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 self- in-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 de- idealization 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 anxious- avoidant 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