Alcoholism is such a common condition that therapists must be exposed to clients who suffer from it, whether the therapist is ‘I have feelings, too’ - The Journey from Avoidant to Secure Attachment Maša Žvelc Abstract: In the article I describe the integrative psychotherapy of the client who showed an avoidant state of mind. I explore how in two and a half years of psychotherapeutic treatment, in a sensitive and caring therapeutic relationship, the client process of integration and development of a secure state of mind is unfolding. The client is becoming more open and accepting of her own internal states, particularly her vulnerability and the need for having a secure, warm and loving relationship with another. An increased contact with self is enabling her to make important decisions and implement changes into her life. Theory of attachment is used as important guideline for diagnosis, treatment planning and understanding of the psychotherapeutic process. Key Words: attachment theory; integrative psychotherapy; avoidant attachment style; case study; EMDR ____________________________ General Information about the Client When Klara came into therapy with me, she was 29 years old. She came upon the recommendation of her colleague, who is a psychologist. Klara is highly educated and very successful in her occupation. She is very slim and always looks impeccable. She likes to have things under control. Klara came into therapy due to the problems which had occurred in the last year: • She had difficulties with driving a car (initially as a driver, later also as a passenger) – she was feeling fear, nausea and a tingling sensation all over her body. Consequently, she gave up driving herself, except for driving around the town centre. International Journal of Integrative Psychotherapy, Vol. 2, No. 1, 2011 22 • Klara had difficulties with her stomach, i.e. she was feeling stomach aches and nausea. Soon after she had entered therapy, she was diagnosed with gastritis. She was prescribed a medication which made her feel better. • Klara was working in a stressful environment and was suffering from burn-out. She was feeling tired and tense. She wished she could take a lengthy break from work. Her symptoms first showed up a year before entering therapy, when Klara was putting all her efforts into studying for an important, very difficult exam. This placed an immense psychological and physical pressure on her. During this time, Klara was neglecting her need for rest as well as regular eating. Even when she wanted to eat, she was unable to do so due to a sensation of having a lump in her throat. She also described how her former partnership relationship had presented an issue for her in the last year. Her former boyfriend lived in the neighbouring country and they rarely saw each other. In a psychological sense, they were rather distant from each other. After spending one evening with her boyfriend, Klara became acutely aware of the emptiness between them, which made her cry in front of him. The next morning she woke up with a tingling sensation throughout the body. From then on, Klara was feeling this tingling sensation in both her legs. Already on our first meeting, Klara was contemplating how her lifestyle in previous years had contributed to her difficulties in the last year. After she had graduated, Klara went to study abroad. She was successful in meeting the deadline for completing her studies. Klara then returned to her homeland and immediately threw herself into work. In therapy, she reflected: »I had no time for myself. I was working around the clock.« When I asked her what makes her happy, she became absorbed in thought. Then she replied: »Well, this is a very good question… I have a feeling I am being guided by things… I do not ask myself what is it that I want.« Later on, she revealed: »In the last few years, I have detached myself from my body. I have only been feeling my head, and the head has been guiding me.« At the time, Klara was living with her father, mother and a younger brother. Her mother was a dominant, strong and emotionally cold woman. Financially, she was very successful. Klara said of her father that "he is a poetry kind of guy". He likes going to the mountains, he is quiet and distant. He gives an impression that nothing interests him. Several months of therapy later, I learned that he was struggling with alcoholism. In Klara's family, relations were emotionally cold and distant. When her mother was dissatisfied with Klara, she would ignore her for several days. Klara called this "the silent treatment". She described her mother as a controlling personality. During the course of therapy, Klara remembered that her mother used to beat her as a little girl. International Journal of Integrative Psychotherapy, Vol. 2, No. 1, 2011 23 Certain Characteristics of Klara's Development From her mother's narration, Klara learned that the babysitter who took care of her from her 3rd to 6th months of age did not give her milk. When Klara's mother found out she dismissed the babysitter. Between the age of 7 and 36 months, the client was banging her head against the wall. She felt pleasure in doing so. She refused food until she was 5 years old. At school, Klara was very successful, but she had no proper friends. She was troubled by the injustice and isolation which some of her socially deprivileged classmates were exposed to. In her adolescence, Klara was hiding her breast development. When she was 17 years old, she was involved in a traffic accident as a passenger. The accident left her shaken, but she did not suffer any physical injuries. First Impression of the Client Klara was talking swiftly. I sensed her anxiety, and how tense and stiff her body was. When I tried regulating her fast rhythm (e.g. with a therapeutic intervention such as: »I suggest we stop here a little… take your time to breathe in… breathe out… and simply observe what you are feeling«), tears welled up in Klara's eyes. She started feeling uncomfortable. Klara was ashamed of her tears and wanted to avoid them. She told me it was extremely difficult for her to seek help, because all her life she had been used to do everything on her own. She could only ever rely on herself. She viewed her coming into therapy as a defeat. Despite her initial ambivalence towards psychotherapy − which Klara was able to perceive and express well − she was determined and committed to psychotherapy treatment. This is what I wrote in my notes after our first meeting regarding my impression of Klara and my countertransference feelings: »An agreeable woman. I feel her stiffness, tension and anxiety, and I think to myself: ‘How much pain and loneliness reside in her… how many tears that have never been cried.’ On the one hand, I feel warmth and an impulse to give her a "psychological hug", but on the other, I can perceive her upright posture and the serious expression on her face. They make me feel as if I am not to attempt to get closer, as if I am undesired in this sense.