in eye movement desensitization and reprocessing therapy (emdr), elements of mindfulness are embedded within reprocessing of target memories in phases 3-6 (shapiro, 2001), which represents a truncated form of the traditional practice of mindfulness (kabat-zinn, 1990). likewise, the use of in vitro exposure to traumatic experience in cognitive processing therapy (resick & schnicke, 1993) is used in a more limited way compared to prolonged exposure therapy (foa & rothbaum, 2001). this suggests an approach to therapy integration, namely nested hierarchy (nh), designed to resolve such contradictions, referred to herein to as ‘dialectics,’ and thus capture their potential for resolution. the nh strategy encompasses all theoretical approaches, from theories of psychopathology to intervention techniques. this approach also considers that all therapies are integrative to a certain degree, which explains the subheading “integrating the integrative.” nh seeks to bind the interventions used in a therapy in a hierarchical nest, guided and constrained by the theories supporting those interventions. the most general theory sits at the top of the hierarchy, with subordinate theories becoming more specific as one moves down the hierarchy (figure 1). international journal of integrative psychotherapy, vol. 8, 2017 43 level 1 – goal level 2 – objective/theory of psychopathology (t) level 3 – mechanism (m) level 4 – intervention (i) figure 1: nested hierarchy of psychotherapy interventions key = t – theory of psychopathology m – mechanism of change i – intervention downward arrows indicate the hierarchy of causation; upward arrows indicate feedback validation. dark triangles indicate the inverse relationships of universality vs specificity and flexibility vs. treatment fidelity relative to the place in the hierarchy. change or maintenance universality specificity fidelity flexibility t2 t1 m1 11 m2 11 m3 11 i1 i2 i3 i4 i5 international journal of integrative psychotherapy, vol. 8, 2017 44 this approach postulates that nh (a) accommodates and reconciles other approaches to therapy integration, (b) provides a framework for creating new integrative treatments, and (c) allows for an integration process specific to a given therapeutic encounter. in addition, an approach to psychotherapy research will be described that follows from nh principles, and present a clinical case that illustrates nh integration in practice. emdr has been chosen to illustrate the application of nested hierarchy. while acknowledging the arbitrariness of such choice, since many other therapies might serve just as well, emdr provides an excellent example of the nh approach for the purposes of this article. from its inception, emdr was created as an integrative treatment initially developed for trauma-related disorders (shapiro, 1989). within a relatively short time emdr has seen an explosion of modifications and derivative therapies. to name a few, ego state emdr integrates ego states therapy rooted in psychodynamic and attachment theories into emdr (forgash & knipe, 2008; paulsen, 2008). spiritual/mindful resonance emdr integrates traditional spiritual healing with emdr (siegel, 2013). detur is an eclectic model combining emdr interventions with cognitive-behavioral, solution-focused, emotion freedom, and hypnosis techniques, among others (popky, 2005). tdd (treating depression downhill)-emdr integrates emdr interventions into an evolutionary-based therapy for depression (krupnik, 2015a, b). ‘horizontal’ dialectics the notion of ‘horizontal’ dialectics refers to conflicting constraints that arise at the level of methodology and concern the question of how interventions are chosen and applied. we distinguish them from ‘vertical’ dialectics, which refer to conflicting constraints arising between theoretical levels (figure 1) and concern the question of what interventions are chosen. fidelity vs. flexibility treatment fidelity has been emphasized as a necessity for clinical research and as an important contributor to therapy’s effectiveness, as reviewed by prowse & nagel ( 2015). for treatment fidelity in emdr in particular, see maxfield, & hyer (2002). fidelity is commonly understood as implementation of an intervention according to the established protocol. however, once an intervention is adopted into a different context, the rules are, by necessity, bent to accommodate the new context. in emdr, for example, cognitive restructuring is practiced very differently from cognitive behavioral therapy (cbt). while the international journal of integrative psychotherapy, vol. 8, 2017 45 general impetus for changing beliefs about self toward more adaptive and realitybased ones is shared with cbt, the way cognitive restructuring is understood and implemented in emdr is different (shapiro, 2001). cognitive intervention in emdr then becomes a standard to follow within emdr. a derivative therapy, tdd-emdr (krupnik, 2015a), in turn, uses an acceptance-focused cognitive intervention, which is different from emdr proper. it has been shown that therapists routinely deviate from the established prototype of their brand of therapy, ‘borrowing’ elements from cognate treatments, and that the shared elements can be most predictive of therapeutic outcome, as reviewed by ablon & jones, (2002). it is possible that finding the right balance between following the prototype and therapeutic flexibility may help maximize the therapy’s effectiveness. however, how to strike such balance remains a matter of further research. in addition, the therapeutic relationship and, by extension, the therapist’s personality may also interact with the brand of therapy practiced. such interactions may also determine the optimal degree of following/deviating from the prototype. consequently, studying a sample of psychoanalyses, ablon and jones (2005) demonstrated that they are better described as dyad-unique processes of change than a standard procedure of psychoanalysis. specificity vs. universality in psychotherapy, this dialectic has historically been skewed toward universality. initially, psycho-social interventions were not designed for specific disorders but rather targeted symptoms or psychological problems. for example, psychoanalysis was originally designed to treat neuroses (freud, 1966), while behavioral therapies targeted maladaptive information processing and resulting behaviors (franks & wilson, 1974). mental disorders, however, are commonly classified as symptom constellations (diagnostic and statistical manual of mental disorder, 5th ed.; dsm-5; american psychiatric association, 2013). hence, by design psychotherapies were not specific to mental disorders. moreover, the general trend among contemporary therapies has been toward universality rather than specificity. cbt, for example, was initially developed for depressive disorders but has since been used for a number of mental and psycho-somatic conditions. its low specificity (and high universality) has been highlighted in several reviews (butler, chapman, forman, & beck, 2006; haby, donnelly, corry, & vos, 2006; hollon, thase, & markowitz, 2002; parker & fletcher, 2007; shedler, 2010). likewise, emdr was initially developed for trauma-related disorders (shapiro, 1989, 2001), but has been extended to a variety of afflictions including affective, personality, addiction, eating disorders, and migraines international journal of integrative psychotherapy, vol. 8, 2017 46 (marcus, 2008; miller, 2010; mosquera, leeds, & gonzalez, 2014; shapiro, 2009). more recently, a trans-diagnostic integrative therapy has been developed to target all categories of affective and mood disorders, which they approach not from the categorical but dimensional point of view as a “unified negative affect syndrome” (barlow, allen, & choate, 2004). universality of a tool may become a liability against its effectiveness. lack of disorder-treatment specificity has been suggested as one of the factors limiting the success in treating depression, and a new “choose horses for courses” paradigm has been advocated (parker & fletcher, 2007; parker, roy, & eyers, 2003; parker, malhi, crawford, & thase, 2005). the authors suggest choosing an approach specific to the nature of a depressive disorder, differentiating between psychotic, melancholic, secondary depression, and dysthymia. in an attempt to increase treatment-condition specificity, a new self-system therapy for depression varies its approaches depending on the patient’s level of anxiety symptoms (strauman et al., 2013). similarly, emdr has been deemed a trauma-focused, evidence-based therapy (bisson, roberts, andrew, cooper, & lewis, 2013). however, its status regarding other than trauma conditions, depression in particular, is yet to be established. process-oriented exploration of specificity in therapy comes mostly from the psychoanalytic tradition, where it is believed that specificity of the dyadic relationship, that is, the right match between closely timed subjective experiences of analyst and the patient, may serve as a mechanism of therapeutic change. this notion is reflected in the theory of intersubjectivity (stern, 2005; stolorow & atwood, 1992), in the integration of infant development research into psychotherapy (beebe & lachmann, 2002), and in the theory of implicit relational process (group, 2010; tronick, 1998). relational specificity of the therapeutic process has been recognized as the most essential determinant of its effectiveness (bacal & carlton, 2011). still, the science of specificity in psychotherapy is considered to be in its infancy (beutler, 2011; norcross & wampold, 2011). vertical dialectics the emergence of the four main models of therapy integration: technical eclecticism, common factors, principle-based assimilative integration, and theoretical integration suggest different theoretical levels of integration. the highest level concerns the theory of psychopathology that usually suggests a direction for corrective intervention; one level down is the theory of change that international journal of integrative psychotherapy, vol. 8, 2017 47 stipulates mechanisms, through which the corrective intervention effects change; the next theoretical level explicates how a particular intervention carries those mechanisms out. any given therapy includes (explicitly or implicitly) all the mentioned levels, because any intervention has to be justified and guided by a theory of psychopathology as well as a theory of therapeutic action. that necessitates integration of the mentioned theoretical levels within a given therapy in order to execute an internally consistent therapeutic process. such integration has to negotiate the constraints that higher theoretical levels direct down the theoretical hierarchy. for example, emdr is guided by adaptive information processing theory (aip), whereby the source of psychopathology is believed to be maladaptively processed and stored traumatic memories (shapiro, 2001). accordingly, the theory stipulates that transmutation and reintegration of the traumatic memory into a broader memory network is the mechanism of therapeutic change (solomon & shapiro, 2008). the theory further stipulates that the emdr system of interventions triggers the proposed mechanism of change and facilitates its action by engaging and guiding the reprocessing of cognitive, emotional, and sensory aspects of the traumatic memory. one way of negotiating inter-level theoretical constraints was suggested in godfried’s common factors approach (goldfried, 1980).he proposed constructing integrative treatments based on principles of change common to different schools of therapy and identified those principles as: 1) expectation of positive therapeutic change, 2) optimal therapeutic alliance, 3) increasing awareness through an external perspective, 4) improving reality testing, and 5) providing corrective experiences. in a related approach, stages of change are considered such common principles (prochaska & diclemente, 1986). the principles of change approach to therapy integration has its critics, who have identified points of contention. one is that it underestimates the utility of distinct theoretical orientations and the ready-to-use toolboxes associated with them. another related contention is that techniques are more suitable objects for research than principles of change (hill, 2009). as an alternative, hill suggests a therapist-client centered integrative approach, where therapy integration is conceptualized as a dynamic process driven by the therapist’s techniques that are continually adapting and being updated depending on the client’s involvement, therapeutic relationship, and the interplay thereof during the therapeutic encounter (hill, 2005). such process-oriented integration seems to allow for greater flexibility, while still adhering to theory-based techniques, thus negotiating the flexibility vs. fidelity dialectic. international journal of integrative psychotherapy, vol. 8, 2017 48 hoffart & hoffart (2014) have criticized the principles of change approach as being incompatible with the principle of causation in therapy. they maintain that in psychotherapy, principles of causality should determine its interventions, whereas the abstract and trans-theoretical nature of principles of change may violate that causality. they suggest either theoretical or assimilative integration as strategies accommodating causality. in other words, the authors’ objections to the principles of change approach underscore the need for ‘vertical’ (inter-level) integration to construct an internally consistent therapy. the nested hierarchy model of therapy integration suggested here allows for integration of multiple theoretical levels comprising the therapeutic process, thus upholding the causality principle. it also integrates ‘horizontal’ dialectics, as mentioned above. below, we describe the principles and structure of nested hierarchy of integrative treatments. nested hierarchy of theoretical principles for psychotherapy integration in order to integrate theoretical principles of different levels into an internally consistent treatment, we suggest organizing those principles in a hierarchy from the most general to the most specific. such structure imposes causal constraints from the higher to lower levels, with those constraints serving as the main organizing principle of therapy integration. there are also feedback loops that impose constraints on the higher levels, thus refining and organizing the hierarchical trees of possibilities into the nests of reified treatments (see figure 1). the feedback feature is essential for guiding and organizing therapeutic process as it evolves. we have identified four levels in the hierarchy of therapy integration which parallel the logic of case conceptualization. level 1 – the goal of therapy the goal of therapy can either be effecting change or maintenance. although change is the usual goal of therapy, sometimes therapy aims at maintaining the current level of stability, as in the recovery phase of addiction, preventing decompensation, or sustaining the achieved gains of therapy. this does not mean that change cannot occur during maintenance, only that it is not the intended goal. the goal of change vs. maintenance determines the set of theoretical principles at the next level. since therapy is a dynamic process its goals may change depending on the phase of therapy. since our primary interest is in the change nest, no further discussion of maintenance follows. international journal of integrative psychotherapy, vol. 8, 2017 49 level 2 – objective of change/theory of pathology at this level, the objective of change is determined based on a theory of psychopathology. at least implicitly, any theory of pathology suggests a path out of it. although a comprehensive discussion of different theoretical approaches to psychopathology is outside the scope of this paper, we suggest such theory be meta-diagnostic. dsm-5, as well as its previous versions, defines diagnoses as symptom constellations. therefore, a diagnosis-based theory would guide the objective toward elimination of those symptoms. we, on the other hand, consider change a systemic process, whereby a systemic change drives symptom reduction rather than the other way around. therefore, we favor the system/meta-diagnostic level of theory of psychopathology, where symptoms are viewed as a manifestation of the system’s dynamics. aip, the theoretical basis of emdr (shapiro, 2001), is an example of such theory. although emdr was first developed for trauma-related disorders, aip is not centered on traumatic symptoms but approaches them from the standpoint of information processing and memory formation. that breadth of scope has been conducive to expanding emdr application beyond trauma-related disorders. conceptualizing pathology as maladaptive processing and storage of experience suggests an objective for therapeutic change such as adaptive reprocessing of that experience (shapiro, 2001). evolutionary theory is the highest meta-theoretical level in life sciences, because it seeks to explain how the living systems have come to be the way they are including their development and behavior. a number of evolutionary theories of depression consider it a manifestation of the depressive response that evolved as an adaptation to insurmountable adversity (keller & nesse, 2006; nettle, 2004; watt & panksepp, 2009). two therapies have recently been developed based on evolutionary theory of depression. evolutionary-driven cognitive therapy for depression maintains that a mismatch between the modern human environment and innate adaptive depressive reactions that developed early in hominid evolution leads to depressive pathology (giosan et al., 2014). accordingly, it suggests correction of that mismatch as a therapeutic objective. on the contrary, another integrative therapy, treating depression downhill (tdd), considers depressive response adaptive for modern humans as well and prescribes expedited completion of such response as its objective in the initial phase of therapy (krupnik, 2014). a chosen objective for change determines the international journal of integrative psychotherapy, vol. 8, 2017 50 mechanisms of change, which, in turn, inform the corresponding therapeutic interventions. level 3 – mechanisms of change literature concerning mechanisms of therapeutic change is vast and beyond the scope of this paper. in trying to find the common denominator, we suggest that the mechanism of