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 physiological- affective-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. 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