« Diagnostic Assessment Based on the Theory of Attachment Based on their early experiences in interpersonal relations, a child develops implicit mental schemas (Siegel, 1999) including relational schemas International Journal of Integrative Psychotherapy, Vol. 2, No. 1, 2011 24 (Žvelc, 2009, 2010) through which they interpret themselves and the world, as well as anticipate the future. These schemas decisively influence the way we process information. In this context, Bowlby (1969) wrote about working models; Main about mental representations (Main, Kaplan and Cassidy, 1985), Stern (1985) about RIG’s (generalized representations of interaction) and Erskine (2009) about life scripts. The manner of processing information presents one of the key criteria for classification of the client's attachment style (Wallin, 2007). Furthermore, the manner of processing information influences how freely a person is able to think, feel, remember and act. According to Fonagy (Fonagy, Gergely, Jurist and Target, 2002), related and essential to this are mentalisation (which helps us realise how our mind mediates our experience of the world) and reflective function (which means the relation of self towards own internal experience). Individuals with a secure attachment style have a reflective relationship with their own experience, which makes them more open and accepting of their own internal states. For persons with avoidant attachment style, it is typical that they diminish or deny the influence of their own internal experience. They tend to avoid their internal experience and their internal world. Based on my observations, I assessed avoidant attachment style was typical for Klara. Klara avoided her internal world and inner experiences. She had poor awareness of her physiological sensations, her needs and feelings. Consequently, she had poor contact with her body. She was neglecting the messages sent by her body, thus neglecting her physiological needs. Klara was often hungry and over- exhausted. In addition, she was disinterested in her emotional happenings. Emotions presented a threat to her and she preferred to avoid them. She rarely allowed herself to feel them, even rarer to express them. Klara hid not only her need for being emotionally close and receive support from another, but also her vulnerability and weakness. As a matter of fact, she split off this part of self from her consciousness and wasn’t in contact with it anymore. Whenever this part wanted to reappear, it would have upset her and Klara put all her strength into making it go away again. As a result, the client was cut off from her vulnerability and the need for being in a relationship. The above-mentioned characteristics show poor contact with internal experiences, as well as difficulties with affect regulation, both of which are important features of avoidant attachment style (Erskine, 2009; Schore, 1994, 2003; Wallin, 2007).The client had developed a belief that she needed no one and that she could only ever rely on herself. She turned away from relationships, because she had stopped hoping that they could satisfy her basic emotional needs for being close to another, for support, love and security. The described process plays a key role in hypoactivation of the attachment system (Mikulincer, 1995). International Journal of Integrative Psychotherapy, Vol. 2, No. 1, 2011 25 Bartholomew and Horowitz (1991) distinguished between two attachments styles which refer to avoidance in adulthood: fearful-avoidant and dismissive-avoidant. There are some fundamental differences between the two styles. Although individuals with a fearful-avoidant attachment style desire to have close relationships, they are afraid of them. By contrast, people with a dismissive- avoidant attachment style appear to be self-sufficient and dismiss their need to be close to other people. For these individuals, it is very important that they feel independent and self-sufficient. They do not like to rely on other people, nor do they like to be relied upon. They rarely engage in self-disclosure, and even when they do, they do not reveal much about themselves. In terms of emotions, they appear to be more or less inexpressive. They protect themselves from disappointment by avoiding relationships which demand closeness and intimacy, and by preserving a feeling that they are independent and invulnerable. These strategies relate to defences which serve to protect an individual from being aware of their attachment needs, as well as from experiencing their weakness and vulnerability (Žvelc & Žvelc, M., 2006). Klara's mode of functioning in life matched the characteristics of the dismissive- avoidant attachment style. In addition to the schema of "others are emotionally unapproachable", Klara had also developed a schema of "the world is an unsafe place and life is a struggle". The ignorance, neglect and beatings had importantly influenced the development of these schemas. When talking about being beaten or ignored by her mother, Klara assumed a tense posture, with her shoulders pushed forward. It is interesting that if one chose to observe only Klara's body language, her vulnerability, insecurity and fragility would come to the fore. This would present a sharp contrast to her "decisions" and strategies of coping on a conscious level, e.g. "be strong, you do not need others, rely only on yourself". Individuals with a dismissive-avoidant attachment style treat themselves and others in the same way as they were treated by significant others in their childhood or in a manner that they experienced their relationship with others (Erskine, 2009; Wallin, 2007). Klara grew up experiencing family relations marked by emotional detachment, inapproachability and coldness, i.e. the absence of intimacy, warmth and physical expression of affection. Klara's emotional needs for receiving love and being close to another had been unmet. Her mother was a controlling person who had beaten Klara as a child or intentionally ignored her. Researchers have found that children who grow up in the same kind of family environment as Klara did tend to be classified as adults with avoidant attachment style (Beebe and Lachman, 1988, 1994, in Siegel, 1999; Cugmas, 1998; Ainsworth, 1978; Sroufe, 1985; Sroufe, Cooper and DeHart, 1996; both in Cugmas, 1998). Children of parents who fit the above description develop an internal model of attachment and they believe that their parents are useless in terms of satisfying their emotional needs. Consequently, they see no sense in seeking closeness with their parent when they meet again. International Journal of Integrative Psychotherapy, Vol. 2, No. 1, 2011 26 Let me sum up the ideas presented thus far. Klara's life, marked by physical and emotional neglect, control and physical abuse from her primary caretakers, had influenced the development of the following working models or in other words relational schemas about herself and others: • I am helpless, vulnerable and bad. • Other people are rejecting, controlling and aggressive. These contents were split off from consciousness, because they were too painful and threatening to the established psychological balance of the client. On a conscious level, Klara functioned on the basis of these beliefs: • I am strong and I can rely on myself. • Other people are weak, dependant and worse than me. Klara's withdrawal from relationships had occurred on an emotional level, since she no longer expected from close relations to present a source of intimacy, warmth and support for her. However, Klara had not completely removed herself from relationships – quite the contrary, in fact. In her family, she was playing the role of a mediator and "a merrymaker". Being chatty and cheerful, Klara was filling the void and masking the coldness of her family relations. She also used this strategy to avoid mother's aggression. She excelled at school, which was another attempt of hers to gain some affection. Although she had had friends both as a child and as an adult, she was not particularly close to any of them. Klara was not used to discussing personal matters with friends, nor did she like other people confiding in her or expressing their emotions. She did not know how to react in such situations. She had had several relationship partners. In therapy, she mostly talked about two of them. Both relationships were marked by little psychological intimacy. Both partners were from another country and, geographically speaking, relatively far away from her. In all likelihood, this was not a coincidence, for it allowed Klara to keep a distance from them, which she wasn’t aware of. Hazan and Shaver (1987) similarly describe partnership relationships of adults with avoidant attachment style. The transference and countertransference characteristics further point to an individual with avoidant attachment style. For the client, I was the professional person providing therapy – and nothing more. She did not invest her needs and wishes into me. She expected nothing more than a formal, professional relationship. On one of our therapy sessions, she told me that her friend was seeing a psychotherapist who hugged her at each therapy session. Klara said this would be completely unacceptable to her. With Klara, I often felt the way I described our first therapy session: »On the one hand, I feel warmth and an impulse to give her a "psychological hug", but on the other, I can perceive her upright posture and serious expression on her face. They make me feel as if I am not to attempt to get closer, as if I am undesired in International Journal of Integrative Psychotherapy, Vol. 2, No. 1, 2011 27 this sense.