therapeutic change is experience of change. although it may sound like circular reasoning, it is not. instead, we offer that change in therapy comes from experiential learning, which can only come from a new experience. common examples of this idea are catharsis in psychoanalysis (freud, 1966), developing new core beliefs in cognitive therapy (beck, 1967), habituation in prolonged exposure (foa & kozak, 1986), and memory transmutation in emdr (solomon & shapiro, 2008). at level 2, the objective (see figure 1) directs and constrains the pathway to experiential learning, which can only be carried out through appropriate mechanisms. not every mechanism of change may support a given pathway. for example, emdr theorists posit that fear extinction, which is the proposed mechanism of change in pe (foa & kozak, 1986), would not mediate the restructuring of traumatic memory sought in emdr (shapiro, 2014). therefore in emdr, exposure is de-emphasized and its amount is limited. although the late development of emotional processing theory, specifically the notion of inhibitory learning (craske et al., 2008), may suggest a greater overlap between the mechanisms of change operating in pe and emdr than has been acknowledged. level 4 – intervention (the delivery of change) once the direction of change and its supporting mechanism/s are determined, they require a set of interventions to carry them out. again, not all interventions may support a certain mechanism of change, though some may prove universal enough to fit many or most. for example, it is difficult to see how free association could help achieve habituation to a single trauma experience of a car accident, or how neurofeedback could accomplish cognitive reappraisal. on the other hand, a quality therapeutic alliance and active empathic listening appear to facilitate treatment across highly diverse therapies (for examples see erskine, 2015; goldfried, 1980). there has been considerable research on the importance of such non-specific interventions for therapy outcome (for review see messer & wampold, 2002). the intervention level is where psychotherapy integration meets the client. international journal of integrative psychotherapy, vol. 8, 2017 51 intra-level nesting the identified levels of therapy integration may contain sub-levels within them (nest inside a nest). for example, aip theory contains several levels of abstraction (shapiro, 2001), starting with conceptualizing the therapeutic action of emdr as transmutation of dysfunctional traumatic memory, proceeding to suggesting a memory structure consisting of cognitive, emotional, and sensory neural networks, and further onto hypothesizing putative neural mechanisms of emdr’s effects (for a recent review see shapiro, 2014). likewise, the evolutionary theory of depression suggests the depressive response to be an evolved adaptation, which includes sub-theories of such adaption on social, cognitive, physiological, genetic, cellular, and neural levels (andrews & thompson, 2009; nettle, 2004; watt & panksepp, 2009). these sub-levels bear on both the putative mechanisms of change and the corresponding interventions of different levels, where the different levels of intervention may need reconciliation. for example, it is believed that in the desensitization phase of emdr, it is important to maintain an optimal level of emotional arousal (shapiro, 2001), whereas cognitive interweave, an intervention of a different level, has a potential to resolve and thusly decrease that arousal and, if ill-timed, may prove premature and counterproductive. the nested hierarchy tree features a one-to-many relationship down, as well as many-to-one, up the hierarchy. thus, more than one theoretical construct may correspond (be nested) to a single construct at the higher hierarchical level (see figure 1). such arrangement creates a gradient of freedom of choice from more stringent at the top to more relaxed at the bottom. hence, there can be no flexibility at level 1, since it is a dichotomous choice between change and maintenance. at level 2, it is conceivable that more than one objective of change is pursued. for example, in emdr, desensitization to traumatic experience is sought along with its cognitive reappraisal (shapiro, 2001). accordingly, multiple mechanisms may be at play at level 3 to carry those objectives out, including affect modification, accommodation and assimilation of beliefs, and behavioral reinforcement. finally, at level 4, all interventions with a potential to facilitate the involved mechanisms of change may be recruited in various combinations. such integrative processes may appear to foster a chaotic multiplicity of therapies. however, the bottom-up feedback loops (see figure 1) are meant to safeguard against that possibility by selecting and binding the nest’s components through an iteration of feed-forward and feedback cycles, as the nest evolves into a stable and reproducible therapy. in choosing an intervention the therapist will track back whether it is optimal (in theory and observation) for the intended mechanism of change, and whether that mechanism is optimal for the pursued international journal of integrative psychotherapy, vol. 8, 2017 52 objective of change prescribed by the theory of psychopathology that s/he bases interventions on. nh offers, in this way, several advantages. it reconciles the above mentioned horizontal and vertical dialectics, integrates the existing approaches to psychotherapy integration, and suggests a unified system for classification of therapies. nh also offers testable predictions and suggests directions for psychotherapy research. finally, nh advocates for a more creative role for therapist in the process of integration. from dichotomies to integration fidelity and flexibility in nested hierarchy, the constraints on integration relax as one moves down the hierarchy, thus increasing flexibility while decreasing fidelity (see figure 1). in a study of therapeutic process, ablon and jones (1999) compared how closely the protocols of cbt and interpersonal therapy for depression were followed. they observed a significant overlap between interventions used in those therapies. interestingly, a drift by interpersonal therapists toward cognitive therapy correlated with better outcome. the nh model of integration suggests theoretical hierarchy as a guiding principle for a flexible adoption of interventions, while constraining this flexibility empirically through feedback loops (see figure 1). specificity and universality nh both accommodates and constrains universality, thereby providing for specificity of integrative therapies. specificity increases and universality decreases down the hierarchy (see figure 1). at level 1, universality is highest, since the choice between change and maintenance applies to all imaginable treatments, clients, and settings. at the level of theory (level 2), the choice becomes specific to the client’s pathology and diagnostic category. the more universal a theory of pathology, the more conditions and diagnoses its nested therapy could be applied to. aip theory of psychopathology is universal for all traumatic experiences, hence emdr has been applied to a wide spectrum of conditions believed to be trauma-related (shapiro, 2009). in contrast, the evolutionary theory of depression is specific to depressive disorders, and therapies that are based on it have only been applied to them and shown to be specific to those disorders (giosan et al., 2014; krupnik, 2014). international journal of integrative psychotherapy, vol. 8, 2017 53 putative mechanisms of therapeutic actions (level 3) further constrain universality, making the treatment more specific, as illustrated by modification of the standard emdr protocol for current trauma (shapiro & laub, 2008). at the lowest level (level 4), therapy grows even more specific, as the choice of interventions is specific not only for the theory of pathology and the putative mechanism of change but also for a particular client and therapeutic dyad. vertical integration the commonly identified pathways to psychotherapy integration technical eclecticism, common factors, assimilative integration, and theoretical integration are already arranged in a hierarchical order. theoretical integration appears at the top, followed by assimilative integration, then common factors, and eclecticism at the bottom. these integration strategies, however, are traditionally thought of as alternative. moreover, according to hoffart and hoffart (2014) only theoretical and assimilative integration uphold the principle of causation and are thus seen as being the only valid integrative models. nh accommodates the mentioned pathways by organizing them at different levels of the hierarchy (see figure 1), so that theoretical integration happens at level 2, technical – at level 4, common factors – at level 3, and assimilative integration organizes interventions across levels 3 and 4 under the theoretical principle of choice from level 2. hence, theoretical and assimilative integration together would comprise the whole nest under the level 1 goal. ego states emdr therapy can illustrate such integration. at level 1, the goal of this therapy is to effect change in a traumatized client, specifically a client with a fragile and disrupted ego. accordingly, at level 2, aip theory is integrated with ego psychology, where they are treated as complementary (knipe, 2015; paulsen & lanius, 2009). in short, ego states are viewed as functional units organizing and biasing the processing of information, particularly information relevant to the traumatic experience. adaptive information processing, therefore, requires well-integrated stable ego states. this theoretical principle can assimilate a number of mechanisms of change at level 3, as long as they do not contradict it. examples of such mechanisms include inactivation of psychological defenses, modification of the attachment style, improved reality testing and affect control, and reconfiguration of traumatic memory networks in the service of integrating different ego states. of note, level 2 and 3 (figure 1) integration in ego states emdr appears seamless and organic, because adaptive information processing can be considered the main (if not only) ego function, which both international journal of integrative psychotherapy, vol. 8, 2017 54 serves and depends on well-integrated ego states. it should also be noted that common factors and principles of change are, by definition, trans-theoretical and therefore are amenable to integration into most theoretical nests. interventions (level 4) in ego states emdr include an array of techniques supporting the above mentioned mechanisms of change. their examples include developing insight into different ego states in order to better integrate them, establishing a trusting therapeutic relationship to facilitate change in the attachment style, practicing affect tolerance in order to facilitate reprocessing of traumatic memories, and reprocessing and desensitization of those memories. in addition to meeting the requirement of not violating the nest’s causal hierarchy (see the feedback dashed arrows in figure 1), integration of these interventions also meets the criterion of necessity. a disrupted ego may not be conducive to reprocessing of traumatic experience, thus requiring interventions to stabilize and integrate it. nested hierarchy and integrative therapy nested hierarchy does not describe any particular model of integrative therapy but suggests a set of principles that can assist in developing one by providing both generative and constraining rules. metaphorically speaking, nh is a methodological scaffold for construction (or rather co-construction) of a coherent, causation-driven treatment. for this reason, it is more concerned with the content of therapy than its process, although in psychotherapy the two are inextricably intertwined. potentially, this methodology can assist development of as many integrative therapies as there are therapeutic encounters. the yet unproven rationale for using it is that the resulting coherence may entail consistent effectiveness. how nh relates to particular models of integrative therapy is too broad a question to address in a context of introducing nh principles and is, therefore, beyond the scope of this article except for the purpose of illustrating certain aspects of nh. above, i used ego states emdr as an example of how nh achieves vertical integration of theoretical principles and therapeutic interventions. relational or process-oriented therapeutic models, including erskine’s model of integrative psychotherapy (erskine & moursund, 2011; erskine & trautmann, 1996), correspond to nh in a more comprehensive way, since relational principles are embedded in nh. psychotherapy is a process of social transaction, therefore therapeutic relationship is implicitly or explicitly present throughout nh. the relational nature of the nest is evident starting from international journal of integrative psychotherapy, vol. 8, 2017 55 level 1 (see figure 1), since the choice of therapeutic goal is arrived at through establishment of a therapeutic alliance. at level 2, most theories of psychopathology are rooted in the developmental and, therefore, relational perspective, whereas all interventions at level 4 happen through social transactions. mechanisms of change (level 3), on the other hand, may be viewed as intra-psychic, not necessarily relational. however, from the psychodynamic/developmental perspective, one would claim that many if not most intra-psychic processes happen in relation to other people, for whom the therapist may serve as a transferential object. this view aligns with erskine’s understanding of human suffering as coming from disrupted relational needs and the corresponding goal of therapy to repair those disruptions through contactful therapeutic presence (erskine, moursund, & trautmann, 2013). on a formal level too, erskine’s integrative psychotherapy can be aligned with nh. the stated primary goal of his integrative psychotherapy is integration of the client’s self, which falls under the goal of change in nh (figure 1). following that goal at level 2, erskine’s model integrates multi-level theories of the client’s functioning from physiological reactions through systemic social constraints and influences. malfunctioning or deficiencies of the client’s self are understood as stemming from disruptions of relational needs, which points to a possible mechanism of change at level 3, i.e. repair of those disruptions. such repair is believed to facilitate the sought integration of the client’s self. this mechanism of change then requires a suitable set of interventions. whereas in erskine’s integrative psychotherapy this set is comprised of certain techniques such as inquiry, attunement, and involvement, the set is conceptualized as a process of contactful therapeutic presence, which is both the premise and the goal of therapy (erskine, moursund, & trautmann, 2013). where process-based integrative psychotherapy meets the structurebased nest of integration, is nh’s iterative nature. in nh, the top-down theoretical principles are tested and validated (or invalidated) by feedback from the lower levels (dashed arrows in figure 1), thus leading to optimization of the nest. this iterative process is bound to therapeutic relationship, which is the ultimate source of the feedback as well as the endpoint of the top-down corrections. expanding on the above metaphor, we would say that whereas nh is a scaffold on which an integrative therapy is built, it is built in intersubjective space with the material of therapeutic relationship. this metaphor may sound overwrought, but its challenge is to match the complexity of therapeutic encounter. international journal of integrative psychotherapy, vol. 8, 2017 56 classification of therapies besides providing a structure and a guiding principle for therapy integration, nested hierarchy offers a taxonomy of therapies that is also organized as a hierarchical tree with large taxa at the top, comprising families of smaller taxa down the hierarchy. there are two taxa at level 1, change and maintenance. each includes a family of theories of pathology at level 2, which in turn include a family of mechanisms of change at level 3, and finally a family of interventions at level 4 (figure 1). in such a classification a therapy is identified by its nest. for example, emdr would be classified as change (level 1), aip theory (level 2), transmutation of traumatic memory/ desensitization to traumatic memory (level 3), bilateral stimulation, cognitive interweave, emotional awareness, and guided imagery (level 4). ego states emdr would include the integrated aip/ego psychology theory at level 2, additional ego states mechanisms of change, and interventions such as ego states stabilization and integration, reality testing assistance at level 4. notably, elements of such taxonomy have long been in use, although not in a formalized way. cognitive therapy (ct), similar to emdr, has evolved into a family of therapies that includes cbt (rachman, 1997), trauma-focused cbt (cohen, deblinger, mannarino, & steer, 2004), cognitive processing therapy (resick & schnicke, 1993), evolutionary-based ct (giosan et al., 2014), mindfulness-based ct (williams, teasdale, segal, & kabat-zinn, 2007), and exposure-based cbt for depression (hayes & harris, 2000). this confirms that hierarchical taxonomy may be a natural evolution of psychotherapy classification away from a catalogue of treatment brands. nh-based taxonomy may appear cumbersome with ‘fuzzy’ boundaries, which is expected given the complexity of the specimen, but it offers advantages over an unstructured list of brands. one is that nh organizes therapies into a family of related and interconnected procedures, thus doing away with their redundant multiplicity. two, it provides an alternative frame for psychotherapy research, which will be discussed below. three, nh-based taxonomy may help construct integrative treatments by establishing relationships between the elements of cognate therapies, thus instructing practitioners on available options for combining theories and techniques in a systematic fashion. research considerations the nested hierarchy view of psychotherapy multiplicity and interrelationships forges a corresponding approach to psychotherapy research. in the predominant international journal of integrative psychotherapy, vol. 8, 2017 