International Journal of Integrative Psychotherapy, Vol. 12, 2021 1 Review of Integrative Psychotherapy: A Mindfulness- and Compassion- Oriented 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 mindfulness- and 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 self- regulation. 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 co- regulate 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, self- compassionate 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-to- moment 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 Mindfulness- and 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.