« After our therapy sessions, I often felt inadequate and inferior. I even had a fantasy that Klara only persisted in therapy with me because her friend had given her a good recommendation of me. After one therapy session, I had a strong feeling that I had done something terribly wrong. I was thinking "Now she is going to be angry with me", although in reality there were no reasonable grounds for me to have such feelings. However, my internal experience was no coincidence – why did it occur exactly with this client? What was the client trying to unconsciously "communicate" to me through the process of projective identification? Over time in therapy, I learned that Klara was suffering from a feeling of being rejected and not being OK. When she was remembering her mother's beatings or coldness and ignorance, it became obvious how deeply ingrained her humiliation, guilt and feelings of being inappropriate had become. Klara’s behaviour and attitude towards others – her colleagues occasionally called her "the ice queen" – can be understood as a way of establishing a distance between herself and others, so as to feel more secure and worthy. In an attempt to avoid experiencing how vulnerable and powerless she was, Klara developed a stance of self-righteousness. As Erskine (1997, p. 46) pointed out: »… self-righteousness is the protective mechanism that helps the individual to avoid the vulnerability to humiliation and the loss of contact in relationship«. At the same time, it also involves a denial of the need for a relationship (Erskine, 1994). As we can see, this was the case with Klara's psychological world, too. She had been using a double defence (Erskine, 1997): overcompensation through self-righteousness, thus protecting herself against the feelings of shame, humiliation and abandonment, as well as gaining some control over her powerlessness. The emotions which the client had tried to avoid were similar to the ones I was experiencing when doing therapy with her. Prognostic Assessment The client was very motivated for therapy, and we managed to establish a good working alliance already in the first two therapy sessions. She was young, with high intellectual capacity and a well-developed observing ego. She was capable of insightful thinking and good psychological introspection. She has showed good reflective ability and was open to exploring and understanding herself. When coming to therapy, she was in big crisis, which strongly motivated her to go and stay in therapy and also helped her to loosen her defences and show more vulnerability. Persistence and courage were typical of her. Apart from the described difficulties, her life was stable and settled. According to my assessment of the client, the therapy had a good prognosis. International Journal of Integrative Psychotherapy, Vol. 2, No. 1, 2011 28 The Psychotherapy Process Building a solid therapeutic relationship − in which the client feels understood and secure enough to explore and come into contact with her/his internal world, thus integrating her/his split-off parts of self − presents the fundamental principle of integrative psychotherapy (Erskine, 1997; Erskine & Moursund, 1988; Erskine, Moursund & Trautman, 1999; Moursund & Erskine, 2004; Žvelc & Žvelc, M., 2009; Žvelc, & Žvelc, M., 2011). In psychotherapy with Klara, two basic process goals were important: • establishing a therapeutic relationship based on contact • exploring herself and coming into contact with the split-off parts of self, i.e. her needs, feelings, physiological sensations, thoughts, fantasies and memories. Erskine (2009) emphasised that in psychotherapy of individuals with an insecure attachment style one of the most important task of the therapist is to decode the client’s infant and early childhood physiological and affective experiences, and to facilitate the client’s becoming conscious of implicit relational patterns. As a therapist, I wanted to establish such a therapeutic relationship which would allow the client to explore herself, to progress and to change. In order to do so, I employed the three basic methods of integrative psychotherapy: Inquiry, Attunement and Involvement (Erskine et al., 1988; Erskine, 1997; Erskine et al., 1999; Moursund et al., 2004). By using these methods, I helped the client to become aware, to tolerate, to reflect on and to accept the difficult, previously unaccepted contents from her internal world. I helped her make space for these internal experiences and guided her towards understanding them and giving them meaning. The secure base, which we were successfully building in our therapeutic relationship, enabled Klara (in Wallin’s (2007, p.3) words) “to take the risk of feeling what she is not supposed to feel and knowing what she is not supposed to know”. Through this process, Klara was gradually integrating the split-off internal experiences into a more coherent and secure sense of self. The therapeutic relationship, in which we were developing trust and a feeling of being secure, enabled Klara to open up and share her intimate world with me. This was a new relational experience for her, as well as a different kind of relationship from the ones she had known in the past. Gradually, Klara managed to transfer this new experience into relationships outside the therapeutic environment. The therapy took place for two and a half years. We agreed on having regular weekly therapy sessions, except during holidays. I divided the psychotherapeutic process into five stages, according to the themes we were working on in a particular period. International Journal of Integrative Psychotherapy, Vol. 2, No. 1, 2011 29 1. Developing the therapeutic relationship, coming into contact with physiological sensations, strengthening reflective and regulatory mechanisms − 1st to 4th month of therapy The most important achievements in this period were establishing a therapeutic relationship, calming down the hyperactivated autonomic nervous system, coming into contact with physiological sensations and, consequently, recognising physiological needs and developing reflective and regulatory functions. Although I continued to pursue these goals in subsequent stages of psychotherapy, as they were important for the ongoing psychotherapeutic process, the fundamental shifts in the described areas occurred in this phase of therapy. In later stages, we opened up some new areas to explore. In order to calm down her tense and hyperactivated body responses, I employed various therapeutic interventions and techniques. During the therapy sessions, I helped Klara to regulate her rhythm. When she was talking fast and her body appeared to be very tense, I invited her to stop and breathe in. I would then ask her what she was feeling. This allowed Klara to come into contact with her physiological sensations and