57 paradigm, therapies are treated as distinct treatment packages to be compared in efficacy and effectiveness. even when common factors such as therapeutic alliance, empathy, and motivation for change are studied, the assumption is that they are common to independent therapies, and mechanisms of change are mostly studied within their respective theoretical orientations. necessary and useful as it is, this paradigm has its limitations. it leaves certain important questions outside its scope. for example, an important question is how efficacious a hypothesized mechanism of change could be in different therapy contexts. as long as a therapy is considered a fixed set of techniques, the context is presumed constant, although, as mentioned before, in real practice, drift from the fixed sets is common. the same question remains unaddressed in regard to common factors of change, as they too are ‘trapped’ in the context of fixed treatment packages. yet, common factors have been shown as the main contributors to the outcome (laska, gurman, & wampold, 2014), leading to a hypothesis that any therapy that contains all the common factors of change will be efficacious. nested hierarchy offers a hybrid research model that by design would accommodate specific factors, common factors, and context. at level 4 of nh, therapies are represented as sets of interventions (see figure 1 and 3). for the sake of analysis, all interventions can be organized along two dimensions, verbal and non-verbal, thus forming a grid, examples of which (far from comprehensive) are given in figure 2 and 4, the latter representing a case example. each intervention is then given a value according to the length of time it takes up in therapy. that value represents the intervention’s dose, relative to which its contribution will be estimated. on the grid every therapeutic encounter appears as a unique profile of qualitatively and quantitatively represented interventions. accordingly, outcomes are compared not between therapy brands but between sets of interventions, delivered by sets of therapists, to sets of clients, in sets of social encounters. sets of therapists are defined by their theoretical orientation (if any), experience, education, and demographics such as age, gender, socioeconomic status, family and cultural background. sets of clients are defined by their symptoms, diagnosis, demographics (same as for therapists), life experiences, such as traumatic, disruptive, and formative life-events, and the level of motivation. motivation for change is considered essential for therapy outcome (reviewed in ryan et al., 2011). sets of social encounters are defined by the quality of alliance, level of trust, and emotional attunement. whereas some of the above parameters are a matter of factual report, others (e.g. motivation, trust, international journal of integrative psychotherapy, vol. 8, 2017 58 attunement) need to be measured with the existing psychometric tools. obviously, such study cannot be designed as rigorously as randomized clinical trials. instead, a naturalistic design is suggested, where individual cases with the above parameters and outcome measures will be uploaded into a shared database, like a “wikitherapy” of sorts. as the database grows through crowdsourcing, it will be analyzed with multiple regression and factor analysis to estimate the interventions’ contribution to the outcome and to identify clusters of interventions that may belong in the same nest and facilitate the same mechanism of change. gradients of effectiveness can be expected to emerge on the grid, where certain combinations of interventions are more effective than others. the expected large size of the database may minimize the confounding variables unavoidable in such uncontrolled data collection process. the “highly effective intervention” sets will be organized in hierarchical nests with best-fitting theoretical constructs of higher (1-3) levels, thus producing internally consistent integrative therapies. such empirically informed therapies will then be compared to well-established evidence-based brands in randomized controlled trials. the ineffective intervention sets may prove useful as points of comparison for further study of putative mechanisms of change. the proposed two-dimensional grid can be refined with additional dimensions to capture non-verbal communication (including silence), affective expression, or affective synchronization (marci, moran, & orr, 2004). such fine a grid, however, would have its challenges. it will require a detailed analysis of each video recorded session, and the number of potentially relevant variables will result in a statistical power tradeoff. it is important to emphasize that the project outlined here is not meant as a research proposal, but as a description of a possible research paradigm. therefore a detailed description of the proposed database is preliminary at this point and outside of the scope of this article. another potential contribution of the nh approach is that it is designed to capture failed cases. bradley and colleagues (2005) estimate the non-response rate for ptsd treated with evidence-based therapies, including emdr, is 30% at best. these 30% are deemed treatment-resistant and usually fall outside of research focus. the tradition of successful single case reports at the exclusion of failed ones has prevailed since freud’s times. yet, in order to understand how therapy works, it is important to figure out how and why it fails. it is the belief of international journal of integrative psychotherapy, vol. 8, 2017 59 this writer that failed cases carry valuable information that the nh approach is capable of expounding. figure 2: an example of the intervention grid key = bls – bilateral sensory stimulation as used in emdr tft – finger tapping as used in thought field therapy nfb – neurofeedback ht – healing touch therapy tms – transcranial magnetic stimulation ect – electro-convulsive therapy certain interventions can be applied in the same session or even simultaneously. each intervention can be measured in the most appropriate units, e.g. number sessions, procedures, dose. predictions suggesting a strategy for therapy integration implies an expectation of increased effectiveness of integrative treatments relative to their prototypes. accordingly, the overarching prediction for the nested hierarchy approach is that it will lead to more effective therapies. the notion of a greater effectiveness has several dimensions when testable hypotheses are offered. verbal non-verbal bl s tf t nf b ht tm s ec t medications behavioral activation behavioral modification exposure in vivo developing insight analysis of transference cognitive challenge exposure in vitro self-monitoring resources development narrative building mourning hypnosis meditation international journal of integrative psychotherapy, vol. 8, 2017 60 the first of these is the general effectiveness (efficacy) dimension. the prediction is that violating the nest’s hierarchy would decrease the efficacy of an integrative therapy. if an intervention and its putative mechanism of action do not conform to the nest’s level 2 theory, that will constitute such violation and compromise the treatment’s efficacy. for example, it is predicted that integrating the unique prolonged exposure interventions (pe) into emdr will not be beneficial, while integrating the unique interventions of cognitive processing therapy (cpt) may. the hypothesized mechanism of change in pe is habituation (or extinction) of fear response (foa & kozak, 1986). this mechanism is believed to differ from emdr’s theoretical premise and presumed mechanism of action (shapiro, 2014). on the other hand, the putative mechanism of change in cpt is cognitive restructuring (resick & schnicke, 1993), which is compatible with emdr theory, inasmuch as it seeks a positive shift in trauma-associated cognitions (shapiro, 2001). the second dimension is effectiveness for a particular client population. it is conceivable that an integrative therapy may not be more efficacious than its prototype but may produce a better outcome for a certain set of clients. such therapy would need to integrate a theory of psychopathology for that particular subset. for example, the prediction is that evolutionary-based therapies for depression will be effective for clients whose pathology is based in depressive response, while relatively ineffective for conditions where depressive symptoms are secondary to anxiety or trauma-related disorders. the third dimension (less popular in current research) is effectiveness of delivery. that is, how effective a therapist can be in delivering a therapy. a set of interventions may not be neutral to a therapist’s ability to carry them out. inclusion of an incongruent technique may not only be a threat to therapy’s efficacy but may also hamper a therapist’s delivery of it. one of the tenets of adaptive information processing theory of emdr is that the mind has an inherent ability to transform traumatic memory into a more adaptive configuration, which process is facilitated by emdr (solomon & shapiro, 2008). therefore, it is believed that the processing phase of emdr should proceed with least possible interruption. accordingly, emdr therapists use cognitive interventions sparingly during processing (shapiro, 2001). inclusion of systematic cognitive challenges in this phase, as done in cbt, may not only interrupt the flow of processing, but disturb the therapist’s attunement to it. we predict that interventions that do not violate the nest’s hierarchy have less chance to undermine therapist’s effectiveness. international journal of integrative psychotherapy, vol. 8, 2017 61 case vignette the following case vignette provides an example of the co-creation and implementation of integrative therapy. a complicated case was deliberately chosen in order to showcase the flexibility and accommodating capacity of the nested hierarchy approach. the client justin is a 28-year-old married man. he presented at a local mental health clinic after having been hospitalized for five days in a psychiatric unit following an interrupted suicide attempt by ingesting his pain medications. in the clinic, he was assigned a nurse practitioner for medication management and a therapist. during a semi-structured intake interview, justin disclosed a chronic pattern of depressed mood and anxiety with an onset in early childhood, when he was taken from his mother’s custody and placed in his maternal aunt’s household. there, he grew up as the only child with the aunt and her husband until he graduated from high school and enlisted in the military to “get away from the aunt.” as a child, he had visitations with his mother and always dreaded coming back to the aunt. justin did not remember having been happy for more than a week at a time. he remembered himself as a shy, reserved, and socially awkward child that spent much time playing alone. he described his aunt as a strict, domineering and cold woman, whom he tried to avoid as much as he could. justin’s suicide attempt was precipitated by a combination of stressors including having a newborn child, a high workload and a back injury, for which he was awaiting medical retirement. he reported a tendency to be easily overwhelmed by stress, where he would grow anxious and would subsequently “freeze” with a feeling of impending doom. that tendency had remained strong despite his supportive wife and in-laws. justin was diagnosed with persistent depressive disorder (dsm-5) by both his prescriber and therapist. the therapist conceptualized the case as a chronic depression precipitated by the early separation from mother, and sustained by learned and reinforced depressive response. the link between early loss and depression has long been noticed and described (bowlby, 1988), and more recently, depressive response was hypothesized to evolve as a protective mechanism against early separation from international journal of integrative psychotherapy, vol. 8, 2017 62 mother (watt & panksepp, 2007). accordingly, the therapist chose treating depression downhill (tdd)-emdr for therapy, to which justin consented. the process of integration tdd-emdr is a recently developed psychotherapy integrating an evolutionary-based therapy designed specifically for depressive disorders, tdd, and a set of emdr interventions. the main reason for this integration is to facilitate the second phase of tdd, which is based on mindfulness (krupnik, 2014). at level 1 (see figure 1 and 3), tdd and emdr are obviously compatible, since both seek to change the client’s mental condition. noteworthy, emdr uses ‘future template installation’ to ensure that the adaptive change gained in therapy is activated in response to future challenges (shapiro, 2001). tdd, however, does not have a future-oriented intervention, and that distinction became important late in justin’s treatment. at level 2, the therapist followed the evolutionary theory of depression, on which tdd is based, consistent with the case conceptualization that depressive response was driving justin’s psychopathology. emdr has been used for depression before from the perspective of trauma, where depressogenic life events were treated as traumatic, and the standard emdr protocol was used (bae, kim, & park, 2008; broad & wheeler, 2006; grey, 2011; gauhar, 2016; uribe, ramírez, & mena, 2010; hofmann et al., 2014). tdd, on the other hand, considers depressogenic events normative life adversity. this is an important theoretical difference, since it suggests different sources of psychopathology. whereas emdr (and its theoretical basis, aip) sees the source of psychopathology in trauma, tdd finds it in unmet needs and frustrated drives, more in line with freudian (freud, 1966) and maslowian (maslow, 1943) traditions. speaking of unmet relational needs, erskine’s integrative psychotherapy views them as an impediment to personality integration, causing disruption in personal development and interpersonal functioning (erskine, moursund, & trautmann, 2013). although one could make an argument that a failure to meet a person’s needs may be traumatic, equating unmet needs with trauma would strip either concept of its meaning. accordingly, the therapist used the tdd therapeutic frame and integrated it with select emdr interventions that would not violate the tdd nest (figure 3). international journal of integrative psychotherapy, vol. 8, 2017 63 at level 3, the presumed mechanisms of change in tdd differ from emdr. in tdd, the main mechanisms are believed to be (a) inhibition of protest by acceptance of defeat, and (b) behavioral activation of the reward/motivation circuitry, where ‘a’ and ‘b’ are activated sequentially (krupnik, 2014). in emdr, the presumed mechanism of change is reintegration of traumatic memory into a larger neural circuitry, which facilitates the memory’s regulation and increases adaptation. traumatic memory is conceptualized as a multi-domain circuitry that includes physiological, emotional, and cognitive components (solomon, & shapiro, 2008). in order to maintain consistency with level 2, the therapist aligned his interventions with tdd-based mechanisms of change. it is unclear how much overlap there is between the mechanisms hypothesized in tdd and emdr due to their highly speculative and metaphorical nature. still, formulation of such mechanisms is important to guide the choice of interventions. level 4 is where the integration occurred. modified emdr interventions (phases 3 – 7 of the standard protocol) were integrated into the acceptance phase of tdd, as previously described (krupnik, 2015a, b). since emdr interventions are believed to facilitate the transformation of traumatic memories, the therapist hoped they could also facilitate the dispositional transformation from protest to acceptance, sought in acceptance phase of tdd. in evolutionary theory of depression, the transition from protesting disposition (against adversity) to acceptance (or acquiescence) has been seen as the core mechanism of depressive response (watt & panksepp, 2007). the unique procedure of emdr is bilateral sensory stimulation (bls), and although multiple hypotheses have been offered to explain the effect of bls (for review see jeffries, & davis, 2013), its mechanism is poorly understood. however, a plausible hypothesis about the role of bls in the context of tddemdr could be helpful to its practitioner. from a practitioner’s standpoint, we need a level of explanation consistent with the level of practice. that is, a systemic explanation, since a practitioner works with the whole mind, not just its modules or circuitries. in the acceptance phase of tdd-emdr, a transition from protest to acceptance is sought in the same way that the standard emdr protocol seeks transition from the negative self-appraisal to a positive one. in the dynamic systems theory such process can be described as state transition from one attractant state to another. to achieve such transition the system needs to be challenged internally or externally (thelen & smith, 1994). it is speculated that exposure to disturbing thoughts and feelings in conjunction with bls facilitates such state transition by delivering a challenge that is (a) international journal of integrative psychotherapy, vol. 8, 2017 64 sufficient to destabilize the initial attractant state and (b) mild enough to trap the mind in a desirable new attractant state, i.e. acceptance or/and positive selfappraisal. relevant to this hypothesis, data has been found in the recent discovery that auditory bls increases the amygdala activation in response to a noxious image by presumably inhibiting its prefrontal control (herkt et al., 2014). this data can be interpreted as a synergistic destabilizing action of exposure and bls. however, experimental demonstration of bls’ role in the presumed stabilization of the mind in a new attractant state is still to be determined. the use of exposure has recently been expanded from its traditional applications for anxiety and trauma-related disorders to treating depression as well (hayes, beevers, feldman, laurenceau, & perlman, 2005). the idea that bls may render dysfunctional cognitive and emotional circuits labile enough to make them amenable to manipulation and re-integration has been suggested before (coubard, 2014). it is unclear whether the mechanisms of bls and mindful meditation have anything in common, but it is noteworthy that the desensitization phase of emdr utilizes