Alcoholism is such a common condition that therapists must be exposed to clients who suffer from it, whether the therapist is Post-Script to Part 1 of a Case Study Trilogy Marye O’Reilly-Knapp Abstract: The case study by Richard Erskine, Early Affect-Confusion: The Borderline Between Despair and Rage, is an in-depth, intensive analysis of early affect confusion and its impact on the client’s life. Contributions offered by Grover Criswell, Maša Žvelc, Ray Little, and James Allen further enrich the process by bringing their own unique perspective into the discussion. Key Words: integrative psychotherapy, supervision, case study ______________________ As I read the Erskine’s case study I found myself immersed in the process. Sometimes I experienced myself present in the therapy room as a witness to Theresa’s unfolding narrative and Richard’s mastery in using an involved relationship and the transference-countertransference milieu. The consuming intensity of Theresa’s feelings were noted by the therapist as “transferentially expressing previous, and perhaps early, childhood relational conflicts”. The focus on relationship, use of a phenomenological inquiry with an emphasis on the here-and-now, and attention to: emotional stabilization, interruptions of contact with self and others, unmet wants and needs, moment-to- moment experiences between client and therapist, support for behavioral changes/behavioral management - all resonated throughout the first part of the case presentation. Rather than a focus on a diagnosis and pathology, Erskine uses the term “borderline” within a relational framework. Thus, rather than a focus on treatment of a disease, the whole of Theresa’s personhood is highlighted and given attention. The borderline, “between intense neediness and rage, despair and self-reliance, impulsivity and manipulation” frames her intense psychological struggles. Conflicts are met within the therapeutic dialogue where “I-ness” and “otherness” (Winnicott, 1971) are co-created. As I followed the dialogue, two models of Integrative Psychotherapy came to mind: the Self-in-Relationship Model and the Script System. The first, the Self-in- Relationship Model, brought to mind a relational system where Theresa’s feelings, thoughts, behaviors and body sensations were addressed. A few International Journal of Integrative Psychotherapy, Vol. 3, No. 2, 2012 37 examples include: “I inquired repeatedly about Theresa’s internal experiences and the meanings she made ….”; “the desperate emptiness in [Theresa’s] relationships”; “[I]encouraged her to stay with her body sensations and emerging affect”. This model conceptualizes organization of a person – affect, cognition, behavior, and body- and how these components effect the organization of self and relationships with others. The second model, the Script System, identifies unconscious relational patterns and serves as a mechanism to identify core beliefs, needs and feelings repressed at the time of script decisions, observable behaviors, reported internal experiences, old emotional memories and current events (O’Reilly-Knapp & Erskine, 2010). I found myself tracking the observations and responses made by Richard and Theresa. Repeatedly, rather than taking a historical perspective, a phenomenological inquiry disclosed core beliefs, decisions and conclusions, and present-day reactions were reiterated: “fighting and pushing people away”; “depressed and fearing abandonment”; “blaming others and self-criticism”; “confusion about how others treated her”; “relational needs thwarted”; “fights”; “No one is there for me”; “No one understands me”; Something’s wrong with me”; “I’m unlovable”. The case provided me with an opportunity to go back, review and re-assess my beginning years in Integrative Psychotherapy and to add to this knowledge base. I was transported as I ended Part I of the case study trilogy. Then I had the privilege to go to the responses. I felt an eagerness as I began. I was struck by the integrity of each one of the responders in their beginning statements: We need to remember what we know is fragmentary. Grover Criswell. I highly respect the author’s deep and gentle engagement, empathy and respect toward underlying needs, feelings, and defenses. Maša Žvelc. I think when it is when considering a case study by another therapist to hold in mind that the presentation of the client is from that therapist’s particular clinical perspective. Ray Little. Once again, I am impressed by the usefulness of this framework in directing therapeutic interventions. James Allen. Each one addressed the importance of therapeutic engagement and the presence of the therapist. The thought-provoking comments and questions continued throughout the responses. I have taken a few of their responses to consider here. Self-reflective questions by Grover Criswell considered the strengths of Theresa, the level of her disturbance and what her role is in relationships. He also addresses the term “borderline”. In her response, Maša Žvelc noted an appreciation for “gentle engagement, empathy, and respect toward underlying needs, feelings, and defenses”. She also identified areas that were “skillful and useful”: cognitive attunement; individual versus group therapy; the “internal supervisor” of the therapist; and meaning-making. Questions related to countertransference were also raised. Ray