affective states which she had previously been unaware of. Prior to this psychotherapeutic intervention they were covered up by her disquiet and an array of thoughts and words. I noticed how Klara took great care of her visual appearance. Yet despite always looking impeccable, she was not in contact with her internal physiological sensations and the messages her body was sending her. By using mindfulness-based interventions, I taught Klara how to become aware of her body, and how to perceive and regulate her affective states and needs. In addition, I taught her how to do progressive muscle relaxation and the "safe place" visualisation exercise, both of which would help her to relax and reduce anxiety. When we reflected on the "safe place" visualisation exercise, Klara began to cry. She told me about feeling this giant gap between peace (which she had felt during the exercise) and the tension which had been constantly accompanying her. In her daily life, Klara was becoming more attentive of the messages her body was sending to her (e.g. fatigue, hunger, what food suited her stomach, etc.). She started to take these messages into consideration. Klara went to yoga classes and did relaxation exercises at home. Due to better physiological and affective regulation, her work-related stress levels significantly decreased. Klara was gradually becoming better at planning her work rhythm. She allowed herself to have more breaks and was able to cope better with the pressures of her work. It was interesting to see how, during the first few months of therapy, work-related stress presented an important issue for her to work on, but took a back seat as the therapy progressed. However, the fact that she had to seek psychotherapeutic help filled Klara with shame and presented a threat to her psychological stability. The same was true International Journal of Integrative Psychotherapy, Vol. 2, No. 1, 2011 30 for crying in therapy. Klara believed crying pointed out her weakness − and this was something she was terribly ashamed of. To a person with avoidant attachment style, seeking help, showing their vulnerability and weakness (e.g. crying) presents a direct conflict with their identity – i.e. "I am strong and do not need others". During this stage of therapy, we were exploring Klara's protective mechanisms and beginning to understand their function. Klara recognised that she wished to be strong (she did not like to feel weak), she did not want to share her feelings (she understood that as being weak) and she liked to keep people at a distance. She named her defence a suit of armour. When we discussed how the goal of our therapy was not to irrevocably take off her armour, but to help prevent the armour from automatically activating itself, she was very pleased and relieved. Our goal was to make her defence more flexible, so that she could decide on her own when to activate the armour and when to take it off. Klara told me that, for example, she wanted to wear this armour on business meetings, because it is unwise to show weakness in such a situation. In other, more intimate relationships (e.g. a partnership relationship) it might be better to take it off and open up. After she had seen both the positive function of her defence and the price she had had to pay for staying rigid and on guard all the time, Klara became more willing to loosen her control and risk a journey into the unknown. We established a good working alliance. Klara was motivated and dedicated. Already on our second therapy session, she told me that starting therapy had made her want to talk at home, as well. She used to avoid discussing more personal matters with her family members, and would only talk about the weather, what was for dinner and the like. I had a feeling that my interventions “are falling on the fruitful ground” − my client was accepting them and effectively activating her powers to grow. 2. Facing the unknown and accepting the split-off parts of self – 5th to 10th month of therapy On our 18th therapy session, as I inquired about her internal experiences, Klara came into contact with her feeling of loneliness: »I feel somehow lonely in this world. Disconnected. I think I would like to have a partner.« The emerging awareness of loneliness, the need for being close and for love opened a new chapter in our psychotherapeutic process. In that therapy session, Klara reflected on her former relationship. Although she had mentioned it on our first meeting, she did not talk about it up to this session. Afterwards we discussed her relationships with men on several occasions, as well as her meeting a new man. In the first part of our 20th therapy session, Klara was enthusiastically talking about this new male acquaintance of hers. I got a feeling that something was International Journal of Integrative Psychotherapy, Vol. 2, No. 1, 2011 31 hiding behind this. I invited her to focus on her body and inquired about what she was feeling. Klara replied: »Nothing special.« I invited her to feel and describe this "nothing special". At that point, she started to cry and told me how anxious she was about her father.(It is important that as therapists we do not merely follow the client's narrative, but also inquire about the things which have been left unsaid. Had I merely let Klara to talk, we would not − at least not in this therapy session – touch upon this important, shame and fear-inducing content. Stopping and directing the client to focus on physiological sensations and emotional experiencing was strengthening her contact with self, which in turn facilitated coming into contact with other, more difficult contents.) Klara started telling me about her father's alcoholism. She was worried about him, and was asking herself what she could do about it. Her family was minimising this problem. The fact that Klara admitted to herself − and me − that her father was having a problem with alcohol, was something new in therapy. Klara realised how her father's alcoholism was connected to the question of her identity: »I have a father who drinks excessively.« Klara was discovering her shame. In the next two months, she was processing the above-mentioned contents. She was working on her father's attitude towards her (he was distant and did not notice her, as if she did not exist), the relationship between her mother and her father, her mother's denial of the importance of their problems and mother's indifference. Step by step, Klara was making a decision that she was not going to take over the responsibility for her father's alcoholism. She thought it was her mother's task to encourage her father to go into treatment for alcoholism, because she was his wife. She discussed this with her mother, too. Slowly − despite her mother's tendency to deny the problem and distance herself from it − things started moving ahead. Her mother and father finally agreed to enter treatment for alcoholism. The 22nd and the following two therapy sessions, which I am going to describe in the next paragraphs, were the most difficult for Klara in her entire psychotherapeutic process. During this time, her emotional turmoil markedly increased. On the one hand, she had been pondering not coming to the therapy session, but on the other, she was aware that now was particularly important for her to come. While reading T. Harris' book I'm OK − You're OK, she remembered certain events from her childhood which made her realise that her family members had not been showing physical affection to each other. She missed that. She missed the warmth. (The client realised this in the 6th month of therapy; this was something completely new to her, yet at the same time so familiar. She reached a pivotal point in her therapy – a point, at which the client starts to understand what they have already known implicitly, but not explicitly, when