mindfulness of the client’s feelings and bodily sensations in conjunction with bls (shapiro, 2001). it is important to emphasize that although the therapist approached the described case with an agreed upon blueprint of an integrative therapy (tddemdr), the integration evolved through a dynamic interaction of that blueprint with the flow and contingencies of the therapeutic process. the following is an account of these dynamics. the course of therapy at intake, justin had a bdi-ii (beck, steer, & brown, 1996) score of 28 (moderate severity). the exploration phase was psychodynamically informed, aiming at uncovering the developmental and unconscious dynamics driving justin’s depression. he revealed that he had never felt depression-free for a significant length of time since the age of eight, when he was separated from his mother. he did not know and could not reconstruct the exact reason for being removed from her beyond a general notion that she was struggling with her “personal problems.” two major themes emerged over the first three sessions. one was justin’s pervasive disappointment in himself as a worker, husband, and head of the household. the precipitating event for his suicide attempt was an argument with his wife, where she threatened divorce. he felt he was incompetent to handle the stress of his life, stating “i’m not as good as i should have been.” the second theme was his feeling of entrapment in his life situation. international journal of integrative psychotherapy, vol. 8, 2017 65 he injured his back and was facing medical retirement, feeling anxious and uncertain about his ability to provide for the family, especially given that his wife had recently become pregnant with their second child. in exploring the underlying dynamics of justin’s reactions to stress and life challenges, both themes were traced to his early childhood experiences. justin recognized that abandonment by his mother had left him with a sense of low personal value, “not as good as i should have been,” and high vulnerability to slight and criticism both at work and in the family. he also recognized that he had felt trapped and helpless ever since he had been placed in his aunt’s custody. he never felt loved in that house, and though never attempted, always wanted to escape. at this point, the therapist felt the projected helplessness and the implicit expectation of becoming a caretaker for justin, which even prompted him to conduct a structured interview to rule out dependent personality disorder. justin endorsed traits 1, 3, and 7 of dependent personality disorder (dsm-5, code 301.6), falling short of meeting the diagnostic criteria. his neediness, fear of abandonment, low self-esteem, and tendency to feel overwhelmed and helpless under stress were interpreted as vestiges of his childhood loss and entrapment. the sense of loss and low self-esteem were then chosen as the initial targets in the next (acceptance) phase. in the fourth session, the therapist used emdr interventions while cuing justin to the transition from protest to acceptance, according to tdd-emdr protocol (krupnik, 2015a). in short, while evoking the patient’s negative thoughts and feelings related to his experience of loss and his perception of self as unworthy, the therapist applied sets of bls (eye movements), interspersing them with verbal cues. the cues were suggestive of disengagement from the protest, for example, “is there anything you can do about it now? what could you do? can you change that? do you have any control over it?” justin would acknowledge the limits of his control over the situation and of his ability to change it, which would initially perturb him, triggering sadness with the associated visceral bodily sensations such as tightness in the chest and emptiness in the stomach. as the session progressed, the sadness and visceral sensations decreased in intensity, and he felt “calmer.” in session five, justin reported improved mood and a higher confidence, as well as more stable sleep. by that time he had come up with some positive statements about himself during emdr interventions, “i’m as good as i am, i guess,” and expressed a more future-oriented attitude, “i need to move on.” he expressed confidence in his future career path, as well as his ability to provide for international journal of integrative psychotherapy, vol. 8, 2017 66 the family, given his retirement income and benefits. in the sixth session, his bdiii score dropped 50% to 14 (mild severity), at which point the therapist started the behavioral activation phase. behavioral activation continued through the end of therapy along with other interventions. although engaged in his behavioral plan, justin continued presenting with mild and episodic depressive symptoms, including irritability, frustration when dealing with stress, and occasional insomnia. in general, the therapist still perceived in justin a subdued hedonic tone and continuing neediness. when he shared that impression, justin accounted for his residual symptoms by lingering anxiety about his future, as well as his frustration with chronic back pain and accompanying physical limitations. the therapist interpreted justin’s negative reactions to stress as a still unresolved negative self-appraisal. therefore, together they decided to further target his sense of defeat with emdr interventions. in the following emdr session justin’s self-referential statements appeared well-balanced and without sadness. his hedonic tone, however, still appeared mildly depressed, so the therapist decided to return to exploration. in the next four exploratory sessions, again mostly psychodynamically informed, justin focused on the fluctuations of his emotions related to the upcoming separation from his pregnant wife and his toddler daughter. they were moving to their home state ahead of him to set up a household there, while he was waiting for his medical retirement. he also reported a strong reaction to the death of his wife’s grandmother. the reaction surprised him, since his wife dealt with the death with far less distress than he. another set of self-report measures returned a bdi-ii score of 25, and justin admitted that he had again slid into depression, losing his therapeutic gains. in the next session, the theme of his dependency on others, including the therapist, resurfaced. that lack of agency was interpreted as justin’s passive aggression, developed in childhood as a defense against the domination of his aunt. at that point, justin and the therapist decided to target his sense of being overpowered and defeated by life circumstances. again, the therapist used emdr interventions. applying bls, the therapist cued justin into acceptance of the power of life circumstances as well as his personal limitations. in two emdr sessions, justin developed a seemingly more balanced perspective on his personal powers. he recalled instances in his childhood, where he would exercise the power of his agency, escaping the chokehold of his life circumstances. the therapist followed those revelations by ‘resource installation,’ a standard emdr procedure. the therapist guided justin to focus on his international journal of integrative psychotherapy, vol. 8, 2017 67 experiences of agency and the evoked feelings (“freedom,” “power,” “kind of cool”) while performing bls. although not part of tdd-emdr, ‘resource installation’ is especially central to ego states emdr (forgash, & knipe, 2008). the ego strengths perspective does not fall under the nested hierarchy of evolutionary theory of depression, but it does not violate the nest either. recovery from any psychopathology relies on a functional ego. moreover, it can be speculated that a relatively intact ego is necessary for an adaptive depressive response lest such response degenerates into psychosis. another set of self-report measures was taken in three sessions, and justin’s bdi-ii score dropped again to the mild range of 11. he reported feeling emotionally stable and realistically confident in his near future. after two follow up sessions, justin stopped coming to therapy, since he felt he was getting too busy with the logistics of his retirement, which was coming in a month. the total length of his therapy was 20 sessions. figure 3: the nested hierarchy of tdd-emdr. (horizontal arrows indicate overlapping interventions) the case highlights justin’s case is one that did not go according to a clear cut template but instead was convoluted as a majority of psychotherapy practice can be. this case attempts to illustrate how the integration evolved in the process of therapy, co-constructed through patient-therapist collaboration. in that we follow the notion that integrative therapy is not a ready-to-use product but evolves in the process (hill, 2005) and is, in essence, relational (erskine, 2015). this case also international journal of integrative psychotherapy, vol. 8, 2017 68 illustrates the dialectic between the process-driven intuitive “art of therapy” and a scientifically-based structure, where the structure provides a scaffold that is filled with a social encounter, while the scaffold is being built. this way, the structure and the therapeutic flow not only exert mutual constraints, but also build upon each other, not unlike the skeleton and soft tissues of a growing organism. the “integrate-as-you-go” approach has its limitations as well, as justin’s case illustrates. a hierarchical nest is not a ready-to-use treatment package but provides a blueprint for therapy without the power to predict what exact set of interventions may be the most effective reification of the blueprint. for example, the therapist did not explore the likely possibility of justin’s insecure attachment style, and no interventions were used to correct it. nor did he address justin’s lack of assertiveness and his inability to appropriately express his emotions. there are also different theoretical frames that could have been applied to the case, such as grief work over the separation and loss of justin’s mother, or trauma work, had that loss been conceptualized as traumatic. it was not possible to determine before-hand which approach would have worked best, because each of them is backed by an evidence-supported therapy, such as cbt, interpersonal therapy, emotion-focused therapy, and emdr. moreover, each approach’s effectiveness would likely depend on how well it would match a particular therapeutic dyad, and a particular therapist’s style and preferences. at the same time, the freedom of choice plays into the therapist’s strength of using clinical judgment and intuition to assess the effect of chosen interventions, and, if need be, to adjust the nest. the nested hierarchy principle can always guide the therapist in constructing a nest, lest s/he feels ‘lost’ in the multitude of available interventions. it allows the therapist to make a theory-informed choice of interventions without being restricted to a particular treatment package or brand. “integrate-as-you-go” also means that there are as many therapies as there are cases. this clearly presents a challenge to therapy outcome research. the proposed case-based research program described above may serve as complementary to the randomized controlled trial research paradigm. in that approach, justin’s case would be represented in the database as shown in figure 4 along with its hierarchical nest (see figure 3), required psychometric measures, diagnoses, and demographics. international journal of integrative psychotherapy, vol. 8, 2017 69 verbal non-verbal bls* behavioral practice, days (outside session) medications, days (outside session) total sessions developing insight 3 5 30 240 20 analysis of transference 1 challenging cognitions/offering interpretation 7 5 confronting disturbing thoughts and feelings 11 5 self-monitoring 5 resources development and 'installation.' 2 2 unstructured interventions 3 figure 4: justin’s intervention grid *bls = sets of saccadic eye movements, 25-30 movements each. intervention doses are measured in number of sessions, where they were used, unless indicated otherwise. the sum of all sessions by intervention is greater than the total number of sessions, because more than one intervention was used per session. conclusion this paper demonstrates how the nested hierarchy principle accommodates four main strategies of psychotherapy integration theoretical, principle-based assimilative, common factors, and eclectic by organizing them into a hierarchical nest (figure 1 & 3). such hierarchy can guide and constrain integration of interventions and their supporting theories. nh taxonomy may inform practitioners about the relationship between therapy nests. one of the features of nh is its high flexibility at the lower levels (figure 1), which allows for adjustment of the treatment to a given therapeutic encounter, thus increasing the treatment’s specificity. international journal of integrative psychotherapy, vol. 8, 2017 70 one overarching debate in psychotherapy research, although not always framed this way, is that of the art of therapy vs. the science of therapy. the medical model is incompatible with the art model, yet therapy is commonly referred to as an art. nh principles of psychotherapy integration offer a unifying model, whereby integration is organized by scientific rules and its effectiveness is studied with scientific means, and where therapeutic process is artfully constructed by the therapist in an encounter with the client. we see it as analogous to staging a play. the same script can inspire an infinite number of renditions, each powerful in its unique way, although some of them are bound to be a flop. the fact that even most effective therapies have a non-response rate of 30% and that randomized controlled trials demonstrate similar effect sizes for different therapies demonstrates that there may be a significant need for such unique renditions to target clients unresponsive to the standard protocols. how do we define an effective therapist? is it the one who consistently produces 70% success rate, or the one who is able to succeed with the remaining 30%? there is no evidence that the same set of skills is required for the former and the latter. if indeed, as suspected, the skills differ at least in part, the nested hierarchy approach accommodates the therapist in pursuit of either more prototypical or more integrative therapies according to his or her strengths and weaknesses. author: dr. valery krupnik earned his ph.d. in molecular biology from the institute of microbiology and epidemiology in moscow, russia, and did research in immunology and neurodevelopment. he then made a career change to become a practicing psychotherapist. he initially trained in psychodynamic therapy at salem state university in salem, massachusetts, and became a fellow with the american psychoanalytic association. his later interests include development of integrative therapy for depression and applying emdr to its treatment. he is a certified emdr therapist and a member of the emdr international asssociation. he is currently practicing at the department of mental health of the naval hospital at camp pendleton, california. international journal of integrative psychotherapy, vol. 8, 2017 71 references ablon, j. s., & jones, e. e. (1999). psychotherapy process in the national institute of mental health treatment of depression collaborative research program. journal of consulting and clinical psychology, 67, 64-75. doi: 10.1037/0022-006x.67.1.64 ablon, j. s., & jones, e. e. (2002). validity of controlled clinical trials of psychotherapy: findings from the nimh treatment of depression collaborative research program. am j psychiatry, 159, 775-783. ablon, j. s., & jones, e. e. (2005). on analytic process. journal of the american psychoanalytic association, 53, 541-568. doi: 10.1177/00030651050530020101 american psychiatric association. (2013). diagnostic andstatistical manual of mental disorders (5th ed.). arlington,va: author. andrews, p. w., & thompson, j. a. (2009). the bright side of being blue: depression as an adaptation for analyzing complex problems. psychol review, 116, 620-654. bacal, h. a., & carlton, l. (2011). the power of specificity in psychotherapy: when therapy works—and when it doesn't. plymouth, uk: jason aronson. bae, h., kim, d., & park, y. c. (2008). eye movement desensitization and reprocessing for adolescent depression. psychiatry investigation, 5, 60-65. barlow, d. h., allen, l. b., & choate, m. l. (2004). toward a unified treatment for emotional disorders. behavior therapy, 35, 205-230. beck, a. t. (1967). depression: clinical, experimental, and theoretical aspects. new york: hoeber medical division, harper & row. beck, a. t., steer, r. a., & brown, g. k. (1996). manual for the beck depression inventory-ii. san antonio, tx: the psychological corporation. beebe, b., & lachmann, f. m. (2002). infant research and adult treatment: coconstructing interactions.: analytic press, inc. beutler, l. e. (2011). prescriptive matching and systematic treatment selection. in j. c. norcross, vandenbos, g. r., freedheim, d. k. (ed.), history of psychotherapy: continuity and change (2nd ed., pp. 402-417). washington, dc: american psychological association. beutler, l. e., & clarkin, j. f. (2014). systematic treatment selection: toward targeted therapeutic interventions. new york: routledge. bisson, j., roberts, n., andrew, m., cooper, r., & lewis, c. (2013). psychological therapies for chronic post-traumatic stress disorder (ptsd) in adults (review). cochrane database of systematic reviews, (12), art. no.: cd003388. doi:10.1002/14651858.cd003388.pub4 international journal of integrative psychotherapy, vol. 8, 2017 72 bowlby, j. (1988). a secure base: parent-child attachment and healthy human development.: basic books inc. bradley, r., greene, j., russ, e., dutra, l., & westen, d. (2005). a multidimensional meta-analysis of psychotherapy for ptsd. american journal of psychiatry, 162, 214-227. doi: 10.1176/appi.ajp.162.2.214 broad, r. d., & wheeler, k. (2006). an adult with childhood medical trauma treated with psychoanalytic psychotherapy and emdr: a case study. perspectives in psychiatric care, 42, 95-105. brooks-harris, j. e. (2008). integrative multitheoretical psychotherapy. boston: houghton-mifflin. butler, a. c., chapman, j. e., forman, e. m., & beck, a. t. (2006). the empirical status of cognitive-behavioral therapy: a review of meta-analyses. clinical psychology review, 26, 