Little wondered about Theresa’s ego state relational units (Little) and “to consider if this woman lives and functions International Journal of Integrative Psychotherapy, Vol. 3, No. 2, 2012 38 in a split internal world, and whether her relational units are dissociated from each other”. He gives serious consideration to the transference- countertransference process. In his response Jim Allen talked about his own dependence on non-verbal communications and somatic resonance. He skillfully identified a need “to lift these non-symbolic to verbalize symbolic status …. very difficult to describe in words”. The rejoinder by Richard Erskine followed and addressed each of the four responders. Only a segment of the responses will be discussed in this section. To gain a full appreciation of the replies, Treatment Planning, Pacing, and Countertransference: Perspectives in the Psychotherapy of Early Affect Confusion must be read. Following are segments of Richard Erskine’s reactions to the retorts by his colleagues: use of “borderline”; time-limited psychotherapy; transference/countertransference; and idealization. Use of “borderline”. “Borderline” was used as a metaphor to represent Theresa’s early affect confusion and her struggle to relieve her confusion in dealing with her thoughts, feelings, and behaviors. An elaboration of personality on a continuum, from style, to pattern, to disorder, illustrated the differences in the persona. At the extreme level of disorder, Erskine uses “developmentally descriptive and caringly humanistic term early affect confusion” rather than borderline personality disorder. (See text for full discussion of this continuum.) The continuum may assist the clinician in differentiating issues to be encountered. Time-limited psychotherapy. Working with Theresa for seven months, a time- limited psychotherapy is considered by Erskine to be “particularly effective in focusing on a specific problem, facilitating behavioral change, and in managing incidences of ‘acting out’ what has not been resolved in the psychotherapy”. In James Allen’s comments, I resonated with his “twinge of sadness” due to current economic conditions and his poignant question as to how treatment can be preserved “even if shortened or condensed”. Transference/Copuntertransference. A secure working alliance was essential working with Theresa’s aggressive transference. To reiterate, the goals of therapy in seven months was to resolve her fear of abandonment and find constructive ways to be in relationship with her boyfriend. The next part, if Theresa was to return to therapy was to do an in-depth psychotherapy and deal with archaic fixations. It is no surprise that she found the therapist “not doing the right therapy”, “unattuned”, “a failure at validation”. To her frequent attacks, the response was to “remain fully present and sensitive to what she unconsciously needed”. An account of the responsive versus a reactive transference was interesting - “An element in her was very enduring and evoked in me a sense of caring and protection – a responsive countertransference… Alongside that care and protection, I disliked her treatment of others, her aggressive attitude – a reactive countertransference.” International Journal of Integrative Psychotherapy, Vol. 3, No. 2, 2012 39 International Journal of Integrative Psychotherapy, Vol. 3, No. 2, 2012 40 Attention to transference allows the therapist to look for the projections, the unmet developmental needs, and the defenses the client uses to stabilize and protect. A sensitivity to the transference and also to one’s own reactions (countertransference) is a powerful source for therapeutic assessment and interventions. In concluding, Erskine in his case study describes a comprehensive therapeutic process and then invites colleague contributions. This is a wonderful way to enter into the therapeutic session. It is also a model for learning and for tapping into the minds of others. The specific interventions and rational, the accounts of the therapist’s descriptions of his internal experiences, as well as the notable questions and areas presented by the responders were invaluable, both in bringing out specifics and in enhancing our understanding for appropriate therapeutic interventions. Rejoinders to the responders by Richard Erskine contributed to the interchange by bringing the exchange full circle. What an exciting and informative course this has been for me as the reader! A special thank you to Richard Erskine, Grover Criswell, Maša Žvelc, Ray Little, and James Allen for providing me and the readers of this journal an opportunity to be involved in your dialogue. I look forward to the next two parts of the case study. Author: Marye O’Reilly-Knapp, RN, PhD is a psychotherapist in private practice in NJ. In June 2010 she retired from Widener University School of Nursing and was awarded Emerita status. She continues to write and teach. Marye is a Teaching and Supervisor faculty of the International Integrative Psychotherapy Association. References O’Reilly-Knapp, M. & Erskine, R.G. (2011). The Script System: An Unconscious Organization of Experience. In: R.G.Erskine (Ed.), Life scripts: A transactional analysis of unconscious relational patterns. London: Karnac Books. Winnicott, D.W. (1971). Playing and Reality. New York: Basic Books.   Date of publication: 26.12.2012