the unconscious starts becoming conscious.) International Journal of Integrative Psychotherapy, Vol. 2, No. 1, 2011 32 Moreover, she gained insight into how she had wanted to compensate the need for physical contact by excessively striving for success at work. At the therapy session, she was talking enthusiastically about this, i.e. what a remarkable discovery this was for her. When I stopped her, invited her to focus inwardly and inquired about what she was feeling, she began to sob bitterly. At first, she said that she did not know why she was crying. Later on, she revealed that she felt a need for a hug (but added that with this she did not mean I had to hug her.) After this therapy session, she was feeling upset at home as well. Klara cried on her next session, too. She told me that she had no one and how alone she was − and at that age! Klara came into contact with her need for protection, for warmth and for being close to another. These needs had been previously split off. She came into contact with her fundamental conflict: should she open up, trust others and let them into her world – or not? On our next therapy session, Klara was still reporting about being in an intense emotional turmoil and having wished not to come in the therapy. She was asking herself again why she was crying so much. We can understand her emotional turmoil as the consequence of being more fully aware of her internal conflict: »Should I open up, trust others and let them into my world – or not?” and also as a juxtaposition response (Erskine et al. 1999). On one hand, she has closed herself to emotional and psychological intimate sides of relationships, cutting the need for warmth and emotional support of others. On the other hand, there was a therapist, who was supporting, warm and respectfully interested in her inner needs and experiences. That facilitated her to feel the “forbidden” need for warmth and support of other (including therapist). In this therapy session, we worked on understanding what was going on, constructing the meaning of her internal experiences. I explained to Klara how I saw what was going on. I told her how, in accordance with her previous experiences in relationships, she had developed the "be strong" strategy and rejected her vulnerability. Klara added: »Just like my mother.« By using attunement, I explain to Klara how in the last two therapy sessions she had lost her balance when she realised how painful it was for her to live in such a cold family environment. She realised how she had missed care and warmth. What is more, she felt that the need for warmth, for being hugged and, consequently, for allowing herself to be vulnerable, existed in her as well. I was telling her that we had entered her sensitive area – her vulnerability and the need for other… and that these insights allowed her to come in contact with herself and with me (I put my hand on my chest). At this point tears welled up in her eyes. Klara replied: »Yes, I don't accept this feeling (i.e. vulnerability and the need for other), I would rather not have this feeling around. That is why it was difficult for me to come into therapy today.« International Journal of Integrative Psychotherapy, Vol. 2, No. 1, 2011 33 When a client comes in contact with their core feelings, the important (i.e. core- related) memories begin to spontaneously appear. This is what happened in Klara’s case, too. She went on to talk spontaneously about her mother and father, who were both emotionally cold and unapproachable. She remembered the events which illustrated the formation of Klara's life script pretty well: »I used to spend a lot of time alone in the playpen. I would call for my mother… I would call and call... no one came by… and so one day I just stopped calling.« In such situation and similar events, Klara implicitly "concluded" that there was no point in calling out for others. She could not rely on others and she had to take care of herself on her own. The following schema developed about herself: »I am not worthy of love and attention. Something is wrong with me.« Her next memory showed how Klara had already developed a survival strategy which excluded the need for being close to someone and for receiving loving care from another. »I was sitting with my grandmother on a sofa; she wished to embrace me, but I shifted away from her. I felt unpleasant. I was not used to being hugged or caressed…« We talked about her memories and assigned them meanings. Klara was making sense of how as a child she needed her mother and father; she was crying and calling for them. Because nobody responded to her calls, she gradually stopped calling... and eventually stopped needing (she was no longer aware of her need for another person). She put away her emotions and needs in this relationship. Klara added that even as an adult she held such attitude – not just towards her parents and other people, but also towards herself. This revealed her high level of reflective function and the depth of her insight. She put into her own words the theme which has been discussed by many authors of developmental psychology (Erskine, 2009, Wallin, 2007): when a person has not experienced contact in a relationship, the person has no contact with self. We talked about the function of this avoidant pattern, this hypoactivation of the attachment system which she had developed. I normalised the pattern by explaining to her that it had not developed by coincidence. It had an important function: it helped Klara to survive in such relationships, preserve them and thus lessen the pain she was feeling because of them. (In integrative psychotherapy, we emphasise that each disturbing, defensive behaviour or symptom has its own function. We look for its roots in childhood or, as the case may be, in possible later life traumas. We believe that "disturbing" behaviours and symptoms represent the best possible adaptation in a given period, a "normal" response of the child to the abnormal circumstances they have found themselves in (Erskine etc., 1999). With such stance we normalize the responses of the client, who in turn feels understood and accepted and paradoxically-his/her defenses begin to melt.) International Journal of Integrative Psychotherapy, Vol. 2, No. 1, 2011 34 Becoming aware of how things were, hurts. Klara became sad when she felt and realised how she had experienced this as a little girl. She was grieving for what she did not get in her childhood. She was giving up on her infantile hope that her parents will fulfil her needs for love and intimacy and provide her with loving care. In doing so, she was cutting off her infantile ties with her parents, which presents an important step in completing the separation and individualisation process (Blos, 1967; Žvelc, 2003). 3. Changes show externally as well – 11th to 20th month of therapy In this period, Klara implemented a lot of changes into her life: she was separating from her parents, becoming independent and building new relationships outside the family environment. She bought an apartment, moved in and began a partnership relationship. In this stage of psychotherapy, Klara reflected, processed and strengthened her experiences connected with the changes she was introducing into her life. During the therapy sessions, Klara's need for becoming independent from her parents and the related construction of her new identity were coming increasingly to the forefront. She began to look for an apartment and bought one in the 10th month of therapy. She moved in the following month. In therapy, she reflected on this process of becoming independent − she was looking for a new position and role within her primary family. In addition to externally visible separation − moving away from her parents − Klara was also cutting off her internal infantile ties to her parents: »I used to play the role of the mediator in our family. I was artificially creating happy events and behaved like a good girl, so as to please my parents and fill the void… Had I not done this, I would have risked losing them.