17-31. cohen, j. a., deblinger, e., mannarino, a. p., & steer, r. a. (2004). a multisite, randomized controlled trial for children with sexual abuse–related ptsd symptoms. journal of the american academy of child & adolescent psychiatry, 43, 393-402. doi: 10.1097/00004583-200404000-00005 coubard, o. a. (2014). eye movement desensitization and reprocessing (emdr) re-examined as cognitive and emotional neuroentrainment. frontiers in human neuroscience, 8, 1035.doi: 10.3389/fnhum.2014.01035 craske, m. g., kircanski, k., zelikowsky, m., mystkowski, j., chowdhury, n., & baker, a. (2008). optimizing inhibitory learning during exposure therapy. behaviour research and therapy, 46, 5-27. doi: 10.1016/j.brat.2007.10.003 erskine, r. g., & trautmann, r. l. (1996). methods of an integrative psychotherapy. transactional analysis journal, 26, 316-328. erskine, r. g., & moursund, j. p. (2011). integrative psychotherapy in action. london, uk: karnac books. erskine, r., moursund, j., & trautmann, r. (2013). beyond empathy: a therapy of contact-in relationships. routledge. erskine, r. g. (2015). relational patterns, therapeutic presence: concepts and practice of integrative psychotherapy. karnac books. foa, e. b., & kozak, m. j. (1986). emotional processing of fear: exposure to corrective information. psychological bulletin, 99, 20-35. doi: 10.1037/0033-2909.99.1.20 foa, e. b., & rothbaum, b. o. (2001). treating the trauma of rape: cognitivebehavioral therapy for ptsd. new york: guilford press. forgash, c., & knipe, j. (2008). integrating emdr and ego state treatment for clients with trauma disorders. in c. forgash & m. copely (eds.), healing international journal of integrative psychotherapy, vol. 8, 2017 73 the heart of trauma and dissociation with emdr and ego state therapy (pp. 1-59). new york: springer. franks, c. m., & wilson, g. t. (eds.). (1974). annual review of behavior therapy: theory and practice. new york: brunner/mazel. freud, s. (1966). the complete introductory lectures on psychoanalysis (j. strachey, trans.). new york: w. w. norton & company, inc. gauhar, y. w. m. (2016). the efficacy of emdr in the treatment of depression. journal of emdr practice and research, 10, 59-69. doi: 10.1891/19333196.10.2.59 giosan, c., cobeanu, o., mogoase, c., muresan, v., malta, l. s., wyka, k., & szentagotai, a. (2014). evolutionary cognitive therapy versus standard cognitive therapy for depression: a protocol for a blinded, randomized, superiority clinical trial. trials, 15, 83. doi: doi:10.1186/1745-6215-15-83 goldfried, m. r. (1980). toward the delineation of therapeutic change principles. american psychologist, 35, 991-999. doi: 10.1037/0003-066x.35.11.991 grey, e. (2011). a pilot study of concentrated emdr: a brief report. journal of emdr practice and research, 5, 14-24. doi: 10.1891/1933-3196.5.1.14 group, b. c. p. s. (2010). change in psychotherapy: a unifying paradigm. new york: ww norton & company. haby, m. m., donnelly, m., corry, j., & vos, t. (2006). cognitive behavioural therapy for depression, panic disorder and generalized anxiety disorder: a meta-regression of factors that may predict outcome. australian and new zealand journal of psychiatry, 40, 9-19. hayes, a. m., beevers, c. g., feldman, g. c., laurenceau, j.-p., & perlman, c. (2005). avoidance and processing as predictors of symptom change and positive growth in an integrative therapy for depression. international journal of behavioral medicine, 12, 111-122. doi: 10.1207/s15327558ijbm1202_9 hayes, a. m., & harris, m. s. (2000). the development of an integrative treatment for depression. in s. johnson, a. m. hayes, t. field, n. schneiderman & p. mccabe (eds.), stress, coping, and depression (pp. 291-306). mahwah, nj: lawrence erlbaum. herkt, d., tumani, v., grön, g., kammer, t., hofmann, a., & abler, b. (2014). facilitating access to emotions: neural signature of emdr stimulation. plos one, 9(8). doi:10.1371/journal.pone.0106350 hill, c. e. (2005). therapist techniques, client involvement, and the therapeutic relationship: inextricably intertwined in the therapy process. psychotherapy: theory, research, practice, training, 42, 431-442. doi: 10.1037/0033-3204.42.4.431 international journal of integrative psychotherapy, vol. 8, 2017 74 hill, c. e. (2009). reaction to goldfried (1980): what about therapist techniques? applied and preventive psychology, 13, 16-18. doi: 10.1016/j.appsy.2009.10.006 hoffart, a., & hoffart, a. r. (2014). psychotherapy integration through general therapy change principles: missing the core of psychotherapy? journal of psychotherapy integration, 24, 263-274. doi: 10.1037/a0038135 hofmann, a., hilgers, a., lehnung, m., liebermann, p., ostacoli, l., schneider, w., & hase, m. (2014). eye movement desensitization and reprocessing as an adjunctive treatment of unipolar depression: a controlled study. journal of emdr practice and research, 8, 103-112. doi: http://dx.doi.org/10.1891/1933-3196.8.3.103 hollon, s. d., thase, m. e., & markowitz, j. c. (2002). treatment and prevention of depression. psychological science in the public interest, 3, 39-77. jeffries, f. w., & davis, p. (2013). what is the role of eye movements in eye movement desensitization and reprocessing (emdr) for post-traumatic stress disorder (ptsd)? a review. behavioural and cognitive psychotherapy, 41, 290-300. doi: 10.1017/s1352465812000793 jorm, a., allen, n., morgan, a., & purcell, r. (2009). a guide to what works for depression. melbourne: beyondblue. kabat-zinn, j. (1990). full catastrophe living: using the wisdom of your body and mind to face stress, pain, and illness. new york: bantam dell. keller, m. c., & nesse, r. m. (2006). the evolutionary significance of depressive symptoms: different adverse situations lead to different depressive symptom patterns. journal of personality and social psychology, 91, 316330. knipe, j. (2015). emdr toolbox: theory and treatment of complex ptsd and dissociation. new york: springer. krupnik, v. (2014). a novel therapeutic frame for treating depression in group treating depression downhill. sage open, 4, 1-12. doi: 10.1177/2158244014523793 krupnik, v. (2015a). integrating emdr into a novel evolutionary-based therapy for depression: a case study of postpartum depression. journal of emdr practice and research, 9, 137-149. krupnik, v. (2015b). integrating emdr into an evolutionary‐based therapy for depression: a case study. clinical case reports, 3, 301-307. doi: 10.1002/ccr3.228 laska, k. m., gurman, a. s., & wampold, b. e. (2014). expanding the lens of evidence-based practice in psychotherapy: a common factors perspective. psychotherapy, 51, 467-481. doi: 10.1037/a0034332 http://dx.doi.org/10.1891/1933-3196.8.3.103 international journal of integrative psychotherapy, vol. 8, 2017 75 luborsky, l., rosenthal, r., diguer, l., andrusyna, t. p., berman, j. s., levitt, j. t., . . . krause, e. d. (2002). the dodo bird verdict is alive and well— mostly. clinical psychology: science and practice, 9, 2-12. marci, c. d., moran, e. k., & orr, s. p. (2004). physiologic evidence for the interpersonal role of laughter during psychotherapy. the journal of nervous and mental disease, 192, 689-695. doi: 10.1097/01.nmd.0000142032.04196.63 marcus, s. v. (2008). phase 1 of integrated emdr an abortive treatment for migraine headaches. journal of emdr practice and research, 2, 15-25. doi: doi: 10.1891/1933-3196.2.1.15 maslow, a. h. (1943). a theory of human motivation. psychological review, 50, 370-396. doi: 10.1037/h0054346 maxfield, l., & hyer, l. (2002). the relationship between efficacy and methodology in studies investigating emdr treatment of ptsd. journal of clinical psychology, 58, 23-41. doi: 10.1002/jclp.1127 messer, s. b., & wampold, b. e. (2002). let's face facts: common factors are more potent than specific therapy ingredients. clinical psychology: science and practice, 9, 21-25. doi: 10.1093/clipsy.9.1.21 miller, r. (2010). the feeling-state theory of impulse-control disorders and the impulse-control disorder protocol. traumatology, 16, 2-10. doi: doi: 10.1177/1534765610365912 mosquera, d., leeds, a. m., & gonzalez, a. (2014). application of emdr therapy for borderline personality disorder. journal of emdr practice and research, 8, 74-89. nettle, d. (2004). evolutionary origins of depression: a review and reformulation. journal of affective disorders, 81, 91-102. norcross, j. c. (2005). a primer on psychotherapy integration. in j. c. norcross & m. r. goldfried (eds.), handbook of psychotherapy integration (2nd ed., pp. 3-23). new york: oxford university press. norcross, j. c., karpiak, c. p., & lister, k. m. (2005). what's an integrationist? a study of self‐identified integrative and (occasionally) eclectic psychologists. journal of clinical psychology, 61, 1587-1594. doi: 1 0 .1 0 0 2 / jclp.2 0 2 0 3 norcross, j. c., & wampold, b. e. (2011). what works for whom: tailoring psychotherapy to the person. journal of clinical psychology, 67, 127-132. doi: 10.1002/jclp.20764 parker, g., & fletcher, k. (2007). treating depression with the evidence-based psychotherapies: a critique of the evidence. acta psychiatrica scandinavica, 115, 352-359. international journal of integrative psychotherapy, vol. 8, 2017 76 parker, g., roy, k., & eyers, k. (2003). cognitive behavior therapy for depression? choose horses for courses. am j psychiatry, 160, 825-834. parker, g. b., malhi, g. s., crawford, j. g., & thase, m. e. (2005). identifying "paradigm failures" contributing to treatment-resistant depression. journal of affective disorders, 87, 185-191. paulsen, s., & lanius, u. (2009). toward an embodied self: integrating emdr with somatic and ego state interventions. in r. shapiro (ed.), emdr solutions ii (pp. 337-388). new york: norton. paulsen, s. l. (2008). treating dissociative identity disorder with emdr, ego state therapy and adjunct approaches. in c. forgash & m. copely (eds.), healing the heart of trauma and dissociation with emdr and ego state therapy (pp. 141-179). new york: springer. popky, a. j. (2005). detur, an urge reduction protocol for addictions and dysfunctional behaviors. in r. shapiro (ed.), emdr solutions: pathways to healing (pp. 167-188). new york: norton. prochaska, j. o., & diclemente, c. c. (1986). toward a comprehensive model of change. in w. r. miller & n. heather (eds.), treating addictive behaviors: processes of change (vol. 13, pp. 3-27). new york: springer. prowse, p., & nagel, t. (2015). a meta-evaluation: the role of treatment fidelity within psychosocial interventions during the last decade. j psychiatry, 18, 1-7. doi: 10.4172/psychiatry.1000251 rachman, s. (1997). the evolution of cognitive behaviour therapy. in d. m. clark & c. g. fairburn (eds.), science and practice of cognitive behaviour therapy (pp. 3-26). new york: oxford university press. resick, p. a., & schnicke, m. (1993). cognitive processing therapy for rape victims: a treatment manual. newbury park, ca: sage. ryan, r. m., lynch, m. f., vansteenkiste, m., & deci, e. l. (2011). motivation and autonomy in counseling, psychotherapy, and behavior change: a look at theory and practice. the counseling psychologist, 39, 193-260. doi: 10.1177/0011000009359313 schottenbauer, m. a., glass, c. r., & arnkoff, d. b. (2005). outcome research on psychotherapy integration. in j. c. norcross & m. r. goldfried (eds.), handbook of psychotherapy integration (2nd ed., pp. 459-493). new york: oxford university press. shapiro, e., & laub, b. (2008). early emdr intervention (eei): a summary, a theoretical model, and the recent traumatic episode protocol (r-tep). journal of emdr practice and research, 2, 79-96. doi: 10.1891/19333196.2.2.79 international journal of integrative psychotherapy, vol. 8, 2017 77 shapiro, f. (1989). eye movement desensitization: a new treatment for posttraumatic stress disorder. journal of behavior therapy and experimental psychiatry, 20, 211-217. shapiro, f. (2001). eye movement desensitization and reprocessing: basic principles, protocols and procedures (2nd ed.). new york: guilford press. shapiro, f. (2014). the role of eye movement desensitization and reprocessing (emdr) therapy in medicine: addressing the psychological and physical symptoms stemming from adverse life experiences. the permanente journal, 18, 71-77. doi: http://dx.doi.org/10.7812/tpp/13-098 shapiro, r. e. (2009). emdr solutions ii: for depression, eating disorders, performance, and more. new york, ny: ww norton & company. shedler, j. (2010). the efficacy of psychodynamic psychotherapy. american psychologist, 65, 98-109. siegel, i. r. (2013). therapist as a container for spiritual resonance and client transformation in transpersonal psychotherapy: an exploratory heuristic study. association for transpersonal psychology, 45, 49-74. solomon, r. m., & shapiro, f. (2008). emdr and the adaptive information processing model: potential mechanisms of change. journal of emdr practice and research, 2, 315-325. doi: http://dx.doi.org/10.1891/19333196.2.4.315 stern, d. (2005). intersubjectivity. in e. s. person, a. m. cooper & g. o. gabbard (eds.), the american psychiatric publishing textbook of psychoanalysis. (pp. 77-92): american psychiatric publishing, inc. stolorow, r. d., & atwood, g. e. (1992). contexts of being: the intersubjective foundations of psychological life.: analytic press, inc. strauman, t. j., goetz, e. l., detloff, a. m., macduffie, k. e., zaunmüller, l., & lutz, w. (2013). self‐regulation and mechanisms of action in psychotherapy: a theory‐based translational perspective. journal of personality, 81, 542-553. doi: doi: 10.1111/jopy.12012 thelen, e., & smith, l. b. (1994). a dynamic systems approach to the development of cognition and action.: the mit press. tronick, e. z. (1998). dyadically expanded states of consciousness and the process of therapeutic change. infant mental health journal, 19, 290-299. uribe, m. e. r., ramírez, e. o. l., & mena, i. j. (2010). effect of the emdr psychotherapeutic approach on emotional cognitive processing in patients with depression. the spanish journal of psychology, 13, 396-405. watt, d. f., & panksepp, j. (2009). depression: an evolutionarily conserved mechanism to terminate separation distress? a review of aminergic, peptidergic, and neural network perspectives. neuropsychoanalysis, 11, 7-109. http://dx.doi.org/10.7812/tpp/13-098 http://dx.doi.org/10.1891/1933-3196.2.4.315 http://dx.doi.org/10.1891/1933-3196.2.4.315 international journal of integrative psychotherapy, vol. 8, 2017 78 williams, j. m. g., teasdale, j. d., segal, z. v., & kabat-zinn, j. (2007). the mindful way through depression: freeing yourself from chronic unhappiness. new york: guilford press. apa 5th edition template international journal of integrative psychotherapy, vol. 5, no. 1, 2014 1 into the labyrinth a case study of a therapist’s journey with an adult survivor of childhood abuse pamela stocker abstract: this case study describes the therapeutic journey of a client who suffered serious sexual and physical abuse from toddlerhood to adolescence. it considers challenges and ethical issues in the therapeutic partnership with an abuse survivor, exploring the importance of the theoretical framework and of supervision. issues of autonomy and power in relation both to therapy and to church pastoral practices receive attention. central to this therapeutic journey is the role of creative methodology, metaphor and myth in facilitating transformation. key words: childhood sexual abuse, therapeutic relationship, gestalt, creative interventions, metaphor and myth, power and autonomy. ____________________________ introducing abi abi, 47, began therapy with me in 2008 when i was a second year gestalt postgraduate diploma student. we meet weekly in term time, and are now approaching the end of therapy. when we first met abi was unhappily married, dangerously thin, permanently frightened, troubled by disturbing nightmares and emerging memories, and concerned about her ability to care for her sons, then aged seven and five. through couple counselling, which began shortly after she came to me, abi began to recognise abusive patterns in the relationship. her husband, while not physically violent, was emotionally, financially and sometimes sexually coercive. she was afraid of her own capacity to consent to things she did not want to do. her feelings of being manipulated and coerced were familiar from her childhood. compliance no longer made her feel safe, and only increased her self-disgust. her husband believed she was fantasizing and sick. he opposed her entering therapy. labelling herself an “evil fantasist” who was “out of her mind”, she had actively considered suicide. the youngest of four siblings, abi’s family background was wealthy, unpredictable and violent – though this latter seemed to her completely international journal of integrative psychotherapy, vol. 5, no. 1, 2014 2 unremarkable. drunkenness and violent rows played a regular part in the family dynamic. her mother, who died in an unexplained domestic accident when abi was 11, was alcoholic. her father remarried after a short time and this second relationship was also highly volatile. abi is in intermittent but reluctant contact with her stepmother and father, who are still alive, and with some of her siblings. her closest brother treats her with a mixture of kindness, concern and directive roughness. she finds these encounters confusing and disturbing, and has difficulty keeping her sense of herself. starting therapy: “where shall i begin?” my initial training was as a gestalt therapist, but since before i qualified in 2009, i have worked with sandra watson as my supervisor, and with richard erskine on a number of cpd conferences in england. his integrative psychotherapy draws substantially on gestalt understanding of process, phenomenological enquiry and relational contact, but to a gestalt practitioner his approach offers an enriched understanding of relational needs and effective ways of working with the impact of historical patterns on present behaviour and experience. my usual practice at the start of therapy is to ask for only basic personal, relational and medical information. i prefer to allow the client to choose her own route into the labyrinth of her past and present experience. though we may return to chronological narrative at relevant times during therapy, i focus on establishing a dialogic, phenomenologically-observant relationship through experience-near inquiry. this was how i began with abi. what i learnt over several weeks was very serious. she was regularly self-harming, cutting her thighs