International Journal of Integrative Psychotherapy, Vol. 12, 2021 75 My Mother’s Voice: Psychotherapy of Introjection: Part 5 of a 5- Part 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