« Klara was gradually becoming aware that she no longer wished to play this role. However, she was asking herself in what way she could now relate to her parents? From the above description, we can understand how Klara had split off her anger for fear of losing her parents and how she became a good girl who pleased her parents and caused them no trouble. Reflecting on her new partnership relationship took a lot of space in therapy. This relationship was something completely new for Klara, because her partner was bestowing her with a lot of attention, affection and tenderness. Klara was not used to this − not from her relationship with her parents, not from her previous relationships with men (with whom she was involved in psychologically distant and "safe" relationships). In the beginning, she sometimes felt overwhelmed by so much tenderness. She realised that even when she wanted to receive tenderness, she appeared cold and did not know how to respond to it. She was learning new things about herself in relationship. She was recognising her feelings, wishes and needs. She allowed herself space to explore: how she felt when her partner hugged her; how she felt International Journal of Integrative Psychotherapy, Vol. 2, No. 1, 2011 35 when he wanted to have sex with her. Did this suit her or not? What did she want? Because of therapy, she allowed herself to explore what she was feeling and needing, and how to accept this. Gradually, Klara was opening up emotionally. She was able to receive and return affection and tenderness. At the same time, she realised and accepted that she needed time for herself and that she had the right to set boundaries to her partner. She was looking for her space in a partnership: how close, how far. The old way − keeping a distance − broke down, and the new way was gradually being built through processing experiences in therapy. 4. Returning to "the depths" and continuing the process of integration − 21st to 26th month In this stage of psychotherapy, the client worked in depth on her relationship with her mother. In addition to the realisation that her mother was cold and unapproachable, Klara learned that her mother was an aggressive and belligerent person. The central work was processing her traumatic experience for which I used the EMDR method (more on the EMDR method in Shapiro, 2002). Klara revealed how in certain situations − when wanting to protect herself and act assertively − she became paralysed. She would become silent, lost for words and would not stand up for herself. She told me she would like to work on this. I invited her to describe a recent, concrete event when a thing like that happened. She began talking about an occasion when her mother was complaining about her father: »She talked and talked… The more I was withdrawing, the more she was "towering" over me. Maybe I should have reacted differently, but I cannot. I should have done something to protect myself… but I cannot. I am afraid of confrontation… and my mother does not let me go, at all. She simply fails to notice what her verbal barrage effects me. As if I was nothing. As if I was not, incidentally, her daughter. As if someone was digging inside me. I mean, I HAVE FEELINGS, TOO!!« A bit later, she added: »When I am withdrawing backwards, towards the door, I feel that I have no control. I feel anxiety, from my neck to the diaphragm. « I used the "emotional bridge" technique, inviting the client to close her eyes and think of the words "I have no control". I asked her to focus on the feeling of anxiety in her body and directed her to go back in her mind, into her childhood, and ask herself when she felt a similar feeling. I encouraged her to simply allow for any image or thought to occur to her. International Journal of Integrative Psychotherapy, Vol. 2, No. 1, 2011 36 Two things came to her mind. First, there was a memory of being beaten by her mother when she was 4 or 5 years old. Her second memory was of a dream: as a child, she used to have a recurring dream in which she had to eat her bicycle and had a choking sensation in her throat. By using the EMDR method, I helped the client to process the traumatic experience of being beaten and its consequences. Klara remembered "uttering something" which made her mother livid with rage. She began beating her. Klara tried escaping the punches by lying on the floor. Her mother was beating her all over, telling her: »You little brat, you think are going to talk back!« When I asked Klara what she was feeling and thinking about while telling me this, she said: »I cannot go away. Why do I allow this to be happening to me? Why can't I react differently? I am unable to protect myself. I am unable to respond… I am helpless. It is not safe. I have no control. « I inquired what she would like to believe about herself when she was thinking about this event. She replied: »That I am OK. And that I have the right to protect myself.« By using the EMDR method, we processed the event. Klara returned to the event, which activated her Child ego-state. She had a feeling that she was bad, not OK and not a good daughter. She felt the pain of letting her mother down for saying that to her. Then she said: »GO ON, BEAT ME, BUT YOU CANNOT REACH ME. I am not in pain at all. I am not here at all. I have already withdrawn. I leave my body and set myself free!« Klara then commented that she reacted in the same way as rape victims do. She cried and grieved the fact that things had happened this way. How Klara described and experienced this event clearly demonstrates that during the beating she used dissociation as a defence mechanism. She dissociated from her body, so as not to experience the pain and humiliation. In all likelihood, Klara learned to dissociate from her body already as an infant, when she was extremely hungry due to not being fed. Such events helped strengthen her pattern of dissociation and maintained it until she came into therapy. While processing these feelings, Klara remembered two more events. On one occasion, she was home alone, waiting for her parents, and on the other her parents were having an argument. On both occasions, Klara felt separation anxiety − she was afraid of losing them. As a child, Klara interpreted these events as a consequence of her not being good enough. Therefore, she resorted to becoming an even better child. We can understand this as Klara repressing the anger and rage towards her parents, so as to preserve their relationship. In order to preserve a good image of her mother (and father), Klara "swallowed" the bad part, which she then carried within herself and experienced herself as bad (Fairbairn, 1952, Little, 2001). International Journal of Integrative Psychotherapy, Vol. 2, No. 1, 2011 37 Although the feeling of guilt and of being bad persisted for a few more therapy sessions, it was losing its grip on Klara. In the Adult ego-state, the client knew it was not her fault; however, in her Child ego-state, she had a fixated feeling of being guilty and bad. It is important for the client to experience this ego-state and to tolerate it, because such mindful process facilitates further change. In order to leave a place (and all it encompasses) behind, client has to arrive there first (Greenberg & Paivio, 1997). When Klara was processing this event, she regressed to the Child ego-state. She was feeling guilty and bad. Through processing this memory, empathy, self-acceptance and power sprang from this ego-state. Klara said: »I am alright. And I did not deserve this to happen to me.