and torso. she was unable to eat. she knew her behaviour was putting her at risk. she was afraid of the impact she might be having on her sons. she spent her nights either awake and terrified, or suffering nightmares. domination and escape were recurrent themes. over recent months memories had begun to emerge of serious sexually abusive encounters primarily with her father and uncle. these seemed to have taken place in a number of family houses between toddlerhood and puberty, but they were fragmentary and hard to make coherent sense of. there seemed also to be a puzzling and disturbing presence of other men and boys in her dreams and recollections, and she had a strong sense of exposure, shame and being watched. abi was terrified that these experiences might really have happened. we did not name it then, but we both wondered if she had been a victim of a paedophile ring. in the therapy room, abi exhibited dissociative patterns, and found it very difficult to “come back.” physically she often became locked in her breath and in her legs and lower torso, and needed to locate “out there” securely, so that she knew how to escape, either physically or emotionally. as an inexperienced international journal of integrative psychotherapy, vol. 5, no. 1, 2014 3 practitioner, i needed to do some urgent ethical reflection in supervision regarding my fitness to work with her. issues of competence, confidence and experience: “am i competent to work with you?” i quickly realized the scale and scope of abi’s problems were extremely challenging for someone at my stage of training. ethical issues of competence, given the “limitations of my training and experience”, needed consideration. could i provide a “good quality of care … [to a] client who posed a risk of serious harm to herself” (bacp ethical framework, 2013, pp. 5 – 6)? working closely with my supervisor, i questioned whether it was in the client’s best interests to continue with me. my career in chaplaincy and pastoral work meant i was less inexperienced than my stage of training suggested. i was in personal therapy myself, where i had worked extensively with shame processes. i had a skilled and experienced supervisor willing to accompany me closely. i could study and undertake further relevant professional development. additionally, abi and i had quickly established a sense of trust and partnership. she was a writer, articulate and psychologically aware. she enjoyed the gestalt approach and creative methodology, particularly responding to imagery and story. we could meet each other instinctively and easily. i originally trained as a dancer, so my sensitivity to body process meant that i could be quickly aware of the nuances of her experience demonstrated somatically, and could work to support her to work in this important area. the experience of the first few weeks suggested that the therapeutic relationship and the support to which i had access would be enough to contain the work safely. after each session i used a framework for reflecting offered by my supervisor, and agreed that i would contact her for extra help if i were unsure. we explored referral routes if that became necessary. after careful consideration, my supervisor and i shared the opinion that it was, to the best of our informed judgement, in abi’s interests for us to continue. i outlined the situation to abi and offered to support her in finding a more experienced therapist if she preferred. i explained how i might need to refer her on if i felt the work she needed to do was beyond my competence. on that basis, she chose to continue. she knew i would look after both of us by having the supervision i needed. this modelled self-care, and unhooked her from her temptation to protect me from the difficult things she had to relate. often we would discuss insights from supervision and evaluate how they might support us in our work together. this mutuality and partnership has been an important part of the reparative relational experience of therapy for this client. our subsequent work together has confirmed the wisdom of our decision. reflection and supervision together enabled me to ensure that ethical principles of autonomy international journal of integrative psychotherapy, vol. 5, no. 1, 2014 4 and fidelity, beneficence, non-maleficence, client self-respect and therapist selfcare were observed (bacp ethical framework, 2013, pp. 3 4). without doubt, the work has significantly increased my competence. therapeutic presence: “stay with me!” much of my work as a gestaltist lies in helping the client build awareness of her patterns of contact in relationship with herself, others and her environment, and of the therapeutic relational process itself. phenomenological inquiry, in particular being observant about what is going on in her body, has been a route to abi’s physical and emotional re-integration. her body holds the story, one that she was either too young or too traumatised to know before. dissociative reactions were problematic in the early stages of our work, and careful pacing was vital. seemingly minor moments and innocuous comments would trigger extreme physical and emotional distress, and she would lose cognitive function, curling up, unable to talk or move. praise, or notice, or a particular question, or the mention of one of the many houses in which she had lived could all precipitate these very threatening sensations for her. we worked to help abi “stay”, supporting her emotional “escape” (as she had in childhood) to the garden outside the window when she felt overwhelmed or unsafe, and helping her return when she was able to. gradually, she was able to notice me at these times, and in her growing awareness of this process, she began to be able to experience me staying with her until she could re-engage. a different kind of dissociation or distancing was much more evident outside the counselling room, though we would catch it in the tone of her comments from time to time, as she reflected on her experiences of the preceding week. abi routinely used matter-of fact practicality and an internal, dismissive or scornful commentary on her thoughts and actions both to endure difficult encounters and to negate the possibility of the truth of her childhood trauma. this response was signalled by a crisp manner, a particular set of the chin, and a down-to-earth tone of voice. she would repeatedly “prove” that nothing had happened, or that the demands were acceptable and fair. she employed controlled and “reasonable” thinking to manage everyday life and especially to support herself in challenging encounters with her husband, her brother, or her vicar, and in any contact at all with her father. it was a highly effective response that enabled her to continue to function in everyday life. however, the consequence was that she would lose her sense of contact with herself, and often suffered nightmares or self-harmed in the aftermath of encounters to which she had reacted in this way. as we worked together, we focussed on building awareness of this pattern by slowing it down and tracking the process, enabling us, increasingly, to work more directly with her feelings and reactions. both nightmares and self-harming diminished as we followed this approach. we repeatedly traced resonances, echoes with the historic abuse, and noticed how she continued to be subjected to international journal of integrative psychotherapy, vol. 5, no. 1, 2014 5 a similar confusing and inconsistent variety of pressurising behaviours – cajoling, roughness, neediness, anger, affection, gifts, praise – in her present relational experience. we came to understand both her dissociation and her matter-of-fact dismissiveness as ways to evade the feeling or the implications of past and present encounters, establishing narrative facts began to address some aspects of her fear of being a fantasist, though she has persistently returned to this idea during the course of therapy. if she was making it up, it was she who was evil or insane, and she, not her father and uncle, had caused the damage in her family. the vital function of this creative adaptation is that she did not have to believe that these men, who should have cared for her and protected her, could and did do such terrible things to her. only in the late phases of therapy has she had secure enough self-functions to be able to tolerate the intensity of her reactions. her rage and her grief were held at bay, but it also left her current experience irrational and without foundation. it annihilated her – made her a “no thing”, nothing, an object which deserved everything it got. she became groundless, psychologically and physically at risk. a way of grounding abi’s experience has been to check the emerging story against known facts in her childhood. clearly remembered, verifiable events often coincided historically with a specific sexual abuse memory. the catching of a big fish, a beating in a stable, the shooting of her favourite guinea pig while she watched, hiding in a locked room while her father and brothers raged drunk through the house, the death of her mother, a dinner party some months later dressed in her mother’s clothes and makeup – these things she knew had happened. more recently, during her 20-year marriage, she knew she had repeatedly settled large debts accrued by her husband, even when she didn’t want to. the facts helped her recognise how she could be intimidated or coaxed into “giving herself away”. she came to believe that difficult and unacceptable things could be true. it became clear to her that her seemingly extreme physical and emotional responses might be valid and comprehensible. she began to make sense to herself. client safety and containment: “what if i need you when you’re not there?” early on in our work abi’s safety was often in question, so we contracted that she would text me if she was tempted to serious self-harm, or if anything put her at significant risk. “you know where i am” became a catch phrase. i felt there was something necessarily motherly, or even mothering, in my strong instinct not to leave her on her own. this willingness to be available helped to contain her distress, and her promise to contact me contained my concern too. she needed me to acknowledge and respond to her; she needed to make an impact (erskine, moursund and trautmann, 1999). text messages were our first point of contact so that she was confident of not imposing on me. i could international journal of integrative psychotherapy, vol. 5, no. 1, 2014 6 reply at a time that was convenient for me, and she felt able to ask. often she needed only the briefest reply; sometimes she would request a call, or occasionally an extra meeting. as a child, there had been no one to hear her if she called, she was ordered not to tell, so she had learnt to stay silent. there was no point in asking for help. even permission to call me was a reparative experience of relationship, what erskine called a drip of “therapeutic vinegar to the incremental calcifying trauma” of having no one to protect her when she was in dire need as a child (erskine, unpublished lecture, dec. 2012). abi respected our boundary agreements, but also valued my willingness not to abandon her, and to support her in a crisis. there were other breaks that we had to negotiate. i do not work in school holidays. this was challenging for abi. i supported her during these gaps by a number of means, devised in collaboration with my supervisor. transitional objects proved helpful. in different holidays, two halves of a beautiful silver antique buckle linked us, or two stones which we chose for each other reassured her that i was still there “with” her. during these partings, i found i held her in mind in a subconscious or semi-conscious way, perhaps as a mother might a child, and on several occasions collected a shell for her, or pressed a flower that had brought her to mind. she treasured these. we agreed on interim telephone meetings. i believe i was offering a kind of presence in my absence, which attended to unmet relational needs. in addition to the obvious relevance of therapist attunement here, to which i shall return, these measures illustrate the reparative value of working flexibly, accountably and ethically with boundaries. there are different views about interim contact with a client, and clearly the boundaried nature of the contract is vital. however, a gestalt approach to the ethical questions raised in this regard stresses an ethical way of being in the world that gives scope for a relational, contactful resolution of dilemmas in collaboration with the client. lee (2004) describes this as “a different kind of ethics that supports the process of noticing and responding to individuals and of noticing and responding to the larger environmental field” (p. 30). the value of theoretical models: “where are we going? how do we find the way?” integrating cognition has been an important part of the work for both therapist and client. as further reading increased my understanding of the interrelationship of present relational patterns and an abusive history, i shared what i was learning with abi, providing us with maps and frameworks through the labyrinth. abi learnt that her experience was not unique, and that recovery was possible. she could begin to use theoretical understanding to support the emergence of more integrated functioning. international journal of integrative psychotherapy, vol. 5, no. 1, 2014 7 theoretical understanding helped her to be grounded when sensation threatened to overwhelm her. the 4-way gestalt matrix of here-and-now and there-andthen explored by yontef (1988) is a constant support in disentangling historic past, adult past, present experience and our present interaction in the therapeutic encounter. i found that teaching this model, as well as the gestalt cycle of experience and gestalt’s account of modifications to contact (joyce and sills, 2010, pp. 37-39, 107) supported the client in building awareness of her enduring relational patterns. in gaining understanding, she was validated, and her often intense reactions to seemingly innocuous incidents were normalized. one particular theoretical model has been invaluable on this journey: kepner’s (2003) account in healing tasks of recovery of adult survivors of childhood abuse. he offers a map, a holding framework for recovery, which has informed our work at every stage. his four-phase process models the re-development of healthy selfand relational-process. he defines these as: support; self-functions; undoing, redoing and mourning; reconsolidation. he adopts the imagery of growth and learning “which proceeds in spiral fashion” (kepner, 2003, p.3) through recovery phases towards healing rather than rigid progress. kepner understands the recursive nature of growth and learning. in healing as growth, as opposed to linear progression toward cure, we address and readdress certain issues in ever more accomplished and more differentiated ways. (kepner 2003, p. 2) the stages are often co-existent, but they represent the direction of travel. he offers practical and theoretically well-grounded approaches to the changing needs of the client as she makes progress towards healthy autonomy and contact. our journey has closely paralleled his model and his practical approach has repeatedly informed my understanding and practice. it has particularly supported a careful approach to pacing, and validated the time this therapy has required. kepner’s (2003) insights on confronting the perpetrators were helpful. he is clear that the decision to report accusations of abuse is for the client alone. prosecution and justice can be one route to healing for an abused person, but may be “self-abusive” for another (kepner, 2003, pp. 75 78). it is a key area where the therapist must be very careful not to exert pressure. one of the central dilemmas of the abused child is whether to tell, and abi, like many children, was enjoined to secrecy by the perpetrators. at the start of therapy, when she was disclosing her experience for the first time, she was terrified she would be “forced” to report her father to the police. while questions about justice and safety raised by abi’s story are serious, as we explored together the ethical implications of the choice she had to make, it was clear that there was no possibility of ongoing sexual abuse: her father is frail and the uncle is dead. this enabled her to validate her decision not to make a formal report. international journal of integrative psychotherapy, vol. 5, no. 1, 2014 8 abi did, however, impulsively confide in her brother about what had happened when she was small, asking him for confidentiality. he immediately and without her consent, relayed what she had told him to her father. both father and brother demanded that she rescind her accusations. for several months this betrayal had a catastrophic impact on her emotional and physical wellbeing, and on her progress in therapy. a significant theme has involved supporting abi to navigate boundaries with her father, who, though elderly, continues to exert a powerful pull. though she does not want to break all contact, she experiences letters and phone calls with him as intrusive and threatening, especially his expressions of love and intimacy: “to my darling abi, with lots and lots of hugs, your devoted daddy.” he describes himself as heartbroken when she is not in contact, and blames his failing health on her distance and allegations. we ask, “what happens when you read this? how do you respond? what happens in your body? what do you want to say?” usually her reaction is a vehement “get off me!” a process approach diminishes her panic in the face of these accusations, and supports abi in developing healthy self-function. understanding childhood developmental patterns and needs, and in particular the nature of perception and language at different stages has also been important. the work of erskine, moursund and trautmann (1999) on developmental attunement helped me to support abi in making sense of her very early recollections. it seems that the sexual abuse started when abi was a toddler. her earliest recollections took place in the caribbean, when she could not have been more than three years old. disorientating and distressing flashbacks of her uncle reflected above her in a mirror, a sensation of burning dry pain, and a memory of a wooden floor and her bottom in the air were fragmentary and confusing. they made no sense. she could have had