« Klara differentiated the representation of self from the object representation. We could translate this into the following words: »It is not as you have been telling me − that I am bad. I am OK and you should not have done this to me!« On our next therapy session, we continued with processing Klara's experiences (with EMDR) connected with the event (mother is beating her). On this session she came in touch with feelings of humiliation. She came into contact with her shame, pain and vulnerability. She went on to contemplate how as a child, and later, she was unable to ask for help. She experienced somebody offering her help as redundant… »because it makes me seem weak and vulnerable. And if I am seen as weak and vulnerable, I feel humiliated. « These words illustrate how Klara connected her vulnerability not only with the expectation of rejection, but also of humiliation. (In other words, she was certain that should she show her vulnerability, she was going to be rejected or humiliated.) For a child − and for Klara − this is far too painful, too much for her psychological system to cope with. Moreover, Klara needed to preserve a good image of her mother instead of an abuser. As a result, she had developed a defence mechanism in the form of hypoactivation of the attachment system (i.e. avoidance), wherein one can rely on themselves and be strong. Klara then said: »Poor child.« As a therapist, I was moved and felt a deep, profound sadness. Klara then broke off contact with self and commented on the therapy session: »My, how everything was fragmented today.« It is likely that she reached the bottom in this therapy session, yet she could not, as of yet, fully tolerate the experience. This is why she withdrew herself, as illustrated by her feeling of fragmentation. In this therapy we can also see a strong juxtaposition. Klara has showed her vulnerability to me and I was respectful and deeply moved by it. And this was something so far from her experiences in past relationships, so that it was hard to bear. On our next therapy session, we continued with processing these issues. Klara resumed where she had stopped in the previous session. She felt the humiliation of her past… then sadness. And out of this sadness sprang her empathy and compassion towards herself. (She no longer rejected the vulnerable, weak International Journal of Integrative Psychotherapy, Vol. 2, No. 1, 2011 38 and humiliated self!) She felt pride. She felt love for herself. Just as she was, with all she had: being weak and being strong. The stones comprising her wall of personality had been shifting and breaking down throughout therapy; however, now the entire wall broke down and a surge of positive self-evaluation, appreciation of self, dignity and lust for life began to flow freely. We continued the therapy with EMDR by spending two more sessions on processing a "present" event − her mother complaining about her father − and a future event, for which Klara imagined her mother behaving similarly. While doing so, Klara's functional anger was gaining in force: »I have the right to protect myself. I feel strong enough for this! « From her feeling of being paralysed (which she had felt when we started processing these issues), Klara was coming into contact with various feelings, of which I would point out the following three: her sadness about what had happened; her self-acceptance and her functional anger (i.e. the feeling that she was strong enough to set boundaries to another). If we experience ourselves as being worthy enough to be with another and strong enough to set boundaries, then there are no more reasons for withdrawing from relationships. At first, these new realisations made Klara feel angry with her mother, and later grieve for the things she had not received. She gave up hoping that she was ever going to receive warmth from her mother. This enabled her to cut off her internal infantile ties to her mother, followed by a reconciliation with what was and what is. In the coming months (which overlapped with the final stage of psychotherapy), Klara integrated both the good and the bad representation of her mother. In addition to recognising her bad aspects, she was now able to acknowledge and appreciate her mother's good parts. 5. The final stage − 27th to 30th month of psychotherapy The last four months of psychotherapy presented the concluding phase, where the main emphasis was reflecting on the psychotherapeutic process, on changes which had occurred during psychotherapy and on her feelings about the coming termination of therapy. In these last months, I noticed more spontaneity and a more relaxed attitude in Klara's behaviour at therapy sessions. Her previously tense, constricted and upright posture was becoming softer and more relaxed. Klara would now often sit tailor-style, which she had never done before. It is hard to put into words, but this new sitting position reflected Klara's physical relaxation, her loosening control, feeling a greater sense of security and ability to let go. She later revealed how she no longer felt the need to be constantly on guard, to constantly fight. Her International Journal of Integrative Psychotherapy, Vol. 2, No. 1, 2011 39 facial features were becoming softer as well. To me, she looked truly beautiful, more than ever before. Here are some of Klara's thoughts on the changes that had happened to her: • »In relationships, I am able to perceive with good intuition that which "cannot be seen.« • »I have become more sensitive to what is going on in relationships. I strive to understand what is going on. I no longer avoid the things which previously I did not want to see.« • »Until now, I was always on guard, always fighting. Now I see that I do not need to fight all the time. I can take off my armour, too.« • »Before I appeared so determined and firm, some colleagues used to call me "the ice queen". I evoked feelings of fear and respect in people. On the inside, I was scared and fragile… yet nothing in the world could make me show that. Now it's different. OK, at business meetings I am still like that. But not in close relationships. I open up now.« • »Before, I did not show my emotions in relationships. If anything went wrong, or if I did not like something, I just ignored it. Now I tell what I think.« As a therapist, I found that important changes occurred in Klara which were mutually intertwined: • The reduction and the disappearance of symptoms: Symptoms connected with work-related stress (anxiety, feeling tense, fatigue, a desire to withdraw from her job, etc.) and her stomach issues markedly decreased already in the first few months of therapy. Her fear of driving persisted longer, but was losing its grip on her during the course of therapy. Gradually, Klara was widening the geographical area in which she was willing to drive; at the end of therapy, she was able to drive anywhere in Slovenia. • Improved reflective function, affect regulation and regulation of her needs. • She gained important insights about herself and her relationships. • She became more open and accepting of her own internal states. She established a much better contact with herself (with physiological sensations, needs and feelings) and others (her new partner, friends and therapist). • She completed the separation and individuation process, which had previously been blocked. • In the terms of attachment theory she moved from isolation to intimacy and from avoidant to secure state of mind. • Klara managed to integrate those parts of self which she had split off due to contact disturbances in previous relationships. International Journal of Integrative Psychotherapy, Vol. 2, No. 1, 2011 40 Her persistent avoidance of an important part of her internal world in which memories were locked together with feelings of humiliation, vulnerability, weakness, anger and sadness − and also pride, dignity and spontaneity − gave way to awareness and acceptance. Klara established contact with the split-off part of self. She realised how things were for her as a little girl. She allowed herself to feel the shame, the loneliness, the vulnerability, pain and the anger − feelings for which she used to spend so much of her energy to make them go away. Through this process, she encountered her pride and healthy power. She accepted parts of herself she had been afraid of and which she had avoided. In her "dark" corner, she found not only "the dragons and the beasts", but also pride, dignity and empathy towards herself, spontaneity and a relaxed attitude. This is what we call integration. Psychotherapy helped Klara to make this important journey from avoidant to secure attachment. Her internal world was becoming increasingly more secure − it was a world in which she could trust herself and others, where she allowed herself to be who she was, with all her positive and negative traits, with all her pain and joy. Klara was satisfied with the changes that had occurred to her in therapy. When we completed our therapeutic journey, she left feeling that an important process had taken place there and came to a favourable end. She found that although life continued to serve her challenges, she had different tools now, and of better quality, to cope with the problems. She revealed that the therapy was one of the most important things that happened in her life. She was also contemplating that when she decides to have children, some new things may occur to her, and that she might need some therapy then. She wanted to hear that, should she desire so, she could come back to me and continue with psychotherapy. Conclusion Man is like a vast ocean, without an end… and as one is sailing through this ocean, one is discovering the ever new islands. And I imagine a person's development as a shell of a sea snail, because its shell is spirally coiled and all the spirals finally meet at one point. Psychotherapy with Klara was a mixture of sailing through the ocean and climbing up a spiral. Together, we discovered important new lands and glided along many spirals − enough to remove important obstacles which had previously prevented a smooth cruise through her life. Of course, Klara continues to sail on… International Journal of Integrative Psychotherapy, Vol. 2, No. 1, 2011 41 Author: Maša Žvelc has MSc in clinical psychology and is an integrative psychotherapist, accredited by IIPA and EAIP. She is a supervisor approved by European Centre for Psychotherapeutic Studies. She is a co-founder of the Institute of Integrative Psychotherapy and Counselling, Ljubljana and a co-leader of integrative psychotherapy training. She also has a psychotherapy and supervision practice. She is the co-editor of the first Slovenian general psychotherapy book. She can be reached at Institute IPSA, Stegne 7, 1000 Ljubljana, Slovenia. E-mail: masa.zvelc@institut-ipsa.si. Homepage: www.institut-ipsa.si References Ainsworth, M. D. S., Blehar, M. C., Waters, E., & Wall, S. (1978). Patterns of attachment: A psychological study of strange situation. Hillsdale, NJ: Erlbaum. Bartholomew, K., & Horowitz, L. M. (1991). Attachment Styles Among Young Adults: A Test of a Four-Category Model. Journal of Personality and Social Psychology, 61 (2), 226–244. Bowlby, J. (1969). Attachment and Loss: Volume 1. Attachment. London: Penguin Books. Blos, P. (1967). The Second Individuation Process of Adolescence. Psychoanalytic Study of the Child, 22, 162–186. Cugmas, Z. (1998). Bodi z menoj, mami. Razvoj otrokove navezanosti. [Be with me, Mother. Development of Child Attachment] Ljubljana: Produktivnost. Center za psihodiagnostična sredstva. Erskine, R., & Moursund, J. (1988). Integrative Psychotherapy in Action. The Gestalt Journal Press. Erskine, R. (1997). Theories and Methods of an Integrative Transactional Analysis. A Volume of Selected Articles. San Francisco: TA Press. Erskine, R., Moursund, J. P., & Trautmann, R. I. (1999). Beyond Emphaty. A Therapy of Contact-in-Relationship. Brunner/ Mazel. Taylor & Francis Group. Erskine, R. (2009). Life Scripts and Attachment Patterns: Theoretical Integration and Therapeutic Involvement. Transactional Analyses Journal, 39, 3, 207- 218. Erskine, R. (1994). Shame and Self-Righteousness: Transactional Analysis Perspective. Transactional Analysis Journal, 24, 2, 86-102. Fairbairn, W. R. D. (1952). Psychoanalytic Studies of the Personality. London: Routledge. Fonagy, P., Gergely, G., Jurist, L. E, & Target, M. (2002). Affect Regulation, Mentalization and the Development of the Self. London: Karnac. International Journal of Integrative Psychotherapy, Vol. 2, No. 1, 2011 42 mailto:masa.zvelc@institut-ipsa.si http://www.institut-ipsa.si/ Greenberg, L.S., & Paivio, S. (1997). Working with Emotions in Psychotherapy. NY: Guilford Press. Hazan, C., & Shaver, P. (1987). Romantic Love Conceptualized as an Attachment Process. Journal of Personality and Social Psychology, 52 (3), 511–524. Little, R. (2001). Schizoid processes: Working with the Defenses of the Withdrawn Child Ego State. Transactional Analysis Journal, 31, 1, 33-43. Main, M., Kaplan, N., & Cassidy, J.(1985). Security in infancy, childhood, and adulthood: A move to the level of representation. Monographs of the Society for research in Child Development, 50 (1-2), 66–104. Mikulincer, M. (1995). Attachment Style and the Mental Representation of the Self. Journal of Personality and Social Psychology, 69 (6), 1203–1215. Moursund, J. P., & Erskine R. G. (2004). Integrative Psychotherapy: The Art and Science of Relationship. Thomson/ Brooks/Cole. Shapiro, F. (2002). EMDR as an Integrative Psychotherapy Approach. Washington, DC: American Psychological Association. Schore, A., N. (1994). Affect Regulation and the Origin of the Self. The Neurobiology of Emotional Development. NJ: Lawrence Erlbaum Associates. Schore, A. N. (2003). Affect dysregulation and disorders of the Self. NY, London: W.W. Norton & Copmany. Siegel, D., J. (1999). The Developing Mind. Toward a Neurobiology of Interpersonal Experience. New York: The Guilford Press. Stern, D. (1985). The Interpersonal World of the Infant. A View from Psychoanalysis and Developmental Psychology. New York: Basic Books. Wallin, D., J. (2007). Attachment in Psychotherapy. NY: Guilford Press. Žvelc, M. (2003). Razvoj slikovnega testa separacije in individualizacije. Magistrsko delo. [Development of pictorial test of separation and individualisation] Ljubljana: University of Ljubljana. (Unpublished Msc dissertation). Žvelc, M., & Žvelc, G. (2006). Stili navezanosti v odraslosti. [Attachment styles in adulthood] Psihološka obzorja, 15, 3, 51–64. Žvelc, G. (2009). Between Self and Others: Relational Schemas as an Integrating Construct in Psychotherapy. Transactional Analysis Journal, 39, 1, 22–38. Žvelc, G. (2010). Relational Schemas Theory and Transactional analysis. Transactional Analysis Journal, 40,1, 8-22. Žvelc, G., & Žvelc, M. (2010). Integrativna psihoterapija – relacijska smer. [Integrative relational psychotherapy.] In: B. Lojk (Ed.). Psihoterapija na Slovenskem : pregled psihoterapevtskih šol, udeleženk strokovnega srečanja Psihoterapija na Slovenskem, Bled 26.–28. februar 2010. [Psychotherapy in Slovenia: an overview of psychotherapeutic modalities presented by participants of the professional event Psychotherapy in Slovenia, Bled, 26-28 February 2010.] (pp. 83-93). Kranj: Inštitut za realitetno terapijo. International Journal of Integrative Psychotherapy, Vol. 2, No. 1, 2011 43 International Journal of Integrative Psychotherapy, Vol. 2, No. 1, 2011 44 Žvelc, G., & Žvelc, M. (2011). Integrativna psihoterapija. [Integrative psychotherapy] In M. Žvelc, M. Možina, & J. Bohak (Eds.). Psihoterapija. [Psychotherapy] (pp. 565-590). Ljubljana: Založba IPSA. Date of publication: 23.9.2011