no possible developmental cognitive, physical or emotional concept of what was happening to her. she remembers soiling the bed and being in desperate trouble with her mother. even in the therapy room, she still felt culpable for something that she had no developmental possibility of understanding. in our session she had a strong sense of being a “dirty girl” and having been rightly punished for doing something terribly wrong. she had been going along the hallway to the toilet in the night. “it must have been my fault. i should have been in bed. that afternoon i had turned somersaults for my uncle in the garden. i never turned somersaults again.” when working with early material such as this incident, abi sometimes regressed to being without language. she would curl up in a tiny ball in the corner of the sofa and could only look at me with mute appeal in her eyes. i would work with her as if she were the child, bearing in mind the adult abi at the same time, who was unavailable for contact at these times. using language, which mirrored my best guess of her developmental stage at the time of the incident, helped us to manage her regression and supported her to explore her trauma. she described her “hurty tummy.” “which tummy?” patting her lower abdomen – “this one.” after these incidents, as abi came to understand what happened in such international journal of integrative psychotherapy, vol. 5, no. 1, 2014 9 regressions, we carefully worked as judging and evaluating adults with a duty of care to the child. we considered the legal and ethical responsibilities of an adult in relation to a child, enabling her to untangle her confusion. again, cognition served to anchor her. the therapeutic “double-vision” which kept both the adult and child client in view exposed the self-abandonment abi had developed as a creative survival technique. the small abi did not deserve to be kept safe, and the adult abi did not wish to care for herself or keep herself out of danger. in the early stages of therapy she experienced a powerful contempt, almost cruelty, towards both the regressed child and her adult self. she felt she did not deserve or even want my, or her own, care. at these times, it was only by returning to the moral and emotional compass of what she considered appropriate or loving behaviour towards her own sons that she was able to gain any kinder orientation to herself and any clearer judgement about the behaviour of the adults she was remembering. therapist would that be ok to treat j. like that? client (pause) no. (emphatic shaking of head) … no … (more shaking, realizing) no! therapist no, it’s not ok for j to be treated like that. client no, it’s not ok. therapist no, it was not ok for you to be treated like that. client (quieter) no. … no, it wasn’t. working linguistically in both past and present tense helped the client to reintegrate, bringing together her experience of effective and compassionate mothering and the damaging behaviour of adults in her childhood. time and again, this process helped to support her to care for herself. this is painstaking reconstructive work demanding the therapist’s validation, patience and tenderness towards both the adult and the “child” client. later, abi herself was able more consistently to keep her own compassionate double vision towards her adult and child selves. client identity and self-process: “who am i?” because abi’s boundaries were repeatedly breached throughout her history, she had a diminished sense of her own difference, autonomy and equality. experiencing her own agency and working collaboratively were particularly necessary for this client where abusive relationships had exploited confusion between power and care. respect, negotiation and validation have been key. my initial instinct to be honest about offering to journey as coexplorers was reparative and equalising. critically important in her recovery has been her growing sense of her right and capacity to choose, to say yes and no. in the early stages she would easily say yes to me when she did not want to. it international journal of integrative psychotherapy, vol. 5, no. 1, 2014 10 was important that i acknowledged my mistakes, especially if i had inadvertently coerced her in any way. on the first occasion she realized that she could say no to her father’s current appeals for care and sympathy in his old age. i suggested an experiment. “what would it be like to write ‘no’ in the air?” tentatively, she tried it, and felt emboldened. i suggested she stand to make it a little bigger. willingly, she got up and found the first of her physical energy in resisting a current unwelcome demand. however, in my next intervention i lost my attunement to her and failed to graduate the experiment appropriately. excited at her sudden progress, i asked her if she would be willing to try tracing out the letters to the fullness of her stature, a spatial equivalent to a big no! but i had moved the experiment on too fast. she froze and flushed. we both realized what had happened, and she was able to say a determined “no!” to me instead. i had not picked up the subtle physical signals that should have alerted me to a serious disruption in our contact. paul guistolise’s account of the inevitability and necessity of therapeutic failure, and the parallels he draws between good parental response to misattunement and the therapist’s responses were helpful here. (guistolise, 1996) he emphasises the importance of recognising the inevitability of failure and builds on erskine’s and stern’s work concerning “two, separate sequential traumas.” the first occurs when a parent, or therapist misses the child or the client. “the second trauma occurs when the parent fails to respond to the ‘emotional reactions and unmet needs’ (erskine, 1993, p. 185) of the child that are stimulated by the first failure” guistolise observes that, just as in parenting, “perfect empathy and attunement are not possible in relationships” but that “responsibility and repair of disruptions of contact are both possible.” (guistolise, p. 286) he insists that it is vital to the therapy that the therapist be willing to acknowledge his or her momentary failure. when failures are recognized, acknowledged, and discussed, they form the basis for the necessary repair for the client. in so doing, the client has the potential of experiencing the other taking responsibility for a relational failure and the opportunity to experience a failure as not being of the client's own doing. (guistolise, p. 287) i immediately took responsibility for my misjudgement and apologized. together we explored the impact of my mistake. we quickly came to understand the scale of her reaction, and abi could recognise that it was not intentional, and was distressing to me too, and that i did care very much about how i treated her. we validated her enormous “no!”, a word she could not use as a child to stop unwanted things being done to her. in reflecting together, she needed my reassurance that i would try not to push, and i assured her that i would never pressurize her intentionally. she experienced her own agency and power in our relationship. international journal of integrative psychotherapy, vol. 5, no. 1, 2014 11 as we re-connected, the reality of the relationship as co-travellers struck us forcibly. of course we would make mistakes. of course we would miss each other. it was what we did with these moments that mattered. even in the event of rupture, the process of mending can be existentially reparative. we agreed that either of us could “press pause” when we were in danger of getting out of step. now, if i have an idea, i will ask whether she is open to hearing it. this gives her choice at the very start of an interaction. sometimes she says yes, and sometimes no. i respect her wishes. if the idea won’t go away, i tell her so and ask if i may offer it for her to decide if it has relevance or meaning for her. for someone like abi, who has been left to deal alone with intolerable ongoing trauma, it is vital to have someone trustworthy by her side; someone to support her feelings, wants and needs. the process of learning what her own boundaries are, and how to establish them is sometimes difficult, and can be threatening for her. i do not leave her to decide alone. i hold the confidence that she, and we, can find our way, and that this is a safe enough journey to take. in the therapeutic relationship she has the agency and equality she lacked both in her childhood and in her marriage. we are practicing together. this process builds her sense of her autonomy, dignity and worth. inevitably, i still make mistakes, and each time i do we approach the repair in the same open and honest fashion. it is a rich aspect of my learning that i can be a good-enough therapist, and that it is impossible not to make therapeutic errors. in such instances, i deeply appreciate the supportive supervision i receive, and the potential for personal and professional development is rich. issues of self-identity are an important aspect of recovery for survivors of abuse. though i work with couples and with individuals, with men and women, older and younger people, people of faith or no faith, many of my clients are, like abi, middle-aged women from a christian background. issues of difference and equality in this context arise under the guise of similarity. while being at a similar life-stage, and sharing a faith, and many similar interests in creativity, literature and the arts, my awareness of the differentiation between us is critical during abi’s recovery from abuse. i inquire, am curious, and do not make assumptions that she is like me. modelling healthy differentiation, it has been important quietly to assert my “difference” when she makes assumptions about my sameness either to her own or to institutional views. with an abused client such as abi, it is vital to guard against the dynamics of abusive relationships whenever power or care are in the frame. this includes the therapeutic relationship itself. at first, the client is unlikely to have sufficiently strong self-functions to dare opposition, and may gain care by consenting. my ethical therapeutic focus on equality and difference supports her courage to resist pressure, find the strength to refuse direction, refute inaccurate judgements, and choose for herself. i am careful not to replicate power patterns, emphasizing equality and autonomy. international journal of integrative psychotherapy, vol. 5, no. 1, 2014 12 in abi’s christian context, male authority has been historically intrinsic to the culture and seems to have diminished further her sense of her right to proper autonomy. as a wife she was encouraged to submit and yield, and believed this was a god-ordained pattern. she granted authority to both her husband and her minister. there was scope here for real confusion for abi. some of her theological views about the nature of god, salvation, obedience, guidance and guilt increased further the danger that both her deity and her priest could inadvertently encourage her into situations of further abuse. sadly, heavyhanded pastoral involvement failed to acknowledge the possibility or validity of her experience in her childhood or her marriage, and saw her as the problem. there was strong pressure for her to honour her vows and stay in submissive love, with little attempt to understand the dynamics of the relationship. a wellmeaning invitation from her vicar to listen to “her side of the story” and to pray with her was, in fact, dangerously coercive and exploitative. he was distrustful of her being in therapy, and wanted to contact me to ask what we were discussing. perhaps he feared i might take a “non-christian” line, and certainly he had little understanding of the therapeutic process of healing and restoration. naturally, his request was not granted. he did, however, insist that abi should “tell him what had happened in her childhood.” in assenting, she felt pressured into narrating experiences which she was only just beginning to dare to talk about after several months of therapy. she felt violated and exposed, and utterly unsupported. she was removed from positions of leadership until she was “better.” he had no understanding of the potential to re-shame abi in his attempt to save the marriage, and was blind to damage he was doing. with such a client, any hint of expectation or demand, and any failure of consent can be re-traumatizing. this kind of treatment can encourage yet another conspiracy of silence, in a culture where to be honest about difficulties results in what can be perceived as punishment. while it is important to say that there is much fine pastoral care in many churches, this area would merit further research. there is a real need to educate those in church leadership about the issues and challenges of the healing process of abuse victims so they can handle such situations with greater wisdom and sensitivity. working with shame: “i don’t want you to see me.” careful work with abi’s shame was vital. my work with my own shame through personal therapy and group process proved valuable, especially understanding that the double bind of naming shame has itself shaming potential. however, breaking the silence shame imposes offers the only chance of recovery and integration. further reading helped me understand shame processes, especially the “functionality of shaming”, and mechanisms of “what kaufmann (1989) calls a ‘shame spiral’ and what frederickson calls a ‘shame attack’ (j. tager, personal communication, june 23, 1993)” (stein and lee, pp. 107, 106). i was alert to signs of shame’s presence and the possibility of my behaviour reshaming her. i recognised how challenging it was for abi to allow me to “see” her international journal of integrative psychotherapy, vol. 5, no. 1, 2014 13 as she described exposing incidents, for example when a youth summoned for the purpose failed to penetrate her, so she was masturbated by one man and watched by the others seated on three chairs above her. i asked her what it was like for her to be seen by me in her current experience of re-ignited shame. erskine’s (1995) paper dealing with theory and methods of working with shame is helpful in considering the role of therapist and client shame. abi asked that i did not probe further in that moment, but was grateful for my regulating and containing presence. i honoured her request, confident that we could return to the incident if necessary. another time, aged about twelve, just after her periods had started, she was required to undress before being seen nude by her father and another man. she was mocked for her “coyness” when she asked to go behind a screen, as if her modesty itself were shameful. my response was to validate her present and past reactions; the way she had been treated was shameful and shaming, and her sense of being shamed was healthy and functional. we broke the double bind of being ashamed of being ashamed. we agreed that we should treat both child and adult abi with respect. i supported her as she learnt to treat her younger self with kindness and courtesy. observation of body signs of shame often alerted me to territory where, if we slowed up, abi could stay present enough to continue. her neck would flush, her eyes would flicker or she would freeze into stillness. lee (2004) observes that “ground shame” which is consistent with “repeated or severe enough instances of misconnection [ie. consistent or severe physical or sexual abuse] … freezes selfprocess” (lee, 2004, p. 22 23). sometimes my own body signalled shame in the field before i was aware of her reactions. if i failed to track carefully enough, as i did on occasion, she dissociated, became violently self-blaming, and between sessions self-harmed to vent the intensity of her feelings. both therapist and client in this process have to come to tolerate the presence of shame in order to stay present with each other. as abi became conversant with shame theory (another example of theory for this client supporting growth and change, normalizing her experience), she began to be able to “own-up” to self-harming episodes, thus breaking the shame bind, allowing access to further primary material. each time we did this, she experienced a diminution of her sense of “being dirty” in her everyday life. my personal awareness and the mutuality of this process helped me to support the dignity of the client. my own experience of release from shame helped me to support her as she named and explored these very shaming episodes. we had to tread extremely gently as we threaded our way into the labyrinth, finding ways for her to have the voice she chose to have. therapeutic touch with a person who has been repeatedly physically invaded is never neutral, and must be used with particular caution. often abi was unable even to touch her own body, and avoided bathing or ever seeing herself naked in a mirror. without using touch, we developed her physical awareness to lessen her estrangement from her own body. simply describing what i noticed would international journal of integrative psychotherapy, vol. 5, no. 1, 2014 14 initially be experienced as shaming. gradually she became aware of sensation that had been completely numbed, and could experience my presence and observations as support rather than exposure. very occasionally a hand touch with her consent could restore sensation and contact. equally, however, such contact could be threatening and invasive. we always negotiated such moments with great care. on one occasion, we experimented with hand-to-hand contact to explore yielding, resistance and collaboration. it became almost a dance, which i supported with commentary and inquiry. this experiment has often served as a reference point in abi’s growing experience of flexible, negotiated, healthy, noninvasive contact and agency in relationship. restored awareness gave abi access to somatic memory that could be triggered by current events both beyond and within the counselling room. however, it was many months before she admitted that, whenever there was any hint of being pressurised, her locked thighs, pain in the lower abdomen, choking sensation in her throat were also accompanied by sexual arousal. she came to understand that conditioned arousal is not the same as consent, even if consent were a legal and ethical possibility for an underage child. she could see arousal as an important creative adjustment, a survival mechanism, sparing her pain. that her body had responded in the historical abuse situations did not make her culpable. she was not “asking for it”, as she had sometimes been told. in the present, although she would continue to flush with embarrassment, she learnt to accept the validity these reactions; her physical, conditioned responses were not shameful, but signals we could work with, indicating that we were in territory which triggered similar responses as the original abuse. at these moments we carefully tracked what had just happened and explored the historic resonances. metaphor and myth as tools for movement and change: “let’s imagine …” creative methodology has had a powerful role to play in our work. creative ways of working have repeatedly led to effective therapeutic work and breakthrough for the client beyond the therapy space. abi is a writer, and as an ex-english teacher and writer also, i too relish words and images. metaphor is a rich resource in our work. the journey we are taking together has often returned to the traffic circle, a “roundabout” of choices, exits she could choose when she wished she could evade the painful therapeutic process or avoid the truth of her experience. we invented our car – a small, bright orange citroen 2cv – in which to circle the exit options once more – all but one of the following exits led to a diminution of selfhood and an increase in distressing symptoms and self-harm: i made it up. i’m deranged. i should just bury it all again. international journal of integrative psychotherapy, vol. 5, no. 1, 2014 15 i must be evil to believe such a dreadful thing. i caused all the damage. all the symptoms add up to something significant. i’m getting better as we engage with these experiences. let’s carry on with the work. our roundabout was a way of helping her return from a dissociative reaction. we might send the car round the traffic circle several times, as she gradually returned to being present. often we found humour and lightness in place of her panic as we imagined our car’s particularly bouncy suspension. each time, the route of the therapy we were doing seemed the most true, most health-giving and safest of the routes, so we would continue working with the stories of abuse, with her in the driver’s seat and me as navigator until the next time she needed to check where we were going. the traffic circle times were often triggered by pressurising contact with family or her husband, and then she needed me to take the pressure off, patiently and cheerfully going round the circle again as many times and as often as we needed to. abi’s fear that she is making it all up has been helped by a cooking metaphor. she is a fine cook, and loves mixing flavours inventively. she is also a writer of stories, and has always had a vivid imagination, which grownups around her used to criticise. although her memories are unverifiable, we have come to distinguish between her sense of a convincing, but fictional flavour, and one that has the tang of experiential truth. when writing, she consciously reaches, as it were, for the herb or spice she wants. when working with memory, her sensation is of testing something that already has a particular taste. we can’t know it is true, but the flavours suggest very strongly she is not a fantasist. her steady recovery equally supports the view that this is not the merely the concoction of a lively imagination. a jungle metaphor expressed the fear she felt on this journey. though we did not know the way, we could find the path together. we became trusted coexplorers. after one painful session, we ruefully extended the jungle metaphor, deciding we had fallen into an “elephant trap”, unexpected, deep, covered by branches. i realized that elephant trap moments were more likely to happen if abi felt pressure from me to deal with an episode before she was ready, or if she felt i had any agenda with her at all. later, we learnt to anticipate dangerous territory and go more carefully. the elephant trap also signalled episodes demanding attention. it became a useful shorthand. we recognised and admitted that at times we both felt afraid, and while i was responsible for the safety of therapeutic environment, it repeatedly seemed that my honesty met present and historic relational needs, helped her to regulate her own feelings, and gave her a powerful reparative experience of making an impact (erskine et al., 1999, p. 141). we were in this together. at one stage, several months in, i was concerned that she kept skirting memories that were pressing strongly for attention in dreams, flashbacks and difficult international journal of integrative psychotherapy, vol. 5, no. 1, 2014 16 encounters. week after week, she would intend to tell me but other things came to the fore. in supervision, we reflected on this pattern. “how do i help her to go where she needs to go?” i asked. “she’ll take you there when she’s ready.” taking this advice, i stopped feeling that i needed to make this necessary part of the journey happen and resolved to wait. i learnt to “lead by following”, accepting and trusting her pace, maintaining creative indifference. not by coincidence, very shortly afterwards, abi felt ready. “it’s time to do this,” she said. “will you come with me?” we gulped, and stepped down into the elephant trap on purpose, into the darkness of one particular visit of her father to her attic bedroom when she was perhaps five years old, which left her soiled and desperately trying to wash her sheet in the little basin under the skylight. interestingly, her self-harming and emotional distress diminished each time we tackled a particular memory, suggesting we were on the right track. she experienced my presence as she told her story as supportive and comforting, and was more able to connect with the distress of the child. her story had an impact on me, and this impact called her into existence in new ways. the metaphor carried us to a place where abi could begin to make meaning out of confusion and fear. the title of this case study “into the labyrinth” is taken from a final powerful example of creative process that facilitated movement and change. here, the power of myth to carry meaning transformed the client’s lived experience outside the therapy room. abi has divorced her husband, but had to face a court hearing to resolve the settlement, a particularly difficult challenge in the light of her financial history. her survival and that of her sons was at stake. she was terrified by the exposure of a public hearing, watched by many, overseen by a male judge, where she would be unable to control what was said about her. she blushed scarlet at the thought of it. she was afraid of being coerced into neglecting her own interests in favour of appeasement. as the day drew near and her panic increased, we searched for a metaphor or story which would carry her through the ordeal she had to face, and help her to use her new-won skills and awareness in holding her ground and fighting for her own interests. myths are carriers of truth, and, like metaphor, are open to rich interpretation. we explored the setting in the courtroom and imagined that she was facing her exhusband. therapist what does he look like? client like a bull! therapist and client a minotaur! international journal of integrative psychotherapy, vol. 5, no. 1, 2014 17 we had to check the story, in which theseus must go alone into the labyrinth to slay the monster, half-bull, half-man, who devours young men and women to satiate his appetite. the resonances were not lost on us. princess ariadne promises to help him escape the labyrinth by giving him a thread to unroll as he approaches the centre of the maze (plutarch’s lives, trans. dryden 1683). abi became for that session princess ariadne, though she wanted to slay the minotaur herself. aware we were talking about both myth and the forthcoming ordeal in court i asked, therapist what will you do when you meet him? client i won’t look down. i’ll look him in the eye. he’s a coward. i want to kill him. but i’m too weak to do more than tickle him. i can hardly even lift the sword. therapist i can’t go with you to court, but i have an idea. what if i keep one end of a thread, and you have the other, to know that i will be right with you in imagination. perhaps the judge will be theseus for you? it was an important moment of her realisation of both her own vulnerability and strength. in this kind of work, the story is fluid and alive, ideas emerge as a co-creation, a mutual exploration that creates newness and vitality. together we chose a golden thread, which i tied in my diary. we broke it, and abi wound a length to keep. when the day came, abi found she had a just and perceptive judge who recognised her needs and fought for her best interests, a restorative experience of advocacy and justice. the theseus myth and its telling parallels with her present and past experience, and the metaphor of herself as a noble princess rather than the shamed and sacrificed victim, allowed her an experience of standing with her head held high right in the heart of the labyrinth. approaching the end: “are we nearly there yet?” as we approach the ending phase, or reconsolidation in kepner’s model, my client, my supervisor and i all look back with satisfaction at the way we have come. abi has left the marriage, and has had the courage and rootedness to fight for a fair settlement. she is caring successfully for her sons and managing to co-parent with her ex-husband in ways that are more life giving for them and for her. she is no longer frightened. she is eating well. she very rarely cuts, and if she does, she knows she is trying to tell herself something important, and she listens, avoiding the shame trap. abi is able to resist coercion from others, and is learning to set safe boundaries in her relationships. she can still experience intimacy through a toxic mixture of violence and kindness that can put her at risk in new romantic relationships, and there is further work to do in disentangling sensuality and sexuality. however, she understands the process of international journal of integrative psychotherapy, vol. 5, no. 1, 2014 18 change, and that it takes time to establish new patterns. this helps her be patient when she makes risky relational choices. i am able to stay with her nonjudgementally and help her be curious about her process. she is learning to recalibrate, to find a new normal. there remains some history work that abi is steadily tackling, signposted by residual somatic and dissociative reactions, or occasional oddly extreme or unsafe responses to current situations. as earlier in the therapy, we found that week after week she would intend to take me to particular incidents but would instead deal with important and relevant here-and-now issues. she knew she was scared. she also knew that once she embarked on this final detailed and specific work, her final connection with her creative adjustment of herself as the fantasist would be severed. her story would have to be true, with all that implied, especially in relation to what she would do concerning her relationship with her father. while supporting her pacing, i wondered how she would manage to find what she needed to do. in a resourceful way, she has chosen her own creative approach to this phase. she arrived one week with a jigsaw map of the uk, in addition to the bag of wooden houses, trees, cars and people, a collection of stones, and a request. would i make a cardboard cut-out of a figure which could represent the abuser? the cairn of stones representing a kind and caring man enabled us to check the flavour of what she relates. these two symbols help her to visualise healthy and abusive behaviours. “is that what the cairn would do, or the cardboard cut-out?” we have mapped the places she needs to go to, setting out the landscape on the floor and building the many houses where she was abused. gradually she is daring to explore these incidents. she is making sense of the confused impressions, tethering them to verifiable events, trusting that she does know how to do this healing work with me. she has found fury, hurling houses after checking she was allowed to. client i don’t want to go in there! and i won’t! therapist and you don’t have to. you couldn’t choose then, but today, you can choose. client (calmer) today, i’d rather not. is that ok? therapist (smiling with a questioning look) client of course it’s ok. i can choose, can’t i! we’re still doing the work. she has found tears. client they shouldn’t have done that, i was a child. it was not my fault. therapist no abi, it was not your fault. international journal of integrative psychotherapy, vol. 5, no. 1, 2014 19 our sense of partnership is palpable and her groundedness increases all the time. there is poignant irony in using childhood toys to resolve the traumatic experiences of her own childhood. as we play seriously together, she paces her work skilfully, taking responsibility for her own wellbeing. watching abi practising flexible and healthy patterns of contact and consent is one of the most exciting aspects of the final stage of our journey. she is confident that she will have the tools, skills, and self-worth to make her way forward after her therapy comes to an end. in the meantime, we relish this phase, and are confident that together we will know how to finish well when the time comes. she can choose. together we will decide. images, objects, story, reading and theory, supervision, reflection and selfawareness, and most of all, the therapeutic partnership itself have all played their part in ensuring that abi has been ethically and effectively accompanied in her work. my initial fear of not being competent enough for my client’s important and difficult work has not been fulfilled. a children’s book, the kitten who couldn’t get down, by helen pearce (1977) provided a rather less academic holding framework for me when the challenges felt too great! a chestnut kitten repeatedly climbs too high, and then falls while his siblings stay safe in their basket. but the daddy cat teaches his adventurous kitten to climb safely down: “front feet, back feet, front feet, back feet.” step by step, with my supervisor’s wise help, i have gained experience and confidence through this challenging journey. abi is an extraordinary woman – brave, intelligent, honest and resourceful, increasingly able to live a vibrant, choice filled and independent life without being dogged by repeating patterns of abuse. i am humbled to have had the opportunity to accompany such a client so early in my counselling career. author: pamela stocker holds a ba hons., english language and literature, (birmingham university, uk), pgce, ma christian spirituality (heythrop college, uk: university of london); pg dip in gestalt counselling (st john’s college, nottingham, uk); mbacp (accred.). ms stocker is a bacp accredited counsellor working in the east midlands, uk. formerly an english teacher and later a boarding school chaplain, she began her training as a therapist in 2007 and completed an ma in christian spirituality over the same period. a poet, textile artist and dancer, she continues to develop her interest in body process and the therapeutic use of metaphor, myth and other creative approaches. she has particular experience with issues of spirituality. in her private practice in uppingham, rutland, uk, she specializes in longer-term work with couples, individuals, adults and young people. international journal of integrative psychotherapy, vol. 5, no. 1, 2014 20 references erskine, r. g. (1995). a gestalt approach to shame and self-righteousness: theory and methods. british gestalt journal, 4 (2), 108-117. erskine, r., moursund, j. p. and trautmann, r. l. (1999). beyond empathy: a therapy of contact-in-relationship. london and new york: routledge. guistolise, p.g. (1996). failures in the therapeutic relationship: inevitable and necessary. transactional analysis journal, 26 (4), 284-288. joyce, p and sills, c. (2001). skills in gestalt counselling and psychotherapy. london: sage publications. kepner, j. i. (1996/2003). healing tasks: psychotherapy with adult survivors of childhood abuse. london and new york: routledge. lee, r. g. (ed.) (2004). the values of connection: a relational approach to ethics. u.s.: analytic press. pearce, h. (1977). the kitten who couldn’t get down. london: magnet publishing. stein, k. and lee, r. g. (1996). chronic illness and shame: one person’s story. in robert g. lee and gordon wheeler (eds.) the voice of shame: silence and connection in psychotherapy pp. 101-121. m.a. usa: gestalt press. wheeler, g. (1996). self and shame: a new paradigm for psychotherapy. in robert g. lee and gordon wheeler (eds.) the voice of shame: silence and connection in psychotherapy pp. 23-58. m.a. usa: gestalt press. yontef, g. m. (1988). assimilating diagnostic and psychoanalytic perspectives into gestalt therapy. gestalt journal, 11 (1), 5-32. date of publication: 15.11.2014 abstract: this case study describes the therapeutic journey of a client who suffered serious sexual and physical abuse from toddlerhood to adolescence. it considers challenges and ethical issues in the therapeutic partnership with an abuse survivor, exploring the importance of the theoretical framework and of supervision. issues of autonomy and power in relation both to therapy and to church pastoral practices receive attention. central to this therapeutic journey is the role of creative methodology, metaphor and myth in facilitating transformation. introducing abi starting therapy: “where shall i begin?” client safety and containment: “what if i need you when you’re not there?” the value of theoretical models: “where are we going? how do we find the way?” with an abused client such as abi, it is vital to guard against the dynamics of abusive relationships whenever power or care are in the frame. this includes the therapeutic relationship itself. at first, the client is unlikely to have sufficiently strong self-functions to dare opposition, and may gain care by consenting. my ethical therapeutic focus on equality and difference supports her courage to resist pressure, find the strength to refuse direction, refute inaccurate judgements, and choose for herself. i am careful not to replicate power patterns, emphasizing equality and autonomy. working with shame: “i don’t want you to see me.” metaphor and myth as tools for movement and change: “let’s imagine …” approaching the end: “are we nearly there yet?” references